16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fort Worth, TX
2-star overall rating with 2-star inspections with abuse icon flag with $38,486 in total fines with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
424 S Adams St, Fort Worth, TX
(817) 335-5781
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
161
Certified beds
Average residents
106
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1986-04-23
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
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.39% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 18.18% · Lower 95% interval 7.47% |
| Discharge to community | 36.72% |
50.57%
13.9 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 19.35% · Lower 95% interval 22.86% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 20 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 9.52% |
2.29%
7.2 pts worse
|
Numerator 2 · Denominator 21 · Adjusted rate 9.52% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · 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 147 |
| Staff flu vaccination coverage | 80.65% |
42%
38.7 pts better
|
Numerator 200 · Denominator 248 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · 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 10 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
97.1%
0.2 pts worse
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.2% · Q3 97.1% · Q4 92.1% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
97.9%
1.2 pts worse
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.3%
1.4 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.2% · Q3 5.7% · Q4 2.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.1% · Q4 2.2% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
3.3%
1.3 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.9% · Q3 7.1% · Q4 5.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
18.9%
7.1 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 11.3% · Q3 11.0% · Q4 10.0% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
10.8%
3.4 pts worse
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.7% · Q3 14.8% · Q4 10.9% · 4Q avg 14.2% · 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 | 4.4% |
15.4%
11 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.6% · Q3 6.0% · Q4 2.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
16.1%
4.6 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 17.3% · Q3 11.3% · Q4 12.9% · 4Q avg 11.5% · 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 | 11.6% |
15.0%
3.4 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 9.4% · Q3 18.5% · Q4 12.6% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 6.4% · Q3 2.2% · Q4 1.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.4% |
89.7%
28.3 pts worse
|
81.7%
20.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.6% · Q2 63.8% · Q3 53.2% · Q4 43.1% · 4Q avg 61.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
12.0%
6.6 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.7% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.0% · Q3 0.0% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.3% |
88.0%
29.7 pts worse
|
79.7%
21.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
25.9%
1.1 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 27.6% · Expected 24.4% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-18
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-18
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-18
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-01-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-31
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-17
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-12-14
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 2023-12-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-14
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-29
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-15
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-02
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-30
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 2024-12-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-20
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-12-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-20
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-17
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-13
Health
Provide appropriate foot care.
Corrected 2024-09-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-23
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-04-23
Health
Provide appropriate foot care.
Corrected 2024-04-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-23
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-23
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-20
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-12-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-14
Health
Dispose of garbage and refuse properly.
Corrected 2023-12-14
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-16
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 2023-07-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-27
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-10-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-07
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-07
Health
Provide or obtain dental services for each resident.
Corrected 2022-10-07
Penalties and ownership
Fine · fine $16,859
Fine
Fine · fine $10,225
Fine
Fine · fine $9,334
Fine
Fine · fine $2,068
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
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