Cycle 1
Health 2025-07-29 · Fire 2025-07-29
7 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Worth, TX
Mira Vista Court
1-star overall rating with 2-star inspections with abuse icon flag with $87,958 in total fines with 7 recent health deficiencies
7021 Bryant Irvin Rd, Fort Worth, TX
(817) 361-1400
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2005-10-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 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
0.18
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,718
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.82
Baseline 23.22% · Performance 22.41% · Measure score 0.82 · Achievement 0 · Improvement 0.82
Healthcare-associated infections
2.81
Baseline 7.67% · Performance 6.99% · Measure score 2.81 · Achievement 2.81 · Improvement 2.03
Total nurse turnover
4.12
Baseline 60.76% · Performance 46.84% · Measure score 4.12 · Achievement 4.12 · Improvement 3.38
Adjusted total nurse staffing
0
Baseline 3.08 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.47% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 21.5% · Lower 95% interval 9.09% |
| Discharge to community | 47.54% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 35.71% · Lower 95% interval 37.64% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 24 · Denominator 40 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 18 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 5.8% |
2.29%
3.5 pts worse
|
Numerator 4 · Denominator 69 · Adjusted rate 3.72% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 8.16% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 4.76% |
8.2%
3.4 pts worse
|
Numerator 5 · Denominator 105 |
| Staff flu vaccination coverage | 33.33% |
42%
8.7 pts worse
|
Numerator 32 · Denominator 96 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 24 · Denominator 40 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 91.3% |
96.28%
5 pts worse
|
Numerator 21 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.3 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
97.1%
1 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 97.8% · Q4 95.3% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
97.9%
1.1 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.3%
0.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.1% · Q3 4.5% · Q4 4.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
2.7%
0.9 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 1.3% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
18.9%
About the same
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 17.4% · Q3 19.0% · Q4 20.0% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
10.8%
0.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 14.9% · Q3 9.2% · Q4 6.7% · 4Q avg 10.5% · 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 | 7.5% |
15.4%
7.9 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.6% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
16.1%
10.7 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.1% · Q3 6.8% · Q4 5.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
15.0%
1.7 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 10.4% · Q3 6.8% · Q4 14.2% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.2%
0.6 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.7% · Q3 4.4% · Q4 6.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.4% |
89.7%
56.3 pts worse
|
81.7%
48.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.0% · Q2 30.0% · Q3 35.0% · Q4 23.5% · 4Q avg 33.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
12.0%
4.6 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.0% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.5%
1.9 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.2% · Q3 2.0% · Q4 2.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.7% |
88.0%
49.3 pts worse
|
79.7%
41 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
25.9%
9.3 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.0% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
15 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-30 · Fire 2023-03-30
13 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
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
2024-05-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-05-31
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 2024-05-31
F · Potential for more than minimal harm
2024-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-05-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-08
E · Potential for more than minimal harm
2024-05-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
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 2025-11-22
D · Potential for more than minimal harm
2025-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-22
E · Potential for more than minimal harm
2025-07-29
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 2025-08-01
D · Potential for more than minimal harm
2025-07-29
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 2025-08-01
D · Potential for more than minimal harm
2025-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-13
G · Actual harm
2025-01-08
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 2024-12-17
E · Potential for more than minimal harm
2024-10-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-16
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-28
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 2024-09-13
D · Potential for more than minimal harm
2024-06-08
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 2024-06-09
E · Potential for more than minimal harm
2024-05-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-05-31
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-06-08
E · Potential for more than minimal harm
2024-05-31
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 2024-06-05
E · Potential for more than minimal harm
2024-05-31
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 2024-06-05
E · Potential for more than minimal harm
2024-05-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-31
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 2024-06-05
D · Potential for more than minimal harm
2024-05-31
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 2024-06-05
D · Potential for more than minimal harm
2024-05-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-03-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-03-20
D · Potential for more than minimal harm
2023-10-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-14
F · Potential for more than minimal harm
2023-10-03
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 2023-10-10
K · Immediate jeopardy
2023-09-15
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-09-29
K · Immediate jeopardy
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-04-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-30
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 2023-04-07
D · Potential for more than minimal harm
2023-03-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-30
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 2023-04-07
D · Potential for more than minimal harm
2023-03-30
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 2023-04-07
Penalties and ownership
What sits behind the stars
$9,110
2025-01-08
Fine
Fine · fine $9,110
Fine
$78,848
2023-08-31
Fine
Fine · fine $78,848
Fine
$0
2023-08-31
Payment Denial
Payment Denial · denial start 2023-10-13 · 1 days
1 day denial
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Baldridge, Hunter
Operational/Managerial Control · Individual
Bryant Irvin Consulting LLC
Operational/Managerial Control · Organization
Castaneda, Edmundo
Corporate Director · Individual
Nearby options
Other facilities in reach
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Garden Terrace Healthcare Center Of Fort Worth
Fort Worth, TX
3-star overall rating with 2-star inspections with $34,405 in total fines with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Cityview Nursing and Rehabilitation Center
Fort Worth, TX
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
#3
Wedgewood Nursing Home
Fort Worth, TX
2-star overall rating with 1-star inspections with $31,778 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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