5801 Bryant Irvin Rd, Fort Worth, TX 76132 · Tarrant County · (817) 346-3030
210 certified beds, about 184 residents a day · Non profit - Corporation · Medicare and Medicaid since 1996
CMS Care Compare ratings, data as of September 1, 2026 · CCN 675622 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 21, 2025, inspectors cited 6 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 42 health citations since June 2023, 4 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 3 fines totaling $234,014 in the last three years; the largest was $173,713, and the latest is dated July 10, 2025.
Nurses and nurse aides worked 3.34 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.42 of those hours.
38.0% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to Wellsential Health, an affiliated group of 67 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 42 health citations on file.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. -The facility failed to ensure Resident #1, who was diagnosed with congestive heart failure, had physician orders in place for fluid restrictions and daily weights. This failure could place residents at risk for worsening of condition, which could lead to serious harm.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a clean and comfortable environment by providing clean bed linens that are in good condition for 1 of 7 resident (Resident #1) reviewed for safe environment. The facility failed to ensure Resident #1' s bedding was changed when it was saturated in urine. This failure could place the resident at risk of skin breakdown and decreased feelings of self-worth.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needs respiratory care, is provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Residents #19 and #37) reviewed for non-invasive ventilation care.1. The facility failed to ensure there were physician orders for the use of Resident #19's BiPAP machine, which is a non-invasive ventilation machine that is capable of generating two adjustable pressure levels.2 The facility failed to ensure there were physician orders for the use of Resident #37's CPAP machine, which is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure. [...]
Inspectors wroteBased on interview, and record review, the facility failed to provide residents and responsible parties the right to participate in the development and implementation of their person-centered plan of care for 1 of 9 residents (Resident #14) reviewed for quarterly care plans. The facility failed to provide Resident #14 and responsible parties with 4 quarterly care plan conference meetings for the last 12 months. Resident #14's last care plan meeting was dated 08/02/24. This failure could place residents at risk of not receiving inadequate interventions individualized to their care needs.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident of 9 residents (Resident #74) reviewed for care plans. The facility failed to develop a care plan addressing Resident #74's preference to provide self-care for his colostomy (an opening in the colon that lets stool pass from the body without going through the anus). The failure placed residents at risk of not having their care preferences care planned which could result in decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 9 residents (Resident #14) for care plan revisions. The facility failed to review and revise Resident #14's comprehensive care plan after the MDS assessment was completed on 05/10/25. Resident #14's last care plan meeting was dated 08/02/24. This failure placed residents at risk of not having their individual needs met.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 18 residents (Resident #74) reviewed for foot care. The facility failed to ensure Resident #74's toenails were clipped. This failure could result in residents developing fungal infections or other podiatric problems.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #14) reviewed for pharmacy procedures.1. ADON B failed to follow the facility policy of flushing Resident #14's gastrostomy tube with 5-10 mL (or prescribed amount) of water between medications, when she administered medication through gastronomy tube (feeding tube). 2. ADON B failed to check for residual through aspiration before administering medication to Resident #14. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to be free of abuse for 3 of 5 residents (Residents #6, #7 and #8) reviewed for abuse. The facility failed to ensure Residents #7 and #8 had the right to be free from abuse when Resident #6 hit Resident #7 in the face on 06/26/25 and put his hands around Resident #8's neck on 07/02/25. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm . The failure placed residents at risk for abuse.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 5 residents (Residents #1, #2, #3, #4, and #5) of 20 residents reviewed for accommodation of needs. The facility failed to ensure call lights were placed within reach of Residents #1, #2, #3, #4, and #5. This failures could place residents at risk of harm or inability to call for help. Observations on 7/10/25 from 11:03 AM-11:54 AM of the 300 and 400 Halls revealed call light cords were not within reach of Residents #1, #2, #3, #4, and #5. Resident #1's cord was stored in her bedside dresser. Resident #2's cord was under her mattress. