Cycle 1
Health 2025-06-12 · Fire 2025-06-12
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fort Worth, TX
James L West Center for Dementia Care
2-star overall rating with 2-star inspections with abuse icon flag with $63,236 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1111 Summit Ave, Fort Worth, TX
(817) 877-1199
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
101
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2023-04-09
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing
LPN hours / resident day
1.40
Licensed practical nurse staffing
Aide hours / resident day
3.00
Nurse aide staffing
Weekend hours
4.42
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| 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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
97.1%
3.7 pts worse
|
93.4%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
97.9%
1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.3%
0.1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
2.7%
0.4 pts worse
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.7% |
3.3%
6.4 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.0% |
18.9%
19.1 pts worse
|
19.6%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 30.8% |
10.8%
20 pts worse
|
16.7%
14.1 pts worse
|
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 | 26.5% |
15.4%
11.1 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 44.8% |
16.1%
28.7 pts worse
|
14.9%
29.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
15.0%
5.3 pts worse
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.2%
2.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.3% |
89.7%
7.4 pts worse
|
81.7%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
12.0%
1.1 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 11.3% |
1.5%
9.8 pts worse
|
1.6%
9.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.7% |
88.0%
4.7 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.4% |
25.9%
15.5 pts better
|
23.9%
13.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-02-18 · Fire 2023-02-18
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-27
E · Potential for more than minimal harm
2025-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-11
C · Minimal harm
2025-06-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-11
C · Minimal harm
2024-04-18
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-05-29
C · Minimal harm
2024-04-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-02-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-09
Inspection history
Recent health citations
G · Actual harm
2025-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-11
E · Potential for more than minimal harm
2025-06-12
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 2025-07-15
E · Potential for more than minimal harm
2025-06-12
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 2025-07-15
E · Potential for more than minimal harm
2025-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-12
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 2025-07-15
J · Immediate jeopardy
2024-10-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-12
J · Immediate jeopardy
2024-10-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-12
J · Immediate jeopardy
2024-10-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-12
J · Immediate jeopardy
2024-10-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-10-11
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 2024-10-12
J · Immediate jeopardy
2024-08-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-29
J · Immediate jeopardy
2024-08-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-29
J · Immediate jeopardy
2024-04-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-04-18
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-05-17
D · Potential for more than minimal harm
2024-04-18
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-02-21
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 2024-03-14
D · Potential for more than minimal harm
2023-04-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-05
Penalties and ownership
What sits behind the stars
$15,015
2025-06-12
Fine
Fine · fine $15,015
Fine
$0
2025-06-12
Payment Denial
Payment Denial · denial start 2025-07-11 · 16 days
16 day denial
$17,242
2024-10-11
Fine
Fine · fine $17,242
Fine
$8,827
2024-08-06
Fine
Fine · fine $8,827
Fine
$9,872
2024-04-18
Fine
Fine · fine $9,872
Fine
$2,797
2023-10-30
Fine
Fine · fine $2,797
Fine
$2,447
2023-10-23
Fine
Fine · fine $2,447
Fine
$2,098
2023-10-17
Fine
Fine · fine $2,098
Fine
$1,764
2023-10-10
Fine
Fine · fine $1,764
Fine
$3,174
2023-09-18
Fine
Fine · fine $3,174
Fine
Ownership
James L West Presbyterian Special Care Center
5% Or Greater Direct Ownership Interest · Organization
Baldridge, Hunter
Operational/Managerial Control · Individual
Harding, Cheryl
Corporate Officer · Individual
Manuel, Tanisha
Operational/Managerial Control · Individual
Nearby options
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#2
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5-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Downtown Health And Rehabilitation Center
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
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