Cycle 1
Health 2025-07-25 · Fire 2025-07-25
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Worth, TX
Arbor Lake Nursing & Rehabilitation, LLC
2-star overall rating with 2-star inspections with abuse icon flag with $14,667 in total fines with 11 recent health deficiencies
901 Pennsylvania Ave, Fort Worth, TX
(817) 335-3030
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
123
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
1992-03-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.95
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.80
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,322
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.45
Performance 19.83% · Measure score 3.45 · Achievement 3.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 7.24% · Performance 8.50% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.21
Baseline 78.87% · Performance 48.05% · Measure score 5.21 · Achievement 3.82 · Improvement 5.21
Adjusted total nurse staffing
0.94
Baseline 3.58 hours · Performance 3.34 hours · Measure score 0.94 · Achievement 0.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 15.07% · Lower 95% interval 8.22% |
| Discharge to community | 47.66% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 36.36% · Lower 95% interval 34.32% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 58 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 73.53% |
53.69%
19.8 pts better
|
Numerator 25 · Denominator 34 |
| Discharge mobility score | 61.76% |
50.94%
10.8 pts better
|
Numerator 21 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 60 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.5% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 2.04% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 98 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 58.82% |
56.45%
2.4 pts better
|
Numerator 20 · Denominator 34 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.1 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
97.1%
2.2 pts worse
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 95.8% · Q3 100.0% · Q4 89.7% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
97.9%
5.7 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 2.7% · Q4 2.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
2.7%
1.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
3.3%
3.2 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.8% · Q3 1.4% · Q4 6.8% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
18.9%
6.6 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 8.8% · Q3 12.3% · Q4 14.7% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
10.8%
2.1 pts worse
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 7.4% · Q3 12.8% · Q4 16.1% · 4Q avg 12.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.6% |
15.4%
4.8 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.4% · Q3 21.9% · Q4 2.8% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
16.1%
1.3 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 3.1% · Q3 30.3% · Q4 14.7% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
15.0%
4.3 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 25.2% · Q3 19.4% · Q4 21.4% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.2%
3 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.6% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
89.7%
3.9 pts worse
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 91.5% · Q3 93.1% · Q4 67.1% · 4Q avg 85.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
12.0%
5.5 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.8% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.8% |
88.0%
11.2 pts worse
|
79.7%
2.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
25.9%
4.3 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 27.5% · Expected 30.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-09
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-06-23
E · Potential for more than minimal harm
2024-05-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-09
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-05-10
E · Potential for more than minimal harm
2023-04-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-04-09
E · Potential for more than minimal harm
2023-04-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-08
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-09-09
G · Actual harm
2025-07-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-26
G · Actual harm
2025-07-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-07-26
E · Potential for more than minimal harm
2025-07-25
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 2025-07-26
E · Potential for more than minimal harm
2025-07-25
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 2025-07-26
E · Potential for more than minimal harm
2025-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-26
D · Potential for more than minimal harm
2025-05-24
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-05-25
J · Immediate jeopardy
2025-04-15
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 2025-06-11
D · Potential for more than minimal harm
2025-04-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-04-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-11
D · Potential for more than minimal harm
2024-08-15
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-06-25
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 2024-06-26
D · Potential for more than minimal harm
2024-06-03
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-05-09
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 2024-05-10
E · Potential for more than minimal harm
2024-05-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-09
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 2024-05-10
E · Potential for more than minimal harm
2024-05-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-09
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 2024-05-10
D · Potential for more than minimal harm
2024-05-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-01-03
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 2024-01-04
D · Potential for more than minimal harm
2024-01-03
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-01-04
D · Potential for more than minimal harm
2024-01-03
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 2024-01-04
D · Potential for more than minimal harm
2023-11-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-04-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-04-06
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 2023-05-17
D · Potential for more than minimal harm
2023-04-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-06
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 2023-05-20
D · Potential for more than minimal harm
2023-04-06
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 2023-05-17
Penalties and ownership
What sits behind the stars
$598
2025-07-25
Fine
Fine · fine $598
Fine
$14,069
2025-04-15
Fine
Fine · fine $14,069
Fine
$0
2025-04-15
Payment Denial
Payment Denial · denial start 2025-05-15 · 27 days
27 day denial
Ownership
Frio Hospital District
5% Or Greater Direct Ownership Interest · Organization
Arbor Lake Nursing & Rehabilitation LLC
Operational/Managerial Control · Organization
Garetz, David
Operational/Managerial Control · Individual
Hansen Hunter LLC
Operational/Managerial Control · Organization
Ruff, Michael
Corporate Officer · Individual
Nearby options
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