Cycle 1
Health 2025-06-11 · Fire 2025-06-11
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fort Worth, TX
Immanuel's Healthcare
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4515 Village Creek Rd, Fort Worth, TX
(817) 451-8704
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-05-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.26
Registered nurse staffing
LPN hours / resident day
0.74
Licensed practical nurse staffing
Aide hours / resident day
1.73
Nurse aide staffing
Weekend hours
2.55
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
97.9%
0.5 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
2.7%
3.8 pts worse
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.8% |
3.3%
0.5 pts worse
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
18.9%
6.5 pts better
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
10.8%
4 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.1% |
15.4%
10.3 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
16.1%
2.8 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.2%
1.4 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.5% |
89.7%
8.2 pts worse
|
81.7%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
12.0%
12 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
88.0%
8 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.5% |
25.9%
11.4 pts better
|
23.9%
9.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-06-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-06-11
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 2025-06-13
D · Potential for more than minimal harm
2025-06-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-13
E · Potential for more than minimal harm
2024-05-09
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 2024-06-21
E · Potential for more than minimal harm
2024-05-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-01-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-07
F · Potential for more than minimal harm
2023-03-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-23
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-02-10
D · Potential for more than minimal harm
2026-01-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-09-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-06
F · Potential for more than minimal harm
2025-06-11
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 2025-07-05
E · Potential for more than minimal harm
2025-06-11
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 2025-06-18
E · Potential for more than minimal harm
2025-06-11
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 2025-06-13
E · Potential for more than minimal harm
2025-06-11
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 2025-06-13
D · Potential for more than minimal harm
2025-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
D · Potential for more than minimal harm
2024-10-18
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 2024-11-12
E · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-06
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 2024-06-06
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 2024-06-06
D · Potential for more than minimal harm
2024-05-09
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 2024-06-06
D · Potential for more than minimal harm
2024-03-12
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 2024-04-04
E · Potential for more than minimal harm
2023-03-23
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-23
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 2023-04-20
Penalties and ownership
What sits behind the stars
Ownership
Thomas, Brian
5% Or Greater Direct Ownership Interest · Individual
Villa, Ricardo
5% Or Greater Direct Ownership Interest · Individual
Tgr Healthcare, LLC
Operational/Managerial Control · Organization
Thomas, Brian
Operational/Managerial Control · Individual
Villa, Ricardo
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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4-star overall rating with 4-star inspections with $19,009 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
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0-star overall rating with 0-star inspections with abuse icon flag with $21,645 in total fines with 1 fire-safety deficiencies in the latest cycle
#3
Green Oaks Nursing & Rehabilitation
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4-star overall rating with 3-star inspections with $83,850 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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