Health inspection·December 3, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to must provide each resident with the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan by ensuring a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 assistance with timely incontinence care for at least 4 hours on 10/23/25, which resulted in Resident #1 being soaked with urine and soiled through her brief, draw sheet, and bed sheets. This failure could place the residents at risk for decreased feeling of self-worth, skin breakdown, and infection. Findings included: Record review of Resident #1's face sheet, dated 10/23/25, reflected Resident #1 admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Significant Change in Status MDS assessment, dated 09/25/25, reflected Resident #1 had moderate cognitive impairment, with a BIMS of 09. Resident #1 was noted to be dependent on staff for all transfers and substantial/maximum assistance with toileting. The MDS noted that Resident #1 was always incontinent of bowel and bladder. The resident's active diagnoses included hemiplegia (paralysis that affects one side of the body), seizure disorder (condition causing repeated seizures from abnormal brain activity), anxiety disorder (excessive fear or worry that can disrupt daily life), depression (condition causing persistent sadness and loss of interest), bipolar disorder (condition causing extreme mood swings between mania and depression), and cerebral palsy (disorder caused by brain damage that affects movement, muscle control, and coordination). Record review of Resident #1's care plan, dated 10/01/25, reflected Resident #1 had bowel and bladder incontinence. The care plan reflected: Intervention: Check resident every two hours and assist with toileting as needed. Problem: [Resident #1] has an ADL self-care performance deficit r/t weakness, impaired decision-making ability, impaired mobility, left sided weakness, cerebral palsy. Goal: The resident will improve current level of function in ADL's through the review date. Intervention:. Personal Hygiene/Oral Care: The resident requires max/total assist x 1 or 2 staff for personal hygiene and oral care. Toilet Use: The resident requires max/ total assist of 1 or 2 staff for toilet use. Transfer: The resident requires max/total assist of 1 or 2 staff for transferring. Observation and interview on 10/23/25 at 9:39 AM revealed a strong smell of urine in Resident #1's room. Resident #1 revealed she was currently wet and needed to be changed. Resident #1 stated the last time she had been changed was around 4:00 AM. Resident #1 stated she could not recall if she let a staff member know that she needed to be changed or the last time a staff member was in her room. Resident #1 stated she knew how to use the call light but preferred not to bother the staff. Observation and interview on 10/23/25 at 10:45 AM, revealed CNA A pulled back the sheets on Resident #1. CNA A stated the urine had soaked through the sheets. CNA A asked RN B to get new sheets before starting incontinence care. Residents Affected - Few Page 1 of 3 676255 676255 12/03/2025 Fort Worth Transitional Care Center 850 12th Avenue Fort Worth, TX 76104

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/23/25 at 10:50 AM, CNA A revealed night shift had changed Resident #1 last. CNA A stated she started her shift at 6:00 AM, but it was difficult to check on residents every 2 hours. She stated she had not checked on Resident #1 yet. Observation on 10/23/25 at 11:00 AM, revealed CNA A and RN B providing Resident #1 with incontinence care. When Resident #1 was turned onto her side during incontinence care, it was noted that urine had soaked through the resident's brief, draw sheet, fitted sheet, and was wet up to Resident #1's back and gown. When the fitted sheet was removed, there was a pool of urine on the mattress. No skin issues or redness was noted to Resident #1's perineal area. Interview on 10/23/25 at 11:07 AM, Resident #1 revealed she did not typically soak through the sheets. Resident #1 stated she had not been changed yet this shift, but she understood because staff got busy. Resident #1 stated she was happy with the care she received in the building and did not have concerns. Interview on 10/23/25 at 1:08 PM, CNA A revealed she was expected to perform rounds on all residents every 2 hours. CNA A stated she tried to check on residents every 2 hours, but that it could be hard to do that. She stated her assignment had changed which caused a delay. CNA A stated residents, who could use their call light, got incontinence care more frequently. CNA A stated dependent residents unable to use their call light still got incontinence care, but it could take longer. CNA A stated it was not normal for Resident #1 to have urine soaked through the sheets. She stated it was due to the resident lying in urine for a longer period. CNA A stated she had not changed Resident #1 on her shift yet, and Resident #1 told her the last time she had been changed was 4:00 AM. CNA A said it could have been around 7 hours since the last time she had been changed, but she could not confirm for sure. CNA A stated Resident #1 would usually let her know when she was wet, but she did not today. CNA A stated Resident #1 was fully incontinent and dependent upon staff to be changed. CNA A stated if Resident #1 was lying in urine or not being checked on every 2 hours, it put her at risk to have skin breakdown and get pressure sores. CNA A stated she had been employed at the facility for 2.5 weeks and had been trained during orientation to round on residents every 2 hours and to provide care as needed. Interview on 10/23/25 at 2:24 PM, RN B revealed she expected her CNAs to complete their rounds at least every 2 hours. RN B stated she did her own rounds to ensure that the CNAs rounds were completed. RN B stated it was not normal for Resident #1 to have urine wet through the sheets and up her back. RN B revealed Resident #1 was dependent and always incontinent of bladder and bowel. RN B stated she checked on Resident #1 around 7:00 AM, and Resident #1 was dry. RN B stated not changing Resident #1's brief when she was wet, put her at risk of urinary tract infections and skin breakdown. Interview on 10/23/25 at 3:52 PM, ADON C revealed she expected staff to complete rounds as frequently as possible, but at least every 2 hours. ADON C stated she did do frequent spot rounds at random times to ensure that staff rounds were completed. ADON C stated she did skin rounds earlier and checked Resident #1 around 7:00 AM and the resident was dry. ADON C stated Resident #1 should have been checked on again before 11:00 AM, since it was over 2 hours. ADON C revealed it was everyone's job to round on residents. ADON C stated leaving Resident #1 wet placed her at risk of skin breakdown and infections. Interview on 10/23/25 at 4:10 PM, the DON revealed she expected the staff to conduct rounds on residents at least every 2 hours. She stated residents with incontinence should be changed as often as possible and at a minimum of every 2 hours. The DON stated it was all staff's job to ensure that residents were being checked on every 2 hours. The DON stated leaving Resident #1 wet placed her as risk of developing pressure sores, infections, and skin breakdown. Record review of the facility's Perineal Care policy, implemented 10/24/22, reflected: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order promote cleanliness and comfort, prevent infection to the extent possible, and 676255 Page 2 of 3 676255 12/03/2025 Fort Worth Transitional Care Center 850 12th Avenue Fort Worth, TX 76104

F 0677 to prevent and assess for skin breakdown. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676255 Page 3 of 3