Fort Worth Transitional Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
several straps. LVN B stated one of the straps was not secured, which allowed the overlay to slide with the resident, when she slid off the bed instead of staying in place and preventing the resident from sliding out of bed. She stated the air mattress was now fitted with a different type of cover that was more secure than the previous one. Interview on 09/03/25 at 10:40 AM with the DON revealed his investigation into Resident #1's fall revealed the resident's mattress overlay did not have the top right strap secured. When the resident began to slide to her left, the overlay slid with her instead of staying in place, which prevented the built-in bolsters from doing their job of making it harder for her to slide out of bed. The DON stated it was the responsibility of the nurses and CNAs to check the overlay and make sure it was properly secured. He stated he initiated an in-service on proper use of the overlays, as well as resident neglect. The DON stated there was only one other resident in the facility with the type of overlay Resident #1 had. Observation on 09/03/25 at 10:55 AM of Resident #1's mattress overlay revealed it was properly secured to the bed frame with three straps on each side of the mattress. Interview on 09/03/25 at 12:50 PM with CNA C revealed she was familiar with the residents, who were at risk for falls, and she rounded on them more frequently. She stated the fall risk residents were also in a binder at the desk and on the Kardex (a documentation system that summarizes important details and quick access for essential patient data) for those not familiar with the residents. She stated Resident #1 was known to move about a little and work her way to one side of the bed or the other. Interview on 09/03/25 at 1:00 PM with CNA D revealed the nurses told the CNAs when there was a new resident, who was a fall risk, and the residents were also in a binder on the desk. She stated those residents were rounded on more frequently. She stated Resident #1 was particularly prone to sliding out of bed. She stated no matter how often she was positioned in the middle of the bed, with pillows behind her, she would eventually end up on one side of the bed. Interview on 09/03/25 at 2:35 PM with the DON revealed the resident fall risk assessments were conducted on admission and then quarterly thereafter unless there was a fall, in which case an assessment would be completed at that time. He stated Resident #1 should have had a fall risk assessment completed in June 2025 for her quarterly assessment and definitely after her fall on 08/20/25. He stated he did not know why neither one had been conducted.
Interview on 09/03/25 at 3:41 PM with LVN A via telephone revealed on 08/20/25 she positioned herself outside Resident #1's room because she liked to keep a closer eye on the resident. She stated she had returned to her desk outside Resident #1's room, after assisting another resident, and she saw the resident had fallen out of bed. She called for help, and several staff came to assist her with the resident. LVN A stated when she found the resident she noted the mattress overlay had slid off the bed with her. She stated
she had found the overlay unsecured before and had to secure it. She stated when she assessed the resident there were no bruises or obvious injuries. The resident was non-verbal but did not grimace when
she felt the resident for any injury or deformity. When she notified the Resident #1's Family Member, the Family Member insisted the resident be sent to the hospital to be assessed for any injuries. Record review of the facility's Fall Prevention Program policy, dated 08/15/22, reflected: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize
the likelihood of falls.2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk 4 . g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes.
Event ID:
Facility ID:
If continuation sheet
Fort Worth Transitional Care Center in Fort Worth, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Fort Worth, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Fort Worth Transitional Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.