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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.43

Registered nurse staffing

LPN hours / resident day

1.11

Licensed practical nurse staffing

Aide hours / resident day

1.92

Nurse aide staffing

Weekend hours

3.17

Weekend nurse staffing

RN turnover

43%

Annual RN turnover

Total nurse turnover

51%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

100% 9 facilities 2014-08-31

Adedokun, Ade

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01

Bakker, Jeff

Corporate Officer · Individual

0% 2 facilities 2017-04-02

Cocanougher, Charles

Corporate Officer · Individual

0% 2 facilities 2010-10-24

Cook, William

Corporate Officer · Individual

0% 2 facilities 2014-01-13

Duncum, John

Corporate Officer · Individual

0% 2 facilities 2010-03-08

Forbis, Christopher

Corporate Officer · Individual

0% 2 facilities 1994-10-03

Hance, Billie

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01

Montgomery, Kyndra

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01

Norris, John

Operational/Managerial Control · Individual

0% 3 facilities 2024-11-18

Sandford, William

Corporate Officer · Individual

0% 2 facilities 2007-12-10

Scroggins, Brian

Corporate Officer · Individual

0% 10 facilities 2014-10-03

Sicking, Jeffrey

Corporate Officer · Individual

0% 2 facilities 2015-12-15

Waggoner, Debra Sue

Corporate Officer · Individual

0% 2 facilities 2007-12-10

Williams, Carey

Corporate Officer · Individual

0% 2 facilities 2015-12-15

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