8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fort Worth, TX
2-star overall rating with 1-star inspections with abuse icon flag with $300,219 in total fines with 8 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
7100 Trail Lake Dr, Fort Worth, TX
(817) 263-2224
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
2007-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 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
RN hours / resident day
0.50
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.72
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
12,836
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
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
0
Baseline 78.95% · Performance 78.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.04
Baseline 2.73 hours · Performance 3.51 hours · Measure score 2.04 · Achievement 1.50 · Improvement 2.04
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.99% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 24% · Lower 95% interval 8.73% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · 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 105 |
| Staff flu vaccination coverage | 11.32% |
42%
30.7 pts worse
|
Numerator 12 · Denominator 106 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
97.1%
1 pts worse
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 94.5% · Q3 96.0% · Q4 96.8% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
97.9%
2.7 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
2.7%
0.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 6.5% · Q4 1.9% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 17.3% |
18.9%
1.6 pts better
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 23.3% · Q3 17.6% · Q4 8.3% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.6% |
10.8%
3.2 pts better
|
16.7%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 0.0% · Q3 7.1% · Q4 13.5% · 4Q avg 7.6% · 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 | 9.4% |
15.4%
6 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
16.1%
4.5 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 18.9% · Q3 7.1% · Q4 5.0% · 4Q avg 11.6% · 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 | 10.1% |
15.0%
4.9 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.4% · Q3 11.6% · Q4 10.6% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.2%
0.7 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 9.7% · Q3 4.5% · Q4 2.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
89.7%
4.5 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 87.0% · Q3 93.8% · Q4 100.0% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
12.0%
1.6 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 16.7% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
88.0%
1 pts worse
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 6.3% |
25.9%
19.6 pts better
|
23.9%
17.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 8.3% · Expected 31.4% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-05-11
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-05-11
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-05-11
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-11
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-11
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-05-11
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-11
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-05-11
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-30
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2025-04-30
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-04-30
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 2025-04-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-30
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-25
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 2024-11-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-25
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-25
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-28
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-28
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-21
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-02
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
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-05
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 2025-05-09
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-09
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-05-09
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-25
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-11-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-25
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-18
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 2024-06-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-01
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-29
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-31
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-18
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-12-18
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-12-18
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-12-18
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-12-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-22
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-03
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-03
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-03
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-03
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-01
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-09
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-09
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-05-19
Penalties and ownership
Fine · fine $26,685
Fine
Fine · fine $217,565
Fine
Fine · fine $10,699
Fine
Fine · fine $5,375
Fine
Fine · fine $9,311
Fine
Fine · fine $12,124
Fine
Fine · fine $18,460
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Organization
Corporate Officer · Individual
Nearby options
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3-star overall rating with 2-star inspections with $35,552 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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2-star overall rating with 1-star inspections with $31,778 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Fort Worth, TX
2-star overall rating with 1-star inspections with $155,085 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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