Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at James L West Center For Dementia Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically and verbally abused by a CNA, who pinned the resident's hands and used body weight to force compliance during care. The incident was captured on video and reported by the resident's representative, but the facility's administration initially failed to recognize the actions as abusive. The CNA, from an agency, was not trained by the facility, highlighting a gap in training for agency staff.
A resident with severe cognitive impairment was physically restrained by a CNA during care, despite the resident's refusal and distress. The CNA pinned the resident's arms and used body weight to hold the resident down, contrary to the facility's policy. The incident was reported by the resident's representative, leading to the identification of immediate jeopardy due to the failure to ensure the resident's right to be free from restraints.
A resident with severe cognitive impairment was physically abused by an agency CNA who was not trained on the facility's care protocols. The CNA used force and intimidation during care, which was captured on video by the resident's responsible party. The facility failed to provide necessary training to agency staff, leading to an Immediate Jeopardy situation.
A resident with severe cognitive impairment was reportedly abused by a CNA, who handled the resident roughly, leaving red marks on the resident's face. Despite video evidence provided by the resident's RP, the facility failed to thoroughly investigate the incident or prevent further abuse. The facility's staff, including the Administrator and DON, did not view the entire video footage and did not consider the actions abusive at the time. The facility also did not provide training to agency staff on handling resident refusals and abuse prevention, placing all residents at risk for abuse and psychosocial harm.
A resident with severe cognitive impairment was allegedly handled roughly by a CNA, resulting in red marks on the resident's face. The incident was observed by the resident's responsible party through a camera and reported to the facility's DON and ADON. Despite this, the facility did not report the incident to the State Survey Agency as required. The CNA involved was from an agency and had not received training from the facility on handling resident refusals.
A resident with severe cognitive impairment was verbally and physically abused by a CNA in a LTC facility. The incident, captured on video, showed the CNA slapping the resident during a struggle over a bed remote control. The resident, who followed the CNA into another room, was verbally provoked before being slapped. The facility was informed by a family member who witnessed the event via video, leading to the CNA's arrest.
A resident with severe cognitive impairment was slapped by a CNA during a verbal and physical altercation over a bed remote control. The incident was captured on video by another resident's representative and reported to the facility's DON and Administrator. The resident did not sustain visible injuries and did not recall the incident afterward. Interviews with staff revealed awareness of the facility's abuse policy, but the incident indicated a failure to adhere to these policies.
A resident on aspirin experienced an unwitnessed fall with a head injury and significant bleeding. Despite the apparent head injury, the resident was moved by an LVN and a CNA to a wheelchair and taken to the shower room for cleaning before a full assessment was completed. This action was contrary to the facility's fall protocol, which requires a complete assessment before moving a resident after a fall. The resident was later diagnosed with a displaced hip fracture requiring surgery.
The facility failed to update care plans for two residents, one unable to use the call light and another admitted with hospice care and a suprapubic catheter. This led to potential gaps in their care, as staff were unaware of the necessary updates.
The facility failed to enter physician orders for a resident's hospice and catheter care upon admission, leading to incomplete documentation and potential gaps in care. Despite staff claims that the resident did not miss any care, the admitting nurse did not follow the facility's policy on documenting necessary information.
A resident admitted with hospice care had an inaccurate MDS and care plan due to staff oversight and miscommunication. The resident's hospice status was not documented in the MDS or baseline care plan, and it was only updated a month later by the social worker.
A resident requiring a two-person transfer using a mechanical Hoyer lift was transferred by a single CNA, contrary to the resident's care plan and facility policy. This action, captured on camera, left the resident hanging in the air while the CNA sought assistance, placing the resident at risk of injury.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a CNA who physically and verbally abused a resident with severe cognitive impairment. The resident, who required moderate assistance for daily activities and had a history of dementia and depression, was subjected to inappropriate handling by the CNA. The CNA pinned the resident's hands and arms to the bed, used his body weight to force compliance, and verbally intimidated the resident during care. The incident was captured on video by the resident's representative, who reported the abuse to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). Despite being shown the video, the facility's administration initially failed to recognize the actions as abusive. The CNA involved claimed he was trained to continue care despite resident resistance, but this contradicted the facility's policy, which emphasized respecting resident refusals and ensuring their safety. Interviews with other staff members revealed that they were aware of the resident's tendency to refuse care and had been trained to respect such refusals. However, the CNA in question, who was from an agency and not trained by the facility, did not follow these protocols. The facility's lack of training for agency staff and the administration's initial dismissal of the abuse contributed to the deficiency, placing residents at risk for further abuse.
