Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Ridge Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Three cognitively impaired, functionally dependent residents with fall risk care-plan interventions requiring call lights to be within reach were observed with their call lights inaccessible: one resident in bed had the call light tucked at the foot of the bed, another sitting by the sink had the call light positioned behind the bed’s headboard and reported difficulty reaching and pulling it, and a third resident in bed had the call light lying on the floor while housekeeping was preparing to clean the room, contrary to facility policy and staff expectations that call lights remain accessible.
A resident with COPD and moderately impaired cognition had her oxygen tubing and nebulizer mouthpiece left unbagged and exposed on her bed and bedside table when not in use. Staff interviews revealed inconsistent practices and understanding regarding the proper storage of respiratory equipment, and the resident's care plan and facility policy were not consistently followed, resulting in a failure to meet infection control standards.
A resident with multiple chronic conditions and severe cognitive impairment developed a left heel wound, but the care plan was not updated to include this new issue or the physician-ordered wound care interventions. Staff interviews confirmed that care plans should be revised to reflect changes in condition, but this did not occur, resulting in a lack of documented guidance for the resident's wound care needs.
A resident with muscle weakness, lack of coordination, and dizziness experienced a fall, but the care plan was not updated to address fall risk. Despite documentation of the incident and staff acknowledgment of the need for fall-related interventions, the care plan did not include measurable objectives or actions for fall prevention, contrary to facility policy.
The facility failed to ensure call lights were accessible to three residents, preventing them from obtaining assistance when needed. A resident with severe cognitive impairment had her call light on the floor, another had his stuck between the bed and wall, and a third found his unreachable on the wall after being moved to a new room. Staff acknowledged the importance of call lights but did not consistently ensure they were within reach.
The facility failed to implement comprehensive care plans for three residents with indwelling catheters, each lacking appropriate interventions. One resident had a catheter for a sacral wound but only had an intervention to check for kinks. Another resident with urinary retention had a care plan limited to monitoring for infection signs. The third resident, with a prostate history, had a care plan that only monitored discomfort. These deficiencies were noted despite physician orders for regular catheter care.
The facility failed to properly store respiratory equipment for four residents, leading to potential risks of infection. A resident's nebulizer mask was found unbagged and in contact with a sanitizer bottle, while another resident's nasal cannula tubing was on the floor. Similar issues were observed with two other residents' equipment. Staff interviews confirmed the need for proper storage to prevent contamination, but the facility's policy was not provided.
The facility failed to maintain a clean and homelike environment for residents, with observations revealing dirty air conditioning vents and unclean conditions in six rooms. Staff acknowledged the difficulty in cleaning the vents and recognized potential health risks. The facility's policy emphasizes a clean and orderly environment, which was not upheld.
A facility failed to ensure residents were free from unauthorized physical restraints. Four residents with severe cognitive impairments and total dependence on assistance were found with scoop or bolster mattresses on their beds without physician orders or assessments. The facility's policy requires physician authorization for such restraints, which was not obtained, leading to a deficiency in providing a restraint-free environment.
The facility's kitchen failed to meet food safety standards, with staff not wearing appropriate hair and beard coverings, and food items improperly labeled and stored. Sanitation issues were noted, including dirty ice scoop holders and bins. Food transported to resident areas was uncovered, risking contamination. The Dietary Manager acknowledged these deficiencies.
The facility failed to maintain effective infection control during incontinent care for two residents. CNAs did not change gloves or perform hand hygiene after touching contaminated surfaces and before handling clean items. One CNA also failed to wash hands after leaving and re-entering a resident's room. These actions were inconsistent with the facility's infection control policies.
A resident with impaired cognition was found with pointed scissors in their room, posing a risk of injury. The resident used the scissors for cutting paper and briefs, but staff were unaware of the latter use. The facility lacked a policy on sharp objects, contributing to the deficiency in maintaining a safe environment.
A facility failed to secure confidential medical records for two residents, leading to a breach of privacy. An RN left her laptop open during medication administration and wound care, displaying sensitive information visible from the hallway. The RN acknowledged the oversight, and interviews with the ADON, DON, and Administrator confirmed the expectation to protect residents' information.
A wound care cart was left unlocked and unattended by an RN, allowing potential resident access to medical supplies. The cart contained items such as dressings and ointments, which could be misused if accessed. Interviews with facility staff confirmed the expectation that carts should be locked when not in use to prevent resident access.
A facility failed to maintain an effective Infection Prevention and Control Program when a CNA did not perform hand hygiene before donning gloves and failed to change gloves after touching contaminated surfaces during incontinent care for a resident with chronic kidney disease. Despite receiving training, the CNA did not adhere to protocols, leading to potential cross-contamination. Interviews with facility leadership confirmed the importance of hand hygiene and glove changes as per policy.