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 resident (Residents #1 and #2) reviewed for supervision. The facility failed to provide adequate supervision to Residents #1 and #2, who both had severe cognitive impairment and resided on the facility's memory care unit. On 02/02/25, Resident #1 was found fully clothed in Resident #2's bed, and Resident #2 had no clothing on below the waist. The noncompliance was identified as PNC. The noncompliance began on 02/02/25 and ended on 02/03/25. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for abuse.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 6 (Resident #3, #4, and #5) residents reviewed for use of assistance devices for positioning and transfers. 1. On 01/13/25 Hospice Aide K failed to use a drawsheet when repositioning Resident #3 in bed and instead raised her up underneath her armpits hard to pull her up in bed and heard a loud crack or pop. The facility ordered x-rays, and it was determined the resident had sustained a displaced humeral neck fracture (shoulder/upper arm fracture) due to the improper transfer and failure to use a drawsheet to position her in bed. 2. The facility failed to ensure Hospice LVN BB and Hospice Aide CC used a transfer belt when transferring Resident #4 and Resident #5. An IJ was identified on 01/29/25. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from abuse for 1 of 10 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse when Resident #1 hit Resident #2 on both arms, causing a 9.0 cm x 6.0 cm bruise to the right forearm and a 11.0 cm x 7.0 cm bruise to the left forearm and a skin tear on the resident's middle finger, on 08/03/24 with a closed fist during a verbal altercation on the secured unit. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 08/03/24 and ended on 08/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for abuse and psychological harm.
Inspectors wroteBased on observation, interview, and records review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to obtain physician orders for the intrathecal pain pump from the Pain Physician for Resident #1 upon admission on [DATE] for immediate care and needs. After the orders were obtained, the facility failed to assist Resident #1 with a patient controlled bolus as needed for breakthrough pain via a surgically implanted pain pump per the Pain Medicine Physician Orders dated 09/10/24 at 2:25 PM. [...]
Inspectors wroteBased on observation, interview, and records review, the facility failed to ensure that licensed nurses have the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan for one (Resident #1) of one resident reviewed for nursing care/services, in that: Prior to admission, the facility failed to determine the knowledge, competencies, or skill sets of nursing staff to meet the needs of Resident #1 with an intrathecal pain pump (a surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord). [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. This failure could place residents at risk for food contamination and food-borne illness.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly group meetings for 10 of 10 confidential residents reviewed for resident council. The facility failed to provide a private space for resident group meetings. This failure could place residents, who attended resident group meetings, at risk of not being able to voice concerns due to a lack of privacy.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 6 residents (Residents #334, #386, #88 and #109) reviewed for ADLs. 1. The facility failed to ensure Resident #334 received showers as scheduled. 2. The facility failed to ensure Resident #386 received showers as scheduled. 3. The facility failed to provide Resident #88 assistance with daily oral care. 4. The facility failed to provide Resident #109 assistance with daily oral care. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 (Resident #32 and Resident #88) of 6 residents reviewed for respiratory care, in that: The facility failed to obtain physician orders for Resident #32 and Resident #88 to receive oxygen. The facility failed to replace Resident #32's oxygen humidifier bottle when empty. The facility failed to replace Resident #88's nasal cannula when it was discolored and it was not dated. This deficient practice could affect resident who received oxygen therapy continuously placed him at-risk for respiratory infection, and ineffective treatment.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 4 (Resident #30, #75, #127 and #136) of 6 residents reviewed for dialysis. 1. The facility failed to maintain dialysis communication sheets for Residents #30, #75, #88, #127, and #136. This failure could place residents at risk of inadequate post dialysis care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Residents #35 and #246) of 6 residents reviewed for pharmaceutical services. 1. LVN F failed to follow physician orders for administering Exelon transdermal patch to Residents #35. 2. LVN K failed to follow the physician orders for administering medication to Resident # 246s, when he administered Nafcillin Sodium Injection Solution (Nafcillin Sodium) (antibiotic) 12g/1000mls intravenous to Resident #246. These failures could put residents at risk of not receiving their medications as ordered.