Failure to Ensure Resident's Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for the convenience of the staff rather than for medical treatment. This deficiency was identified during the review of an incident involving a resident with severe cognitive impairment and a history of dementia, depression, and muscle weakness. The resident required moderate assistance with daily activities and was sometimes resistant to care due to dementia. Despite this, the care plan included specific interventions to manage the resident's behavior, such as explaining procedures, using dementia-specific care techniques, and allowing the resident to participate in decision-making. On the day of the incident, a CNA was observed on video physically restraining the resident by pinning the resident's arms and using his body weight to hold the resident down while providing care. The resident was visibly distressed, attempting to resist and verbally expressing a desire for the CNA to leave. The CNA continued to restrain the resident despite the resident's refusal of care, which is against the facility's policy. The incident was reported by the resident's representative, who witnessed the event through a camera in the resident's room and reported it to the facility's administration. The facility's administration and DON were not fully aware of the extent of the incident, as they only viewed a small portion of the video. The CNA involved claimed that the resident was aggressive and that he had to restrain the resident to prevent harm. However, the facility's policy clearly states that staff should not restrain residents during care and should back away if a resident becomes combative. The failure to adhere to this policy resulted in the identification of an immediate jeopardy situation, highlighting the need for staff training and adherence to proper care protocols.
Failure to Prevent Abuse and Neglect of Resident
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prevent the neglect and abuse of residents, specifically in the case of a resident with severe cognitive impairment. The resident, who had a history of dementia and was sometimes resistant to care, was subjected to physical abuse by a CNA from an agency. The CNA pinned the resident's hands and arms to the bed, used his body weight to force compliance, and verbally intimidated the resident during care. This incident was captured on video by the resident's responsible party, who reported the abuse to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). The facility did not ensure that the agency CNA was trained on how to care for the resident, particularly in handling refusals of care and dementia-related behaviors. Interviews with facility staff revealed that they were trained to respect residents' rights to refuse care and to re-approach at a later time, but the agency CNA did not receive this training. The DON and Administrator acknowledged that agency staff were not provided with the facility's training, which contributed to the incident of abuse. The Administrator, who is also the abuse coordinator, initially did not recognize the actions as abusive until further review of the video evidence. The facility's failure to provide adequate training and oversight for agency staff, along with the lack of a specific policy to prevent abuse, placed residents at risk. The incident was identified as an Immediate Jeopardy (IJ) situation, indicating a serious threat to resident safety.
Failure to Investigate and Prevent Abuse in LTC Facility
Penalty
Summary
The facility failed to thoroughly investigate and prevent further potential abuse, neglect, exploitation, or mistreatment of a resident during an alleged abuse incident. The incident involved a resident with severe cognitive impairment who was reportedly handled roughly by a CNA, resulting in red marks on the resident's face. The resident's responsible party (RP) reported the incident to the facility, providing video evidence of the CNA's actions, which included restraining the resident and using body weight to force compliance during care. Despite the RP's concerns and evidence, the facility did not conduct a comprehensive investigation or take immediate action to prevent further abuse. The facility's staff, including the Administrator, DON, and ADON, were aware of the incident but failed to follow the facility's abuse policy. The Administrator and DON did not view the entire video footage provided by the RP, and the Administrator did not consider the actions abusive at the time. The DON acknowledged that the CNA's actions, such as pinning the resident's hands and using body weight, constituted abuse, yet no immediate investigation or reporting was conducted. The facility also did not provide training to agency staff, including the CNA involved, on handling resident refusals and abuse prevention. The CNA involved in the incident claimed to have been trained to continue providing care despite resident refusals and did not receive specific instructions on caring for the resident before the shift. The CNA reported being bitten and hit by the resident and believed the resident was experiencing PTSD. The facility's lack of investigation and failure to implement its abuse policy placed all residents at risk for abuse and psychosocial harm, as identified by the surveyors.
