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
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
0.33
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.42
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
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
5.53
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,041
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0158
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Performance 19.71% · Measure score 3.71 · Achievement 3.71 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.49
Performance 6.49% · Measure score 4.49 · Achievement 4.49 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Performance 6.67 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 1.92% · Lower 95% interval 5.86% |
| Discharge to community | 45.85% |
50.57%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 41.86% · Lower 95% interval 35.85% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 71 · Denominator 72 |
| Falls with major injury | 5.56% |
0.77%
4.8 pts worse
|
Numerator 4 · Denominator 72 |
| Discharge self-care score | 49.09% |
53.69%
4.6 pts worse
|
Numerator 27 · Denominator 55 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 30 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 3.28% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 18.95% |
8.2%
10.8 pts better
|
Numerator 29 · Denominator 153 |
| Staff flu vaccination coverage | 44.57% |
42%
2.6 pts better
|
Numerator 78 · Denominator 175 |
| Discharge function score | 58.18% |
56.45%
1.7 pts better
|
Numerator 32 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 65.79% |
96.28%
30.5 pts worse
|
Numerator 25 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 18.75% |
25.2%
6.4 pts worse
|
Numerator 6 · Denominator 32 |
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 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| 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 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 87.8% · Q2 100.0% · Q3 100.0% · Q4 86.4% · 4Q avg 93.4% |
| 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 · 4Q avg 98.9% |
| 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 · Q1 3.3% · Q2 1.2% · Q3 4.5% · Q4 4.5% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 3.4% · Q2 2.5% · Q3 2.5% · Q4 3.8% · 4Q avg 3.1% |
| 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 · Q1 13.5% · Q2 12.3% · Q3 7.2% · Q4 5.8% · 4Q avg 9.7% |
| 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 · Q1 50.7% · Q2 39.4% · Q3 30.6% · Q4 31.0% · 4Q avg 38.0% |
| 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 · Q1 31.9% · Q2 31.8% · Q3 33.3% · Q4 26.1% · 4Q avg 30.8% · 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 | 26.5% |
15.4%
11.1 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 34.6% · Q3 18.0% · Q4 14.9% · 4Q avg 26.5% · Used in QM five-star |
| 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 · Q1 49.3% · Q2 55.2% · Q3 35.5% · Q4 39.7% · 4Q avg 44.8% · Used in QM five-star |
| 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 · Q1 0.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| 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 · Q1 1.1% · Q2 1.2% · Q3 4.7% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 22.9% · Q2 21.6% · Q3 15.5% · Q4 21.0% · 4Q avg 20.3% |
| 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 · Q1 1.2% · Q2 3.4% · Q3 1.9% · Q4 2.1% · 4Q avg 2.1% · Used in QM five-star |
| 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 · Q1 59.7% · Q2 91.1% · Q3 98.7% · Q4 80.0% · 4Q avg 82.3% |
| 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 · Adjusted 13.1% · Observed 16.9% · Expected 14.4% · Used in QM five-star |
| 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 · Q1 16.2% · Q2 12.8% · Q3 7.7% · Q4 8.6% · 4Q avg 11.3% · Used in QM five-star |
| 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 · 4Q avg 92.7% |
| 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 · Adjusted 10.4% · Observed 10.8% · Expected 24.8% · Used in QM five-star |
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
Other facilities in reach
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Trinity Terrace
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
The Stayton At Museum Way
Fort Worth, TX
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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