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater on 2 errors of 27 opportunities for errors leading to 7.41% medication error rates for two (LVN F and LVN K) of four staff observed for medication pass. 1. The facility failed to ensure LVN F administered medications as ordered to Resident #35 by administering Exelon patch (a treatment for Parkinson and dementia) without removing the old patch on 7/23/24. 2. The facility failed to ensure LVN K properly administered medications as ordered to Resident #246 when administering Nafcillin 12gm/1000mls every 24 hours, LVN K did not ensure the bag was completely empty (discarded 400mls) before administered a new bag. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records that were complete and accurate for five (Resident #30, #18, #88, #75, and #127) of six residents reviewed for clinical records. 1. The facility failed to obtain a physician order for Dialysis for Resident #30. 2. The facility failed to obtain a physician order for Dialysis for Resident #18. 3. The facility failed to obtain a complete physician order for Dialysis for Resident #127. 4. The facility failed to obtain a physician order for Dialysis for Resident #88. 5. The facility failed to obtain a physician order for Dialysis for Resident #75. This failure could place residents at risk for incomplete and inaccurately documented medical record that included their progress treatment, services, and interventions.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Residents #25, #71, #103 and #244) of 10 residents reviewed for infection control. 1. The facility failed to provide signage and PPE for Resident #71, who was on Enhanced Barrier Precautions (EBP). 2. LVN L failed to don appropriate PPE (gowns) before providing bolus feeding to Resident #103, who was on Enhanced Barrier Precautions. 3. LVN K failed to perform hand hygiene, disinfect the blood pressure cuff between residents while monitoring blood pressure to Resident #25,and #244 and while administering medication to Residnet#25. [...]
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 6 (Rooms 321. 322, 323, 324, 325, 327) of 6 rooms reviewed for full visual privacy. The facility failed to ensure privacy curtains in rooms Rooms 321. 322, 323, 324, 325, 327 could provide full visual privacy for both residents. This failure could cause a decrease in feelings of self-worth by being exposed during cares.
Inspectors wroteBased on observations, record reviews, and interviews the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 4 (Residents # 93, #236, #243, and #435) of 8 residents reviewed for pest control. The facility failed to ensure Residents # 93, #236, #243, and #435 were free from risk of mosquito bites. This failure could place residents at risk of exposure to viruses spread by mosquitos.
Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #89) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #89 was given a SNFABN (SNFABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.
Inspectors wroteBased on interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 5 residents (Resident #9) reviewed for MDS assessment accuracy. The facility inaccurately coded Resident # 9's quarterly MDS assessment dated [DATE] for dialysis treatment when she was not receiving dialysis treatment. This failure could place residents at risk of not receiving care and services to meet their needs.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #136 and Resident #103) of 7 residents reviewed for comprehensive care plans. The facility failed to update Resident #136's care plan to address dialysis. The facility failed to update Resident #103's care plan to address fecal impaction (constipation). This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #71) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #71' catheter urine collection bag was kept off the floor and had a privacy cover. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for one (Resident #103) of three residents reviewed for gastrostomy tubes. LVN L failed to flush Resident #103's g-tube with 30ml of water before and after medication administration and provide 100 ml before and after his bolus feeding (feeding method using a syringe to deliver formula through feeding tube) as ordered by the physician. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.
Inspectors wroteBased on record review and interview, the facility failed to conduct and document a facility wide assessment that addressed the care required by the resident population and the facility's resources for 1 of 1 facility assessment, in that: -The facility assessment inaccurately reflected that there were no dialysis patients in the facility. -The facility assessment did not include contracts, memorandums of understanding, or other agreements with third parties to provide services for dialysis. This deficient practice could place residents at-risk for inadequate care or treatments due to an inaccurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure agreements pertaining to services furnished by outside resources specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility for 1 of 1 dialysis facilities reviewed for dialysis services. -The facility did not have a written agreement with the dialysis center for Resident #18. This failure could place residents requiring dialysis at risk for failure to receive dialysis services due to lack of coordination of care with a dialysis center and therefore potential physical harm and psychosocial harm.
Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 residents (Residents #109 and #119) reviewed for hospice services. The facility failed: 1. To obtain Resident #119's physician's order for hospice services. 2. To obtain Resident #109's physician's order to discharge from hospice services. [...]
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure residents have the right to receive visitors of his or her choosing on day and time of his or her choosing for 1 of 2 (Resident #2) residents reviewed for resident rights. The facility failed to ensure Resident #2 had the right to receive visits from Family Member #1 since 11/27/23 inside the facility. This failure placed residents at risk of isolation, decreased emotional wellbeing and diminished quality of life.
Inspectors wroteBased on interview and record review, the facility failed to prevent the release of resident-identifiable information to the public, and also failed to maintain medical records that were complete and accurate for 1 Resident #1) of 4 residents reviewed for clinical records. 1. On 11/23/23 LVN A discussed Resident #1's medical conditions with a family member not authorized to receive the information. 2. On 11/23/23 LVN A failed to accurately document Resident #1's disposition after she left AMA, as well as events leading up to Resident #1 leaving AMA. These failures could place residents at risk of incorrect or incomplete documentation of their conditions as well as the release of personal information that could be used for illicit purposes.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for contaminated sharps disposal bins, attached to 1 (LVN A) of 2 nurse medication carts and 1 of 1 Wound Care Carts, on Station Two Wing, reviewed for hazards in that: LVN A failed to ensure contaminated sharps in the sharps bin attached to the Nurse Medication Cart she was responsible for, on Station Two Wing, were below the full line. LVN B failed to ensure contaminated sharps in the sharps bin attached to the Wound Care Cart, on Station Two Wing, were below the full line. These failures placed residents at risk of being exposed to contaminated sharps and possible blood borne pathogens.
Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biological's were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of four (Medication Cart #1 and Medication Cart #2) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended, and medication cart #2's keys were secured by assigned RN. Both carts contained controlled medication lock box. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.
Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for the facility's only kitchen. The facility did not maintain an effective pest control program to ensure the facility was free from rodents in the kitchen and the kitchen's dry storage room. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.
Inspectors wroteBased on record review and interview, the facility failed to submit a discharge MDS assessment and transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State for four (Residents #2, #18, #129, and #140) of four residents reviewed for timely discharge MDS submission. The facility failed to successfully submit discharge MDS assessments for Residents #2, #18, #129, and #140 when they discharged from the facility. This failure could prevent communication about a resident's status from being transmitted to CMS and could interfere with residents receiving needed services after discharge.
Inspectors wroteBased on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance that is palatable, attractive, and at a safe and appetizing temperature for 8 of 11 residents (Resident #36, #46, #10, #125, #91, #121, #73, and a confidential resident) reviewed for regular diets. The facility failed to ensure that regular diets served were prepared by methods that conserve nutritive value, flavor, texture, and appearance. This could place residents on regular diets at risk for a decrease in quality of life and possible weight loss.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 11 residents (Resident #121 and Resident #36) reviewed for reasonable accommodation of needs. 1. The facility staff did not answer Resident #121's call light timely. 2. The facility staff did not place Resident #36's call light within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.
24 fire safety citations on file: 4 on August 21, 2025, 20 on July 25, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| July 10, 2025 | Fine | $173,713 |
| January 31, 2025 | Fine | $11,853 |
| September 17, 2024 | Fine | $48,448 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.34 | 3.39 | 3.86 |
| Registered nurses | 0.42 | 0.43 | 0.69 |
| All nursing staff on weekends | 3.01 | 2.98 | 3.42 |
| Nurse aides | 1.86 | ||
| Licensed practical nurses | 1.05 | ||
| Nursing staff turnover (share who left in a year) | 38.0% | 55.3% | 45.8% |
| Registered nurse turnover | 20.0% | 54.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.85 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.47 on weekdays and 3.01 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.47 in April to June 2025 to 3.34 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.34 | 0.42 | 3.47 | 3.01 | 0.0% | 0 of 90 | 184 |
| Oct to Dec 2025 | 3.28 | 0.40 | 3.42 | 2.93 | 0.0% | 0 of 92 | 180 |
| Jul to Sep 2025 | 3.47 | 0.43 | 3.59 | 3.17 | 0.0% | 0 of 92 | 169 |
| Apr to Jun 2025 | 3.47 | 0.42 | 3.59 | 3.17 | 0.0% | 0 of 91 | 174 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.0 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.9 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.8 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 5.9 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.3 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 7.4 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 17.8 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.2 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 2.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Cityview Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
55.6% this home
No different from the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 141 eligible stays.
