James L. West Center for Dementia Care
1111 Summit Ave, Fort Worth, TX 76102 · Tarrant County · 112 certified beds · avg 99 residents/day · certified since Apr 9, 2023
Abuse citation flag (CMS)
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: 3/5
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 · Oct 11, 2024 · 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: Oct 12, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 11, 2024 · F-0604 · triggered by a complaint
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
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: Oct 12, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 11, 2024 · F-0607 · triggered by a complaint
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.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
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: Oct 12, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 11, 2024 · F-0610 · triggered by a complaint
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.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
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: Oct 12, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 6, 2024 · 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: Apr 29, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Aug 6, 2024 · F-0607 · triggered by a complaint
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.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
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: Apr 29, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Apr 26, 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 (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: Apr 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 12, 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: Oct 11, 2024 (Past Non-Compliance)
All citations in the current public record (17)
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 12, 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. |
| Jun 12, 2025 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 12, 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. |
| Jun 12, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 12, 2025 | 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. |
| Oct 11, 2024 | ▲ 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 |
| Oct 11, 2024 | ▲ J · Immediate jeopardy, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Oct 11, 2024 | ▲ J · Immediate jeopardy, 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 |
| Oct 11, 2024 | ▲ J · Immediate jeopardy, 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 |
| Oct 11, 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 |
| Aug 6, 2024 | ▲ 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 |
| Aug 6, 2024 | ▲ J · Immediate jeopardy, 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 |
| Apr 26, 2024 | ▲ J · Immediate jeopardy, 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 18, 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. |
| Apr 18, 2024 | 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. |
| Apr 18, 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. |
| Feb 21, 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. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 12 | 7 | J ▲ |
| 2025 | 5 | 1 | G ▲ |
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)
9 fines totaling $63,236, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jun 12, 2025 | Fine | $15,015 |
| Jun 12, 2025 | Payment Denial | 16 days from Jul 11, 2025 |
| Oct 11, 2024 | Fine | $17,242 |
| Aug 6, 2024 | Fine | $8,827 |
| Apr 18, 2024 | Fine | $9,872 |
| Oct 30, 2023 | Fine | $2,797 |
| Oct 23, 2023 | Fine | $2,447 |
| Oct 17, 2023 | Fine | $2,098 |
| Oct 10, 2023 | Fine | $1,764 |
| Sep 18, 2023 | Fine | $3,174 |
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) | 5.44 | 3.46 | 3.95 | top 3% in Texas; top 8% in the U.S. |
| Registered Nurse hours | 0.49 | 0.44 | 0.69 | top 27% in Texas; bottom 37% in the U.S. |
| Weekend total nurse staffing | 5.11 | 3.04 | 3.50 | top 2% in Texas; top 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.34 | 0.48 | bottom 48% in Texas; bottom 29% in the U.S. |
| Total nursing staff turnover (%) | 33.9 | 55.3 | 45.8 | top 10% in Texas; top 22% in the U.S. |
| RN turnover (%) | 14.3 | 54.6 | 42.9 | top 3% in Texas; top 7% 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 4.57, RN 0.42, weekend 4.30. Staffing rating: 4/5.
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: 4/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| James L West Presbyterian Special Care Center | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1993 |
| Baldridge, Hunter | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/15/2025 |
| Baldridge, Hunter | Individual | ADP of the SNF | NOT APPLICABLE | 09/15/2025 |
| Harding, Cheryl | Individual | Corporate Officer | NOT APPLICABLE | 02/26/2018 |
| Harding, Cheryl | Individual | ADP of the SNF | NOT APPLICABLE | 02/26/2018 |
| James L West Presbyterian Special Care Center | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/1993 |
| Knebl, Janice | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/1993 |
| Manuel, Tanisha | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/19/2022 |
| Manuel, Tanisha | Individual | ADP of the SNF | NOT APPLICABLE | 08/19/2022 |
| Ross, Sarah | Individual | ADP of the SNF | NOT APPLICABLE | 08/20/2020 |
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?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "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 |
|---|---|---|---|---|---|
| Trinity Terrace | 0.1 mi | Fort Worth, TX | ★★★★★ | 5/5 | |
| The Stayton at Museum Way | 0.6 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Downtown Health and Rehabilitation Center | 0.6 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Arbor Lake Nursing & Rehabilitation, LLC | 0.8 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | abuse |
| Fort Worth Transitional Care Center | 0.9 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| DFW Nursing & Rehab | 0.9 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Arlington Heights Health and Rehabilitation Center | 3.3 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 | 3.6 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuse |
| Park View Care Center | 3.7 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| Marine Creek Nursing & Rehabilitation | 4.5 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Fort Worth Wellness & Rehabilitation | 4.5 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 745019.