Arbor Lake Nursing & Rehabilitation, LLC
901 Pennsylvania Ave, Fort Worth, TX 76104 · Tarrant County · 123 certified beds · avg 86 residents/day · certified since Mar 16, 1992
Abuse citation flag (CMS)
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 15, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 11, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 25, 2025 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 26, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 25, 2025 · F-0744 · triggered by a complaint
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 26, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 19, 2026 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Sep 8, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Jul 25, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 25, 2025 | ▲ G · Actual harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Jul 25, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 25, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 25, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 24, 2025 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Apr 15, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 25, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jun 3, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| May 9, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| May 9, 2024 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| May 9, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 9, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 9, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| May 9, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 9, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| May 9, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Jan 3, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 3, 2024 | D · Potential for harm, one-off | The facility did not provide or obtain x-rays and other imaging tests when ordered, or did not promptly tell the ordering doctor the results. · from a complaint |
| Jan 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Nov 9, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Apr 6, 2023 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 6, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 6, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 6, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 6, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 15 | 0 | E |
| 2025 | 11 | 3 | J ▲ |
| 2026 | 1 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $14,676, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jul 25, 2025 | Fine | $607 |
| Apr 15, 2025 | Fine | $14,069 |
| Apr 15, 2025 | Payment Denial | 27 days from May 15, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.69 | 3.46 | 3.95 | bottom 7% in Texas; bottom 6% in the U.S. |
| Registered Nurse hours | 0.53 | 0.44 | 0.69 | top 22% in Texas; bottom 43% in the U.S. |
| Weekend total nurse staffing | 2.39 | 3.04 | 3.50 | bottom 10% in Texas; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.63 | 0.34 | 0.48 | top 6% in Texas; top 21% in the U.S. |
| Total nursing staff turnover (%) | 52.7 | 55.3 | 45.8 | bottom 48% in Texas; bottom 30% in the U.S. |
| RN turnover (%) | 61.5 | 54.6 | 42.9 | bottom 38% in Texas; bottom 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.11, RN 0.62, weekend 2.76. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Frio Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2024 |
| 901 Pennsylvania Ave TX, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Arbor Lake Nursing & Rehabilitation LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Continuum Rehab Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Dailey, Elizabeth | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Garetz, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Gibraltar Trust | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Gurwitz, Solomon | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/26/2025 |
| Hagins, Elizabeth | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/09/2025 |
| Hansen Hunter LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2024 |
| Hansen Hunter LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/26/2025 |
| Kaplan, Esther | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/26/2025 |
| Kaplan, Mordechai | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/09/2025 |
| Larchmont Realty, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Lewis, Adolphus | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/1994 |
| Mindle, Adam | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/09/2025 |
| Montgomery Sky Trust | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Opco Ca Skilled Mgmt INC. | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Opco Texas Skilled Mgmt LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Ruff, Michael | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "How are residents' personal funds handled here, and what records can families review?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| DFW Nursing & Rehab | 0.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Downtown Health and Rehabilitation Center | 0.2 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| James L. West Center for Dementia Care | 0.8 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | abuse |
| Fort Worth Transitional Care Center | 0.8 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| Trinity Terrace | 0.9 mi | Fort Worth, TX | ★★★★★ | 5/5 | |
| The Stayton at Museum Way | 1.3 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Park View Care Center | 3.2 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| Stonegate Nursing and Rehabilitation | 3.5 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Arlington Heights Health and Rehabilitation Center | 3.5 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| River Oaks Health and Rehabilitation Center | 4.4 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuse |
| Tuskegee Airmen Texas State Veterans Home | 5.1 mi | Fort Worth, TX | —/5 | abuse | |
| Marine Creek Nursing & Rehabilitation | 5.3 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 675034.