Cityview Nursing and Rehabilitation Center
5801 Bryant Irvin Rd, Fort Worth, TX 76132 · Tarrant County · 210 certified beds · avg 184 residents/day · certified since Jul 30, 1996
Part of chain: WELLSENTIAL HEALTH (67 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jul 10, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 11, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jan 31, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 1, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Sep 17, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Sep 18, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Sep 17, 2024 · F-0726 · triggered by a complaint
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Sep 18, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (41)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 10, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 10, 2025 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jun 17, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 31, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 31, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 17, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Sep 17, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Jul 25, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed. · from a complaint |
| Jul 25, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. · from a complaint |
| Jul 25, 2024 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jun 4, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint |
| Jun 4, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 20, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Sep 15, 2023 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jun 8, 2023 | E · Potential for harm, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jun 8, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 8, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (19 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | F |
| 2024 | 25 | 2 | K ▲ |
| 2025 | 11 | 2 | K ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $234,014.
| Date | Type | Amount / length |
|---|---|---|
| Jul 10, 2025 | Fine | $173,713 |
| Jan 31, 2025 | Fine | $11,853 |
| Sep 17, 2024 | Fine | $48,448 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.33 | 3.46 | 3.95 | top 49% in Texas; bottom 28% in the U.S. |
| Registered Nurse hours | 0.42 | 0.44 | 0.69 | top 42% in Texas; bottom 26% in the U.S. |
| Weekend total nurse staffing | 3.00 | 3.04 | 3.50 | top 42% in Texas; bottom 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.34 | 0.48 | top 47% in Texas; bottom 33% in the U.S. |
| Total nursing staff turnover (%) | 38.0 | 55.3 | 45.8 | top 16% in Texas; top 31% in the U.S. |
| RN turnover (%) | 20.0 | 54.6 | 42.9 | top 6% in Texas; top 13% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.34, RN 0.42, weekend 3.01. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Decatur Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/31/2014 |
| 5801 Bryant Irvin Road, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Adedokun, Ade | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Adedokun, Ade | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Baird, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/13/2021 |
| Bakker, Jeff | Individual | Corporate Officer | NOT APPLICABLE | 04/02/2017 |
| Carvajal, Antonio | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
| Clapp, Barbara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2021 |
| Cocanougher, Charles | Individual | Corporate Officer | NOT APPLICABLE | 10/24/2010 |
| Cook, William | Individual | Corporate Officer | NOT APPLICABLE | 01/13/2014 |
| Cortese, Daren | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/10/2021 |
| CSV Rhea Management Holdco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Decatur Hospital Authority | Organization | ADP of the SNF | NOT APPLICABLE | 09/10/2025 |
| Dekowski, Donovan | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Duncum, John | Individual | Corporate Officer | NOT APPLICABLE | 03/08/2010 |
| DWD TX Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Forbis, Christopher | Individual | Corporate Officer | NOT APPLICABLE | 10/03/1994 |
| Gibson, Patricia | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2021 |
| Gonzales, Veronica | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/16/2024 |
| Hance, Billie | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How are residents and families included in care plan meetings, and how often do those meetings happen?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Garden Terrace Healthcare Center of Fort Worth | 0.3 mi | Fort Worth, TX | ★★★★☆ | 3/5 | |
| Ignite Medical Resort Fort Worth, LLC | 0.9 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | |
| Mira Vista Court | 1.2 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Wedgewood Nursing Home | 1.2 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Ft. Worth Southwest Nursing Center | 1.8 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Renaissance Park Multi Care Center | 1.9 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Avir at Fort Worth | 2.0 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | abuse |
| Benbrook Nursing & Rehabilitation Center | 2.7 mi | Benbrook, TX | ★☆☆☆☆ | 1/5 | abuse |
| Stonegate Nursing and Rehabilitation | 3.8 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Arlington Heights Health and Rehabilitation Center | 4.4 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Ridgmar Medical Lodge | 5.0 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Willow Ridge Wellness & Rehabilitation | 5.6 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675622.