15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fort Worth, TX
2-star overall rating with 2-star inspections with abuse icon flag with $31,539 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
4825 Wellesley St, Fort Worth, TX
(817) 732-6608
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 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
RN hours / resident day
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
5,927
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.77
Baseline 54.00% · Performance 44.19% · Measure score 4.77 · Achievement 4.77 · Improvement 2.87
Adjusted total nurse staffing
2.14
Baseline 4.12 hours · Performance 3.69 hours · Measure score 2.14 · Achievement 2.14 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 11.32% · Lower 95% interval 6.77% |
| Discharge to community | 44.17% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 31.25% · Lower 95% interval 33.6% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 27 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 174 |
| Staff flu vaccination coverage | 6.05% |
42%
36 pts worse
|
Numerator 15 · Denominator 248 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.7 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
97.1%
1.9 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
97.9%
1.2 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.1% · Q3 3.1% · Q4 2.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 2.6% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
3.3%
2.1 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.1% · Q3 0.0% · Q4 1.1% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
18.9%
7.9 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 7.9% · Q3 12.5% · Q4 11.6% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
10.8%
9.2 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 26.2% · Q3 15.1% · Q4 14.5% · 4Q avg 20.0% · 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 | 20.3% |
15.4%
4.9 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 24.4% · Q3 9.7% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
16.1%
4.7 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 25.0% · Q3 17.6% · Q4 15.4% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.9% · Q4 0.8% · 4Q avg 0.7% · 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 | 22.2% |
15.0%
7.2 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 22.2% · Q3 17.7% · Q4 21.3% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.2%
0.6 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 4.0% · Q4 7.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
89.7%
2.2 pts worse
|
81.7%
5.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 83.5% · Q3 87.3% · Q4 90.3% · 4Q avg 87.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
12.0%
5.9 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 7.4% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
88.0%
3 pts worse
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
25.9%
2 pts better
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 25.9% · Expected 25.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-09-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-09-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-03
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-29
Inspection history
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-12-12
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-12
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-12
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-12-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-12
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-12-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-16
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-16
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-02-16
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-27
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-09-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-09
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 2024-01-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-10
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-10
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-10
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-05
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-11-05
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-09-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-25
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-25
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-25
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-09-25
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-18
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-30
Penalties and ownership
Fine · fine $8,281
Fine
Fine · fine $15,126
Fine
Fine · fine $8,132
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
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