Failure to Maintain Accessible Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call lights were accessible to residents as required by their care plans and facility policy. For one male resident with a history of cerebral infarction, muscle weakness, severe cognitive impairment (BIMS score 00), and dependence for transfers, hygiene, showering, and dressing, the comprehensive care plan identified fall risk and included an intervention to keep the call light within reach. During an observation, this resident was found awake in bed with the call light tucked at the foot side of the bed, and when asked where his call light was, he only shrugged his shoulders, indicating he did not know its location. A female resident with chronic pain, anxiety, lack of coordination, severe cognitive impairment (BIMS score 00), and dependence for hygiene, dressing, transfer, and bed mobility also had a care plan indicating she was at risk for falls and that her call light should be within reach. During observation, she was sitting by her sink while her call light was located behind the headboard of her bed. When asked if she could reach it, she stated it would be difficult for her to reach and pull the cord, and although she could ambulate, she was unable to pull the call light in that position. Another female resident with muscle weakness, chest pain, shortness of breath, severe cognitive impairment (BIMS score 00), and need for assistance with hygiene, dressing, and transfer had a care plan intervention to maintain the call light within reach due to fall risk. During observation, she was in bed with eyes closed and her call light was on the floor as housekeeping staff prepared to clean the room. The facility’s own policy, “Answering the Call Light,” revised September 2022, states that staff must ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. Staff interviews confirmed that call lights are used by residents to call staff when they need something or are in distress, and that call lights should always be within residents’ reach.
Failure to Properly Store Respiratory Equipment for Resident with COPD
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received such care in accordance with professional standards, the resident's care plan, and the resident's preferences. Specifically, the resident, who had a history of COPD and hypertension and was assessed as having moderately impaired cognition, was observed to have her oxygen tubing left unbagged on her bed and her nebulizer mouthpiece left unbagged on her bedside table when not in use. The resident reported that she removed her oxygen tubing and placed it on her bed when leaving for smoke breaks and typically placed the nebulizer mouthpiece on the bedside table after use. Staff interviews confirmed that the charge nurse was responsible for bagging the mouthpiece after medication administration, and that the resident often left respiratory items exposed after use. Record review showed that the resident's care plan included interventions for continuous oxygen via nasal cannula and noted a risk for infection due to non-compliance with nasal cannula use, with instructions for nursing to monitor and replace the cannula if found on the floor. Facility policy required nebulizer equipment to be stored in a plastic bag with the resident's name and date, but the policy on oxygen tubing storage was unclear. Staff interviews indicated inconsistent understanding and implementation of proper storage procedures for respiratory equipment, resulting in the resident's respiratory items being left exposed and not stored in accordance with infection control standards.
Failure to Update Care Plan for New Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan was not updated to include a left heel wound that was identified by a physician order. The resident, an older adult male with chronic kidney disease stage 3, heart failure, and pneumonia, had severe cognitive impairment as indicated by a BIMS score of 06. Despite the physician's order to apply xeroform and a bordered gauze dressing to the left heel, the care plan dated after the wound was identified did not reflect this new condition or the required interventions. Interviews with facility staff, including the Administrator, Wound Care Nurse, MDS Coordinator, and DON, confirmed that it was their responsibility to update care plans to reflect changes in residents' conditions. Staff acknowledged the importance of including all resident needs in the care plan to ensure appropriate and consistent care. The facility's own policy required ongoing assessment and timely revision of care plans as residents' conditions changed, but this was not followed in the case of the resident with the left heel wound.
Failure to Care Plan for Resident's Fall Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of falls. Record review showed that the resident, an elderly female with diagnoses including muscle weakness, lack of coordination, and dizziness, had an unwitnessed fall that was documented in the facility's incident report and progress notes. Despite this incident and the resident's high risk for falls, her quarterly care plan did not include any interventions or objectives related to fall prevention. The resident's MDS assessment indicated moderate cognitive impairment and a need for extensive assistance with activities of daily living. Interviews with facility staff, including the ADON and MDS nurse, confirmed that the resident should have been care planned for falls following the incident, but this was not done. Both staff members acknowledged their responsibility, along with the DON, for ensuring care plans were updated to reflect the resident's fall risk. The facility's policy requires an interdisciplinary approach to care planning based on MDS triggers and care area assessments, but this process was not followed in this case.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents, which could prevent them from obtaining assistance when needed. Resident #29, a female with severe cognitive impairment and dependent on staff for activities of daily living (ADLs), was observed with her call light on the floor at the foot of her bed. Despite being awake, she did not respond when asked about how she called for staff assistance. Resident #73, a male with severe cognitive impairment and requiring maximal assistance for ADLs, was found with his call light stuck between the bed and the wall. When questioned about the call light, he merely shrugged his shoulders, indicating a lack of awareness or ability to address the issue himself. A Certified Nursing Assistant (CNA) later repositioned the call light to be within reach. Resident #82, a male with moderate cognitive impairment, was transferred to a new room and found his call light coiled and unreachable on the wall. He expressed that he had to leave his room to seek assistance. The Director of Nursing (DON) and other staff acknowledged the importance of call lights and the expectation that they should be within reach of residents at all times, but this was not consistently ensured during staff rounds.
