River Oaks Health and Rehabilitation Center
2416 NW 18th St, Fort Worth, TX 76106 · Tarrant County · 120 certified beds · avg 47 residents/day · certified since Apr 1, 1992
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.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · 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 · May 1, 2026 · 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: May 2, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 1, 2026 · 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: May 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 25, 2024 (Past Non-Compliance)
All citations in the current public record (38)
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 10, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| May 1, 2026 | ▲ 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 |
| May 1, 2026 | ▲ 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 |
| May 1, 2026 | 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 17, 2026 | 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. |
| Apr 17, 2026 | 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. |
| Apr 17, 2026 | 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 17, 2026 | 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 17, 2026 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Apr 17, 2026 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Apr 17, 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. |
| Dec 2, 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. · from a complaint |
| Jun 17, 2025 | 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 |
| Apr 24, 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 24, 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 |
| Apr 24, 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 |
| Jan 30, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 30, 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. |
| Dec 23, 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 |
| Dec 23, 2024 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Dec 23, 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 |
| Dec 11, 2024 | ▲ 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. · from a complaint |
| Dec 11, 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 |
| Feb 6, 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. · from a complaint |
| Jan 19, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Dec 7, 2023 | F · Potential for harm, facility-wide | 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 7, 2023 | 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 7, 2023 | E · Potential for harm, repeated | The facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed. |
| Dec 7, 2023 | 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. |
| Dec 7, 2023 | D · Potential for harm, one-off | 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 |
| Dec 7, 2023 | D · Potential for harm, one-off | 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. |
| Dec 7, 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. |
| Oct 17, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Oct 17, 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. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Oct 10, 2023 | 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 |
| Oct 10, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 10, 2023 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 0 | F |
| 2024 | 7 | 1 | G ▲ |
| 2025 | 7 | 0 | E |
| 2026 | 11 | 2 | J ▲ |
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 $60,095.
| Date | Type | Amount / length |
|---|---|---|
| Apr 17, 2026 | Fine | $52,036 |
| Dec 11, 2024 | Fine | $8,059 |
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) | 0.00 | 3.46 | 3.95 | — |
| Registered Nurse hours | 0.00 | 0.44 | 0.69 | — |
| Weekend total nurse staffing | 0.00 | 3.04 | 3.50 | — |
| Weekend RN hours (not acuity-adjusted) | 0.00 | 0.34 | 0.48 | — |
| Total nursing staff turnover (%) | 95.6 | 55.3 | 45.8 | bottom 5% in Texas; bottom 1% in the U.S. |
| RN turnover (%) | 100.0 | 54.6 | 42.9 | bottom 8% in Texas; bottom 1% 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 0.00, RN 0.00, weekend 0.00. 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: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Fort Worth VI Enterprises, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/2024 |
| Bass, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2025 |
| Blake, Gary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Blake, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Blake, Malisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Blake, Malisa | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Clanton, Auston | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Clanton, Auston | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Creative Solutions in Healthcare INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Creative Solutions in Healthcare INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Eamiguel, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Eamiguel, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Fort Worth VI Enterprises, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Huggins, Linda | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Huggins, Linda | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Villegas, Rachel | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2025 |
| Willig, Zachary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Willig, Zachary | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "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 |
|---|---|---|---|---|---|
| Fort Worth Wellness & Rehabilitation | 1.0 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | |
| Marine Creek Nursing & Rehabilitation | 1.6 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| The Stayton at Museum Way | 3.2 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Trinity Terrace | 3.5 mi | Fort Worth, TX | ★★★★★ | 5/5 | |
| James L. West Center for Dementia Care | 3.6 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | abuse |
| Fort Worth Transitional Care Center | 4.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| Lake Lodge Nursing & Rehabilitation | 4.1 mi | Lake Worth, TX | ★☆☆☆☆ | 2/5 | |
| Downtown Health and Rehabilitation Center | 4.2 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Arlington Heights Health and Rehabilitation Center | 4.4 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Arbor Lake Nursing & Rehabilitation, LLC | 4.4 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | abuse |
| DFW Nursing & Rehab | 4.5 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Ridgmar Medical Lodge | 4.5 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
All facilities in Fort Worth →
Facility data as of CMS processing date 2026-08-01. CCN 675018.