Burleson, TX

Advanced Rehabilitation & Healthcare of Burleson

3-star overall rating with 3-star inspections with $22,121 in total fines with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

275 SE John Jones Drive, Burleson, TX

(817) 730-4603

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

121

Certified beds

Average residents

105

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Advanced Healthcare Solutions

Operator or chain grouping

Approved since

2021-01-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.27

Registered nurse staffing

LPN hours / resident day

1.00

Licensed practical nurse staffing

Aide hours / resident day

2.04

Nurse aide staffing

Weekend hours

2.86

Weekend nurse staffing

RN turnover

60%

Annual RN turnover

Total nurse turnover

61%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	2.0	2.1 0.1 pts better	1.8 0.2 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	3.3% 0.1 pts better	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	2.2%	2.7% 0.5 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	4.4%	3.3% 1.1 pts worse	5.4% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.1%	18.9% 5.8 pts better	19.6% 6.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	3.8%	10.8% 7 pts better	16.7% 12.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	17.9%	15.4% 2.5 pts worse	16.3% 1.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	15.2%	16.1% 0.9 pts better	14.9% 0.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.5% 0.1 pts worse	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.8%	15.0% 0.2 pts better	19.8% 5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	5.3%	4.2% 1.1 pts worse	5.1% 0.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	89.7% 9.9 pts better	81.7% 17.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	4.9%	12.0% 7.1 pts better	12.0% 7.1 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.5% 0.5 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.0%	88.0% 10 pts better	79.7% 18.3 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.5%	25.9% 0.4 pts better	23.9% 1.6 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-22 · Fire 2024-08-22

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 2 Health 2023-06-29 · Fire 2023-06-29

5 health deficiencies

Top issue: Resident Rights (2 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-05-12 · Fire 2022-05-12

1 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-08-22

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-22

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-22

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-22

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-02

F · Potential for more than minimal harm 2024-08-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-02

F · Potential for more than minimal harm 2024-08-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-22

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-10-04

F · Potential for more than minimal harm 2024-08-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-09-10

F · Potential for more than minimal harm 2023-06-29

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-11-25

F · Potential for more than minimal harm 2023-06-29

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-11-25

F · Potential for more than minimal harm 2023-06-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-25

E · Potential for more than minimal harm 2023-06-29

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-11-25

E · Potential for more than minimal harm 2023-06-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-11-25

F · Potential for more than minimal harm 2022-05-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-01-05

F · Potential for more than minimal harm 2022-05-12

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-02-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-30

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Not marked corrected

D · Potential for more than minimal harm 2026-01-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Not marked corrected

D · Potential for more than minimal harm 2025-05-27

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-30

D · Potential for more than minimal harm 2025-05-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-06-30

E · Potential for more than minimal harm 2024-08-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-04

D · Potential for more than minimal harm 2024-08-22

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-10-04

K · Immediate jeopardy 2024-05-31

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-05-29

D · Potential for more than minimal harm 2024-05-23

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-06-17

D · Potential for more than minimal harm 2024-05-23

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-06-17

D · Potential for more than minimal harm 2024-05-23

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-06-17

E · Potential for more than minimal harm 2023-06-29

F776 · Administration Deficiencies

Health

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Corrected 2023-07-20

D · Potential for more than minimal harm 2022-05-12

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-06-02

Penalties and ownership