Failure to Report Abuse Allegation Involving Resident
Penalty
Summary
The facility failed to report an abuse allegation involving a resident who was allegedly handled roughly by a CNA, resulting in red marks on the resident's face. The incident was observed by the resident's responsible party (RP) through a camera in the resident's room. The RP reported the incident to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON), showing them a video of the incident and a picture of the resident's reddened face. Despite this, the facility did not report the incident to the State Survey Agency as required by state law. The resident involved in the incident was an elderly male with severe cognitive impairment, as indicated by a BIMS score of 4. His care plan noted that he had a self-care performance deficit related to dementia and was sometimes resistant to assistance with personal care. The care plan included interventions such as allowing sufficient time for dressing and using dementia-specific care techniques to alleviate fear and frustration. However, the CNA involved in the incident was from an agency and had not received training from the facility on handling resident refusals. Interviews with facility staff, including the Administrator, DON, and ADON, revealed that the facility's policy was not followed in this case. The Administrator, who was responsible for reporting and investigating abuse allegations, did not consider the incident abusive at the time and did not report it. The facility's use of agency staff without providing them with training on the facility's procedures contributed to the deficiency, as the CNA involved was not aware of the facility's protocol for handling resident refusals.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse, specifically verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with severe cognitive impairment, Alzheimer's disease, non-Alzheimer's dementia, and depression. The resident was involved in an altercation with CNA B, who verbally and physically abused her. The incident was captured on video by another resident's representative, showing CNA B slapping the resident during a struggle over a bed remote control. The resident, who was known to follow staff around, entered another resident's room where CNA B was present. A verbal exchange ensued, during which CNA B used inappropriate language and eventually slapped the resident. The resident responded by calling CNA B names and attempting to defend herself. The altercation continued with both parties struggling over the bed remote control until CNA B eventually walked away. The incident was reported by a family member who witnessed it via video surveillance. The facility's staff, including the Licensed Vocational Nurse (LVN) and Director of Nursing (DON), were informed, and the police were called. The resident was assessed and found to have no visible injuries or recollection of the incident. CNA B was removed from the floor and later arrested by the police. The facility's policy on abuse and neglect was reviewed, and it was noted that CNA B had no prior allegations of abuse against her.
Failure to Prevent Resident Abuse by CNA
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, specifically for one resident who was reviewed for abuse. The incident involved a certified nursing assistant (CNA) who was reported to have slapped a resident. The incident was captured on video by another resident's representative, who then reported it to the facility's Director of Nursing (DON) and Administrator. The video showed the CNA engaging in a verbal and physical altercation with the resident, which included the CNA slapping the resident across the face. The resident involved in the incident was an elderly female with severe cognitive impairment, Alzheimer's disease, non-Alzheimer's dementia, and depression. Her care plan included interventions to manage anxiety related to her dementia. On the day of the incident, the resident was in another resident's room when the CNA entered to change the bed linens. A struggle ensued over the bed's remote control, leading to the CNA slapping the resident. The resident did not sustain visible injuries and did not recall the incident afterward. Interviews with facility staff, including the Licensed Vocational Nurse (LVN) and the DON, revealed that the CNA had no prior allegations of abuse. The staff was aware of the facility's abuse policy and de-escalation techniques. The facility's policy on abuse, neglect, exploitation, and misappropriation of property was reviewed, but the incident indicated a failure to adhere to these policies, resulting in the abuse of the resident.
Failure to Follow Fall Protocols Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. A resident, who was on aspirin, experienced an unwitnessed fall resulting in a head injury and significant bleeding. Despite the apparent head injury, the resident was moved by an LVN and a CNA to a wheelchair and taken to the shower room for cleaning before a full assessment was completed. This action was contrary to the facility's fall protocol, which requires a complete assessment before moving a resident after a fall. The resident, who had severe cognitive impairment and was at high risk for falls, was found on the floor with a large laceration on the back of his head and a puddle of blood. The LVN, who was notified by the CNA, assessed the resident's vitals, which were normal, but did not perform a full assessment due to the excessive blood. The resident was then moved to a wheelchair and taken to the shower room for further assessment. It was only after the resident was cleaned that the LVN noted no other injuries besides the head laceration. The resident was later sent to the hospital, where a displaced hip fracture was diagnosed, requiring surgery. Interviews with the DON and ADON revealed that the LVN did not report being unable to complete an assessment before moving the resident. The facility's policy for assessing falls requires evaluating for possible injuries and completing a head-to-toe assessment before moving a resident. The failure to adhere to this protocol led to the identification of an Immediate Jeopardy situation, as the resident was moved without a proper assessment, potentially causing further harm.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise and review the care plan for two residents, leading to deficiencies in their care. Resident #2, a severely cognitively impaired male with a history of falls, was unable to use the call light system to request help. Despite multiple falls and being a high fall risk, his care plan was not updated to address his inability to use the call light. Staff interviews revealed that Resident #2 had been unable to use the call light for at least three months, and his care plan did not reflect this critical need for assistance, potentially compromising his safety and care quality. Resident #74, admitted with hospice care and a suprapubic catheter, also had deficiencies in his care plan. His baseline care plan did not mention hospice care, and his interim care plan incorrectly indicated he did not have a catheter. It was only a month after admission that his comprehensive care plan was updated to include hospice services, but it still failed to reflect his use of a suprapubic catheter. Interviews with staff, including the LVN, ADON, and Social Worker, revealed a lack of awareness and responsibility for ensuring the care plan accurately reflected Resident #74's needs, leading to potential gaps in his care. The facility's policy on care plans emphasizes the importance of timely and accurate updates to meet residents' needs. However, the failure to update and review the care plans for Residents #2 and #74 resulted in deficiencies that could lead to inadequate care. The staff's lack of coordination and communication regarding care plan updates contributed to these deficiencies, highlighting the need for improved processes to ensure residents receive appropriate and timely care.
