3 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Worth, TX
5-star overall rating with 4-star inspections with 3 recent health deficiencies
2501 Museum Way, Fort Worth, TX
(817) 632-3600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
46
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Buckner Retirement Services
Operator or chain grouping
Approved since
2011-12-29
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 3 health / 4 staffing / 5 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
1.20
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.96
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
7,662
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.14% · Performance 22.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.09
Baseline 5.25% · Performance 6.61% · Measure score 4.09 · Achievement 4.09 · Improvement 0
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
4.64
Baseline 2.92 hours · Performance 4.39 hours · Measure score 4.64 · Achievement 4.61 · Improvement 4.64
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 328 · Observed rate 8.84% · Lower 95% interval 7.59% |
| Discharge to community | 58.81% |
50.57%
8.2 pts better
|
Better than the National Rate · Eligible stays 343 · Observed rate 55.69% · Lower 95% interval 53.77% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 233 · Denominator 233 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 233 |
| Discharge self-care score | 67.68% |
53.69%
14 pts better
|
Numerator 111 · Denominator 164 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 82 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 0.86% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 233 · Adjusted rate 0.94% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 212 · Observed rate 5.19% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 16.42% |
8.2%
8.2 pts better
|
Numerator 11 · Denominator 67 |
| Staff flu vaccination coverage | 98.48% |
42%
56.5 pts better
|
Numerator 65 · Denominator 66 |
| Discharge function score | 64.63% |
56.45%
8.2 pts better
|
Numerator 106 · Denominator 164 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 164 · Denominator 164 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 3.97% |
25.2%
21.2 pts worse
|
Numerator 5 · Denominator 126 |
Quality measures
| 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 · 4Q avg 100.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
18.9%
0.7 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.5% |
10.8%
6.3 pts better
|
16.7%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
16.1%
4 pts better
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.5%
1.9 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
0.8%
3.9 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
15.0%
10.8 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.2%
0.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
12.0%
4 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.4% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.9%
1.1 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 21.5% · Expected 20.6% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-14
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-11-25
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 2025-11-25
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-11-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-27
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-27
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 2024-12-02
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 2024-12-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-02
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-02
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-04
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-04
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-11
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 2024-10-04
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-15
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 2023-09-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
Fort Worth, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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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
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