Fort Worth Transitional Care Center
850 12th Avenue, Fort Worth, TX 76104 · Tarrant County · 136 certified beds · avg 93 residents/day · certified since Jul 22, 2010
Part of chain: WELLSENTIAL HEALTH (67 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Apr 8, 2026 · F-0695
The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Apr 8, 2026 · F-0693
The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Why it matters: Unnecessary or poorly managed feeding tubes can cause serious complications like lung infections and take away the ability to eat normally.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 24, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 28, 2025 (Past Non-Compliance)
All citations in the current public record (46)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 8, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 8, 2026 | ▲ H · Actual harm, repeated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Apr 8, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 8, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 8, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 8, 2026 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Apr 8, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 3, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 24, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 24, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Apr 11, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 13, 2024 | E · Potential for harm, repeated | The facility did not verify that its nurse aides had completed their required training, or did not retrain aides who had been out of nurse aide work for 2 years. · from a complaint |
| Oct 30, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Oct 30, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Oct 30, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Aug 16, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Apr 30, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 30, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Apr 30, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Apr 30, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 14, 2023 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Dec 14, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 14, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Sep 18, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 21, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 21, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (13 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 11 | 0 | E |
| 2024 | 10 | 0 | E |
| 2025 | 18 | 1 | G ▲ |
| 2026 | 7 | 2 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $51,036.
| Date | Type | Amount / length |
|---|---|---|
| Apr 8, 2026 | Fine | $36,040 |
| Jun 24, 2025 | Fine | $8,964 |
| Aug 16, 2024 | Fine | $6,032 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.74 | 3.46 | 3.95 | bottom 9% in Texas; bottom 7% in the U.S. |
| Registered Nurse hours | 0.53 | 0.44 | 0.69 | top 22% in Texas; bottom 43% in the U.S. |
| Weekend total nurse staffing | 2.35 | 3.04 | 3.50 | bottom 8% in Texas; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.51 | 0.34 | 0.48 | top 12% in Texas; top 32% in the U.S. |
| Total nursing staff turnover (%) | 68.8 | 55.3 | 45.8 | bottom 20% in Texas; bottom 7% in the U.S. |
| RN turnover (%) | 65.2 | 54.6 | 42.9 | bottom 34% in Texas; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.09, RN 0.60, weekend 2.66. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Decatur Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/25/2014 |
| 850 12th Avenue, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Baird, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/13/2021 |
| Bakker, Jeff | Individual | Corporate Officer | NOT APPLICABLE | 04/02/2017 |
| Carvajal, Antonio | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
| Clapp, Barbara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2021 |
| Cocanougher, Charles | Individual | Corporate Officer | NOT APPLICABLE | 10/24/2010 |
| Cook, William | Individual | Corporate Officer | NOT APPLICABLE | 01/13/2014 |
| Cortese, Daren | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/10/2021 |
| Crow, Bradley | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/14/2025 |
| Crow, Bradley | Individual | ADP of the SNF | NOT APPLICABLE | 07/14/2025 |
| CSV Rhea Management Holdco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Decatur Hospital Authority | Organization | ADP of the SNF | NOT APPLICABLE | 03/04/2026 |
| Dekowski, Donovan | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Duncum, John | Individual | Corporate Officer | NOT APPLICABLE | 03/08/2010 |
| DWD TX Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Forbis, Christopher | Individual | Corporate Officer | NOT APPLICABLE | 10/03/1994 |
| Gessner, Bruce | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Gibson, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2021 |
| Gonzales, Veronica | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Downtown Health and Rehabilitation Center | 0.8 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| DFW Nursing & Rehab | 0.8 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Arbor Lake Nursing & Rehabilitation, LLC | 0.8 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | abuse |
| James L. West Center for Dementia Care | 0.9 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | abuse |
| The Stayton at Museum Way | 0.9 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Trinity Terrace | 1.0 mi | Fort Worth, TX | ★★★★★ | 5/5 | |
| Arlington Heights Health and Rehabilitation Center | 2.7 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Stonegate Nursing and Rehabilitation | 2.7 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Park View Care Center | 4.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| River Oaks Health and Rehabilitation Center | 4.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 676255.