Cycle 1
Health 2025-08-21 · Fire 2025-08-21
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fort Worth, TX
Cityview Nursing and Rehabilitation Center
2-star overall rating with 1-star inspections with abuse icon flag with $234,014 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5801 Bryant Irvin Rd, Fort Worth, TX
(817) 346-3030
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
210
Certified beds
Average residents
169
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1996-07-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,950
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 18.59% · Performance 20.23% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Healthcare-associated infections
2.07
Baseline 7.77% · Performance 7.22% · Measure score 2.07 · Achievement 2.07 · Improvement 1.50
Total nurse turnover
4.77
Baseline 50.44% · Performance 44.20% · Measure score 4.77 · Achievement 4.77 · Improvement 1.94
Adjusted total nurse staffing
1.88
Baseline 3.23 hours · Performance 3.61 hours · Measure score 1.88 · Achievement 1.88 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.67% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 156 · Observed rate 13.46% · Lower 95% interval 8.62% |
| Discharge to community | 55.61% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 46.1% · Lower 95% interval 43.98% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.72% |
95.27%
3.5 pts better
|
Numerator 154 · Denominator 156 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 156 |
| Discharge self-care score | 50.86% |
53.69%
2.8 pts worse
|
Numerator 59 · Denominator 116 |
| Discharge mobility score | 38.79% |
50.94%
12.1 pts worse
|
Numerator 45 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 1.28% |
2.29%
1 pts better
|
Numerator 2 · Denominator 156 · Adjusted rate 1.18% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 7.46% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 177 |
| Staff flu vaccination coverage | 89.32% |
42%
47.3 pts better
|
Numerator 184 · Denominator 206 |
| Discharge function score | 42.24% |
56.45%
14.2 pts worse
|
Numerator 49 · Denominator 116 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 38 · Denominator 40 |
| Transfer of health information to patient | 96.84% |
96.28%
0.6 pts better
|
Numerator 92 · Denominator 95 |
| Resident COVID-19 vaccinations up to date | 45.83% |
25.2%
20.6 pts better
|
Numerator 33 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.9 · Expected 3.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.1
1.4 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.0 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
97.1%
3.4 pts worse
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.4% · Q3 92.5% · Q4 86.1% · 4Q avg 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
97.9%
6.5 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.3%
0.7 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.9% · Q3 2.7% · Q4 3.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
2.7%
0.7 pts worse
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 4.7% · Q3 4.2% · Q4 3.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
3.3%
1.3 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.1% · Q3 5.1% · Q4 3.4% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
18.9%
0.5 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.1% · Q3 17.8% · Q4 18.5% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
10.8%
4.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.5% · Q3 7.6% · Q4 5.1% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.6% |
15.4%
6.8 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 13.4% · Q3 10.8% · Q4 6.2% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
16.1%
5.6 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 13.4% · Q3 12.3% · Q4 10.3% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.5% · Q3 0.7% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
15.0%
2.6 pts worse
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 19.5% · Q3 17.5% · Q4 11.6% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.2%
2.4 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 1.5% · Q4 2.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
89.7%
7.8 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 97.7% · Q3 99.3% · Q4 96.9% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
12.0%
0.8 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
88.0%
6.4 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
25.9%
8.2 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 16.7% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-25 · Fire 2024-07-25
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
5 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-21
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-08-22
F · Potential for more than minimal harm
2025-08-21
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-08-22
F · Potential for more than minimal harm
2025-08-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-08-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-22
F · Potential for more than minimal harm
2024-07-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Not marked corrected
E · Potential for more than minimal harm
2025-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-22
K · Immediate jeopardy
2025-07-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-07-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-03
K · Immediate jeopardy
2025-01-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-01
D · Potential for more than minimal harm
2025-01-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-03
K · Immediate jeopardy
2024-09-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-18
K · Immediate jeopardy
2024-09-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-07-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-06-04
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-06-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-11
E · Potential for more than minimal harm
2024-02-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-21
F · Potential for more than minimal harm
2023-09-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-06-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-06-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-06-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-09
Penalties and ownership
What sits behind the stars
$173,713
2025-07-10
Fine
Fine · fine $173,713
Fine
$11,853
2025-01-31
Fine
Fine · fine $11,853
Fine
$48,448
2024-09-17
Fine
Fine · fine $48,448
Fine
Ownership
Decatur Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Adedokun, Ade
Operational/Managerial Control · Individual
Bakker, Jeff
Corporate Officer · Individual
Cocanougher, Charles
Corporate Officer · Individual
Cook, William
Corporate Officer · Individual
Duncum, John
Corporate Officer · Individual
Forbis, Christopher
Corporate Officer · Individual
Hance, Billie
Operational/Managerial Control · Individual
Montgomery, Kyndra
Operational/Managerial Control · Individual
Norris, John
Operational/Managerial Control · Individual
Sandford, William
Corporate Officer · Individual
Scroggins, Brian
Corporate Officer · Individual
Sicking, Jeffrey
Corporate Officer · Individual
Waggoner, Debra Sue
Corporate Officer · Individual
Williams, Carey
Corporate Officer · Individual
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