Downtown Health and Rehabilitation Center
424 South Adams Street, Fort Worth, TX 76104 · Tarrant County · 161 certified beds · avg 99 residents/day · certified since Apr 23, 1986
Abuse citation flag (CMS)
Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)
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.
2/5
Health inspection rating (on-site)
3
Serious findings on record
$36,418
Fines, last 3 years
3.65
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
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 · Feb 11, 2025 · F-0600 · triggered by a complaint
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 (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: Dec 29, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 5, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: Feb 15, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Sep 26, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: Sep 16, 2023 (Past Non-Compliance)
All citations in the current public record (52)
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 |
|---|---|---|
| Jun 16, 2026 | 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. · from a complaint |
| Jun 16, 2026 | 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 |
| May 7, 2026 | D · Potential for 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. · from a complaint |
| May 7, 2026 | 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 |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 12, 2026 | F · Potential for harm, facility-wide | 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. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted. |
| Mar 12, 2026 | 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. |
| Feb 17, 2026 | 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 |
| Nov 25, 2025 | D · Potential for 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. · from a complaint |
| May 14, 2025 | E · Potential for harm, repeated | 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 |
| May 14, 2025 | 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 |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 8, 2025 | 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. · from a complaint |
| May 8, 2025 | 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 |
| May 4, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Apr 1, 2025 | D · Potential for harm, 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 1, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Feb 11, 2025 | ▲ J · Immediate jeopardy, 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. · from a complaint |
| Dec 23, 2024 | D · Potential for harm, one-off | 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 |
| Dec 19, 2024 | E · Potential for harm, repeated | 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. |
| Dec 19, 2024 | 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. |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint |
| Dec 19, 2024 | 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. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 4, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| Dec 4, 2024 | 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. · from a complaint |
| Sep 12, 2024 | E · Potential for harm, repeated | 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 |
| Sep 5, 2024 | E · Potential for harm, repeated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| Sep 5, 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 |
| Jul 24, 2024 | 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. · from a complaint |
| Jul 24, 2024 | E · Potential for harm, repeated | 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 27, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Apr 27, 2024 | E · Potential for harm, repeated | 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 20, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Apr 20, 2024 | E · Potential for harm, repeated | 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 20, 2024 | D · Potential for harm, one-off | The facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed. · from a complaint |
| Apr 7, 2024 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| Mar 5, 2024 | ▲ G · Actual 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 |
| Feb 21, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Feb 21, 2024 | 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 |
| Feb 21, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 19, 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. · from a complaint |
| Dec 19, 2023 | D · Potential for harm, 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 |
| Nov 15, 2023 | D · Potential for harm, one-off | The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. |
| Nov 15, 2023 | D · Potential for harm, one-off | 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. |
| Nov 15, 2023 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. |
| Nov 15, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Sep 26, 2023 | ▲ G · Actual 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 |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 1 | G ▲ |
| 2024 | 25 | 1 | G ▲ |
| 2025 | 10 | 1 | J ▲ |
| 2026 | 10 | 0 | F |
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)
3 fines totaling $36,418.
| Date | Type | Amount / length |
|---|---|---|
| Dec 19, 2024 | Fine | $16,859 |
| Feb 21, 2024 | Fine | $10,225 |
| Sep 26, 2023 | Fine | $9,334 |
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) | 3.65 | 3.46 | 3.95 | top 27% in Texas; bottom 44% in the U.S. |
| Registered Nurse hours | 0.39 | 0.44 | 0.69 | top 49% in Texas; bottom 21% in the U.S. |
| Weekend total nurse staffing | 3.19 | 3.04 | 3.50 | top 29% in Texas; bottom 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.13 | 0.34 | 0.48 | bottom 7% in Texas; bottom 4% in the U.S. |
| Total nursing staff turnover (%) | 93.6 | 55.3 | 45.8 | bottom 8% in Texas; bottom 1% in the U.S. |
| RN turnover (%) | 88.9 | 54.6 | 42.9 | bottom 12% in Texas; bottom 2% 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 3.24, RN 0.35, weekend 2.83. 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: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Fannin County Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/31/2017 |
| Akinmerese, Olawale | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2025 |
| Blake, Gary | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2022 |
| Blake, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2022 |
| Blake, Malisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2022 |
| Ford, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 04/12/2025 |
| Fort Worth IV Enterprises, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2022 |
| Fort Worth IV Enterprises, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2022 |
| Holt, Erin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/25/2020 |
| Huggins, Linda | Individual | Corporate Director | NOT APPLICABLE | 11/01/2022 |
| Keeton, Wendy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/29/2012 |
| Kissling, Monica | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/21/2017 |
| McBean, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/30/2021 |
| Sanderson, Clark | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/29/2012 |
| Sanderson, Clark | Individual | Corporate Officer | NOT APPLICABLE | 10/29/2012 |
| Trompler, Kelly | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/22/2022 |
| Willig, Zachary | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "When a new resident arrives, how do you make sure the doctor's orders for their care and medications are in place from day one?"
- "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 |
|---|---|---|---|---|---|
| Arbor Lake Nursing & Rehabilitation, LLC | 0.2 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | abuse |
| DFW Nursing & Rehab | 0.3 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| James L. West Center for Dementia Care | 0.6 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | abuse |
| Trinity Terrace | 0.7 mi | Fort Worth, TX | ★★★★★ | 5/5 | |
| Fort Worth Transitional Care Center | 0.8 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| The Stayton at Museum Way | 1.1 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Park View Care Center | 3.3 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| Arlington Heights Health and Rehabilitation Center | 3.4 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Stonegate Nursing and Rehabilitation | 3.5 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| River Oaks Health and Rehabilitation Center | 4.2 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuse |
| Marine Creek Nursing & Rehabilitation | 5.1 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Fort Worth Wellness & Rehabilitation | 5.1 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 455651.