Failure to Enter Physician Orders for Immediate Care
Penalty
Summary
The facility failed to ensure that Resident #74 had physician orders for immediate care upon admission. Specifically, the facility did not enter orders for the resident's hospice and catheter care. Resident #74, an [AGE] year-old male with diagnoses including Dementia, Type 2 Diabetes, Hypothyroidism, and Hypertension, was admitted with a suprapubic catheter and was supposed to be on hospice care. However, the admission records and baseline care plan did not reflect these needs accurately. The interim care plan and progress notes indicated discrepancies regarding the resident's hospice status and catheter care, leading to incomplete documentation and potential gaps in care. Interviews with facility staff, including an LVN, ADON, and DON, revealed that the admitting nurse was responsible for entering all orders from the hospital discharge paperwork, but failed to do so for Resident #74. The ADON and DON acknowledged that the orders for hospice care and catheter care were missed during the admission process and subsequent reviews. Despite these omissions, staff claimed that the resident did not miss any care due to the oversight. The facility's policy on admission notes requires the admitting nurse to document all necessary information, including physician orders, which was not adhered to in this case.
Failure to Update Care Plan for Hospice Resident
Penalty
Summary
The facility failed to revise and review the care plan for one resident, leading to an inaccurate Minimum Data Set (MDS) that did not indicate the resident was on hospice care. The resident, an elderly male with diagnoses including dementia, type 2 diabetes, hypothyroidism, and hypertension, was admitted to the facility with hospice care. However, the MDS dated after his admission did not reflect this, and the baseline care plan also failed to mention hospice care. It was only a month later that the comprehensive care plan was updated to include hospice services, after the social worker noticed the omission and updated the care plan accordingly. Interviews with various staff members, including an LVN, the ADON, the DON, and the social worker, revealed a lack of awareness and communication regarding the resident's hospice status. The admitting nurse was responsible for entering orders upon admission, but this did not happen correctly. The MDS Coordinator, who was responsible for ensuring the accuracy of MDS assessments, was unaware of the omission. The social worker eventually updated the care plan, but this was not her responsibility. This series of oversights and miscommunications led to the resident not having an accurate care plan that reflected his hospice care needs.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1, who required a two-person transfer using a mechanical Hoyer lift, was transferred by a single CNA. This action was captured on camera footage, which showed the CNA attempting to transfer the resident alone, leaving the resident hanging in the air while the CNA went to get assistance. The resident's care plan and MDS indicated that a two-person assist was necessary for transfers, and the facility's policy required two staff members for such transfers. Interviews with staff revealed that the CNA was aware of the requirement for two-person transfers but attempted the transfer alone to check if the Hoyer lift was functioning properly. The Director of Nursing was not aware of the incident until the interview and confirmed that staff were trained to use two people for Hoyer lift transfers. The facility's policy on safe lifting and movement of residents, revised in 2017, also mandated that only trained staff should perform such transfers. The failure to follow these protocols placed the resident at risk of injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Terrace | 0.1 mi | ★★★★★ | 0 | 0 |
| The Stayton At Museum Way | 0.6 mi | ★★★★★ | 3 | 0 |
| Downtown Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 10 | 0 |
| Arbor Lake Nursing & Rehabilitation, Llc | 0.8 mi | ★★★★★ | 2 | 0 |
| Fort Worth Transitional Care Center | 0.9 mi | ★★★★★ | 18 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.