Village Creek Nursing & Rehabilitation
3825 Village Creek Rd, Fort Worth, TX 76119 · Tarrant County · 100 certified beds · avg 88 residents/day · certified since May 29, 2003
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · 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 · Jul 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: May 8, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · May 25, 2024 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 26, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (20)
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 |
|---|---|---|
| Jul 2, 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 |
| Dec 3, 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 |
| Aug 14, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 14, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Aug 14, 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. |
| Aug 14, 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. |
| Jul 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 |
| Jul 11, 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. |
| Jul 11, 2024 | 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. |
| Jul 11, 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. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jul 11, 2024 | 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. |
| Jul 11, 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. |
| May 25, 2024 | ▲ G · Actual 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 |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jun 15, 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. |
| Jun 15, 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. |
| Jun 15, 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. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
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 | 6 | 0 | E |
| 2024 | 8 | 2 | J ▲ |
| 2025 | 5 | 0 | D |
| 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 $19,009.
| Date | Type | Amount / length |
|---|---|---|
| Jul 11, 2024 | Fine | $10,842 |
| May 25, 2024 | Fine | $8,167 |
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) | 2.46 | 3.46 | 3.95 | bottom 2% in Texas; bottom 3% in the U.S. |
| Registered Nurse hours | 0.40 | 0.44 | 0.69 | top 47% in Texas; bottom 22% in the U.S. |
| Weekend total nurse staffing | 2.22 | 3.04 | 3.50 | bottom 4% in Texas; bottom 4% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.34 | 0.48 | top 48% in Texas; bottom 32% in the U.S. |
| Total nursing staff turnover (%) | 51.4 | 55.3 | 45.8 | top 48% in Texas; bottom 33% in the U.S. |
| RN turnover (%) | 50.0 | 54.6 | 42.9 | top 41% in Texas; bottom 39% 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 2.87, RN 0.46, weekend 2.59. 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: 5/5 · short-stay residents: 4/5
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 |
| 3825 Village Creek Road, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Altitude Realty Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Continuum Rehab Group LLC | Organization | 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 |
| 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 | 01/01/1989 |
| 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 |
| Osborne, Gloria | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Ruff, Michael | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Unger, Jeffrey | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/26/2025 |
| Village Creek Nursing & Rehabilitation LLC | Organization | Operational/Managerial Control | 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.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "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 |
|---|---|---|---|---|---|
| Immanuel's Healthcare | 0.6 mi | Fort Worth, TX | ★★★☆☆ | 3/5 | |
| Park View Care Center | 3.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | |
| Green Oaks Nursing & Rehabilitation | 3.5 mi | Arlington, TX | ★★★☆☆ | 2/5 | |
| Tuskegee Airmen Texas State Veterans Home | 3.7 mi | Fort Worth, TX | —/5 | abuse | |
| Avir at Kennedale | 4.8 mi | Kennedale, TX | ★☆☆☆☆ | 2/5 | |
| DFW Nursing & Rehab | 5.4 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuseSFF |
| Arbor Lake Nursing & Rehabilitation, LLC | 5.4 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | abuse |
| Downtown Health and Rehabilitation Center | 5.6 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| James L. West Center for Dementia Care | 6.1 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | abuse |
| Fort Worth Transitional Care Center | 6.1 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675977.