11.7% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 156 eligible stays.
7.2% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 134 eligible stays.
48.9% this home
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 88 residents counted.
0.8% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 123 residents counted.
0.0% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 123 residents counted.
96.3% this home
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 80 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: DECATUR HOSPITAL AUTHORITY. CMS links this home to Wellsential Health, a group of 67 nursing homes averaging 2.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Decatur Hospital Authority | 5% or greater direct ownership interest | Organization | 100% | 08/31/2014 |
| Baird, Daniel | Managing control - governing body | Individual | 04/13/2021 | |
| Carvajal, Antonio | Managing control - governing body | Individual | 05/16/2024 | |
| Clapp, Barbara | Managing control - governing body | Individual | 06/01/2021 | |
| Cortese, Daren | Managing control - governing body | Individual | 08/10/2021 | |
| Gibson, Patricia | Managing control - governing body | Individual | 08/01/2021 | |
| Gonzales, Veronica | Managing control - governing body | Individual | 05/16/2024 | |
| Kaufman, Nicole | Managing control - governing body | Individual | 08/10/2021 | |
| Mandelbaum, Elliot | Managing control - governing body | Individual | 09/01/2022 | |
| Bakker, Jeff | Corporate officer | Individual | 04/02/2017 | |
| Cocanougher, Charles | Corporate officer | Individual | 10/24/2010 | |
| Cook, William | Corporate officer | Individual | 01/13/2014 | |
| Duncum, John | Corporate officer | Individual | 03/08/2010 | |
| Forbis, Christopher | Corporate officer | Individual | 10/03/1994 | |
| Sandford, William | Corporate officer | Individual | 12/10/2007 | |
| Scroggins, Brian | Corporate officer | Individual | 10/03/2014 | |
| Sicking, Jeffrey | Corporate officer | Individual | 12/15/2015 | |
| Waggoner, Debra Sue | Corporate officer | Individual | 12/10/2007 | |
| Williams, Carey | Corporate officer | Individual | 12/15/2015 | |
| Adedokun, Ade | Operational/managerial control | Individual | 01/01/2025 | |
| Hance, Billie | Operational/managerial control | Individual | 01/01/2025 | |
| Montgomery, Kyndra | Operational/managerial control | Individual | 01/01/2025 | |
| Norris, John | Operational/managerial control | Individual | 11/18/2024 | |
| 5801 Bryant Irvin Road, LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Csv Rhea Management Holdco, LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Decatur Hospital Authority | Adp of the SNF | Organization | 09/10/2025 | |
| Dwd Tx Holdings LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Jack and Nancy Dwyer Workforce Development Center Inc | Adp of the SNF | Organization | 10/01/2018 | |
| Reg Hg Opco 1, LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Reg Hg Opco LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Reg Master Tenant II, LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Reg Operator Holdco LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Regency IHS Clinical Consulting, LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Regency IHS of Cityview Fort Worth LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Regency IHS Rehab LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Regency Integrated Health Services LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Regency Texas Holdings LLC | Adp of the SNF | Organization | 10/01/2018 | |
| Adedokun, Ade | Adp of the SNF | Individual | 10/01/2018 | |
| Dekowski, Donovan | Adp of the SNF | Individual | 10/01/2018 | |
| Hance, Billie | Adp of the SNF | Individual | 01/01/2025 | |
| Montgomery, Kyndra | Adp of the SNF | Individual | 01/01/2025 | |
| Norris, John | Adp of the SNF | Individual | 11/18/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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