Cycle 1
Health 2025-02-13 · Fire 2025-02-13
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fort Worth, TX
Fort Worth Transitional Care Center
2-star overall rating with 2-star inspections with $33,557 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
850 12Th Avenue, Fort Worth, TX
(817) 882-8289
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
136
Certified beds
Average residents
81
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
2010-07-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 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
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.65
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
0.70
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,506
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.28% · Performance 22.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.07
Baseline 5.96% · Performance 7.52% · Measure score 1.07 · Achievement 1.07 · Improvement 0
Total nurse turnover
0.18
Baseline 68.66% · Performance 65.67% · Measure score 0.18 · Achievement 0 · Improvement 0.18
Adjusted total nurse staffing
0.50
Baseline 2.88 hours · Performance 3.17 hours · Measure score 0.50 · Achievement 0 · Improvement 0.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.45% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 18.1% · Lower 95% interval 7.46% |
| Discharge to community | 54.85% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 39.29% · Lower 95% interval 42.78% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 95 · Denominator 95 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 95 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 24 · Denominator 48 |
| Discharge mobility score | 60.42% |
50.94%
9.5 pts better
|
Numerator 29 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 6.32% |
2.29%
4 pts worse
|
Numerator 6 · Denominator 95 · Adjusted rate 5.19% |
| Healthcare-associated infections requiring hospitalization | 7.52% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 11.76% · Lower 95% interval 4.95% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | 20% |
42%
22 pts worse
|
Numerator 45 · Denominator 225 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 28 · Denominator 48 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | 94.87% |
96.28%
1.4 pts worse
|
Numerator 37 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 7.32% |
25.2%
17.9 pts worse
|
Numerator 3 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.3%
0.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.1% · Q3 1.5% · Q4 4.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
2.7%
0.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.9% · Q4 3.9% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
3.3%
3.7 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 14.5% · Q4 5.8% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
18.9%
1.9 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 17.2% · Q3 16.9% · Q4 16.4% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
10.8%
1.3 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.0% · Q3 11.5% · Q4 12.2% · 4Q avg 9.5% · 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 | 6.1% |
15.4%
9.3 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.5% · Q3 8.1% · Q4 4.7% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
16.1%
10.3 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 5.6% · Q4 11.5% · 4Q avg 5.8% · 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 | 14.6% |
15.0%
0.4 pts better
|
19.8%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 23.2% · Q3 13.1% · Q4 11.1% · 4Q avg 14.6% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.2%
2.1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.7% · Q3 5.9% · Q4 4.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.7%
9.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 98.3% · Q3 98.4% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.0% |
12.0%
9 pts worse
|
12.0%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 25.4% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 2.5% · Q4 2.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
88.0%
7.7 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
25.9%
5.8 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 40.3% · Expected 30.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-19 · Fire 2022-10-19
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-12-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-22
F · Potential for more than minimal harm
2023-12-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-22
F · Potential for more than minimal harm
2023-12-14
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 2024-01-22
D · Potential for more than minimal harm
2023-12-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-22
F · Potential for more than minimal harm
2022-10-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
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 2025-12-04
D · Potential for more than minimal harm
2025-09-03
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 2025-09-04
G · Actual harm
2025-06-24
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 2025-05-28
D · Potential for more than minimal harm
2025-06-24
F693 · Quality of Life and Care Deficiencies
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 2025-06-25
D · Potential for more than minimal harm
2025-04-11
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-02-13
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 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F756 · Pharmacy Service Deficiencies
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 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F803 · Nutrition and Dietary Deficiencies
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 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-02-13
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 2025-02-14
E · Potential for more than minimal harm
2025-02-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-02-13
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 2025-02-14
D · Potential for more than minimal harm
2025-02-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-02-13
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 2025-02-14
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-12-13
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-10-30
F693 · Quality of Life and Care Deficiencies
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 2024-11-04
D · Potential for more than minimal harm
2024-10-30
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-08-16
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-06-26
F690 · Quality of Life and Care Deficiencies
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 2024-07-19
E · Potential for more than minimal harm
2024-04-30
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 2024-06-07
E · Potential for more than minimal harm
2024-04-30
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 2024-06-07
D · Potential for more than minimal harm
2024-04-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-30
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 2024-06-07
E · Potential for more than minimal harm
2023-12-14
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 2024-01-02
E · Potential for more than minimal harm
2023-12-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-14
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 2024-01-02
D · Potential for more than minimal harm
2023-12-14
F693 · Quality of Life and Care Deficiencies
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 2024-01-02
D · Potential for more than minimal harm
2023-12-14
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 2024-01-02
D · Potential for more than minimal harm
2023-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-14
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 2024-01-02
D · Potential for more than minimal harm
2023-11-30
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 2023-12-01
D · Potential for more than minimal harm
2023-09-18
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 2023-09-19
D · Potential for more than minimal harm
2023-08-21
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 2023-08-22
D · Potential for more than minimal harm
2023-08-21
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 2023-08-22
J · Immediate jeopardy
2023-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-07-21
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 2023-07-22
D · Potential for more than minimal harm
2023-07-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-22
E · Potential for more than minimal harm
2023-05-23
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 2023-06-15
E · Potential for more than minimal harm
2023-05-23
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 2023-06-15
G · Actual harm
2022-10-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-21
F · Potential for more than minimal harm
2022-10-19
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 2022-10-21
E · Potential for more than minimal harm
2022-10-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-10-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-10-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-10-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-10-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-10-19
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 2022-10-21
Penalties and ownership
What sits behind the stars
$13,790
2025-06-24
Fine
Fine · fine $13,790
Fine
$6,032
2024-08-16
Fine
Fine · fine $6,032
Fine
$13,735
2023-07-21
Fine
Fine · fine $13,735
Fine
$0
2023-07-21
Payment Denial
Payment Denial · denial start 2023-08-19 · 3 days
3 day denial
Ownership
Decatur Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Bakker, Jeff
Corporate Officer · Individual
Cholico, Christopher
W-2 Managing Employee · Individual
Cocanougher, Charles
Corporate Director · Individual
Cook, William
Corporate Director · Individual
Dekowski, Donovan
Operational/Managerial Control · Individual
Duncum, John
Corporate Director · Individual
Forbis, Christopher
Corporate Director · Individual
Regency Ihs Of Fort Worth LLC
Operational/Managerial Control · Organization
Sandford, William
Corporate Director · Individual
Scroggins, Brian
Operational/Managerial Control · Individual
Scroggins, Brian
Corporate Director · Individual
Scroggins, Brian
Corporate Officer · Individual
Scroggins, Brian
W-2 Managing Employee · Individual
Sicking, Jeffrey
Corporate Officer · Individual
Waggoner, Debra Sue
Corporate Director · Individual
Williams, Carey
Corporate Officer · Individual
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DFW Nursing & Rehab
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#3
Arbor Lake Nursing & Rehabilitation, LLC
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2-star overall rating with 2-star inspections with abuse icon flag with $14,667 in total fines with 11 recent health deficiencies
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