Inadequate Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, each with an indwelling catheter, which did not include appropriate interventions. Resident #36, a female with a surgical site infection on the sacrum, had a care plan that only included checking for kinks in the catheter each shift, despite having a physician's order for Foley Catheter Care every shift and as needed. The resident experienced abdominal pain, leading to the removal of the catheter, which was initially placed to aid in the healing of her wound. Resident #68, a male diagnosed with urinary retention, had a care plan that only included monitoring for signs and symptoms of urinary tract infection. This was insufficient given the physician's order for Foley Catheter Care every shift and as needed. During an interview, the resident confirmed the presence of the catheter due to bladder issues, and the MDS Coordinator acknowledged the lack of comprehensive interventions in the care plan. Resident #79, a male with a history of malignant neoplasm of the prostate, had a care plan that only included monitoring for signs and symptoms of discomfort on urination and frequency. The care plan did not align with the physician's order for Foley Catheter Care every shift and as needed. Observations revealed the resident had a catheter leg bag secured to his right leg, and staff noted the need to replace the catheter with a leg strap due to the resident's tendency to drag it. The MDS Nurse recognized the need to update the care plan to include more interventions.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for four residents, leading to potential risks of respiratory infection and unmet respiratory needs. Resident #16's nebulizer mask was found unbagged and in contact with a bottle of sanitizer, which could lead to cross-contamination. The Licensed Vocational Nurse (LVN) was unaware of the mask's ownership and acknowledged the need for it to be bagged when not in use. Resident #28's nasal cannula tubing was observed on the floor, unbagged, and connected to an oxygen concentrator, which was not in use at the time. Similarly, Resident #40's oxygen tubing was found unbagged in a drawer, and Resident #38's nebulizer mask was left on top of the nebulizer without proper storage. These observations indicate a lack of adherence to infection control practices regarding respiratory equipment. Interviews with staff, including LVNs, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), confirmed that respiratory items should be stored in bags when not in use to prevent contamination. Despite this understanding, the facility's policy for bagging nasal cannulas and breathing masks was not provided, highlighting a gap in policy implementation and staff compliance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six of the ten rooms reviewed. Observations revealed that the air conditioning units in these rooms had vents filled with black and brown dirt-like debris. Additionally, one room had a bedside table with red stains, and another room's mini fridge contained personal items such as hairbrushes, a towel, and sandwiches wrapped in napkins. These conditions were noted during a survey conducted on January 14, 2025. Interviews with facility staff, including the Administrator, a housekeeper, and the Housekeeping Supervisor, confirmed that housekeeping was responsible for cleaning the air conditioning units. The staff acknowledged the difficulty in removing dirt particles from the vents and recognized the potential health risks to residents due to the unclean conditions. The facility's policy on maintaining a homelike environment emphasizes the importance of a clean, sanitary, and orderly setting, which was not upheld in this instance.
Unauthorized Use of Restraints in Facility
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment. Specifically, four residents were found to have scoop or bolster mattresses on their beds without the necessary physician orders or assessments. These mattresses were intended to assist in fall prevention but were used without proper authorization, potentially restricting the residents' movement in bed. The facility's policy requires that any physical restraint must be ordered by a physician and used only when necessary to treat a medical condition, which was not adhered to in these cases. The residents involved had severe cognitive impairments and were totally dependent on assistance for activities of daily living. Despite their conditions, there were no physician orders for the use of scoop or bolster mattresses for these residents, as confirmed by the Director of Nursing (DON) after checking the records. The facility's failure to obtain the required physician orders and assessments for the use of these mattresses constitutes a deficiency in providing a restraint-free environment as mandated by their policy.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. Staff were not wearing appropriate hair and beard coverings, which could lead to hair contamination in food. Specifically, the Dietary Manager was seen preparing food without a beard guard, and another staff member was observed without a head covering while plating food. These lapses in protocol were acknowledged by the Dietary Manager, who admitted that such coverings are necessary to prevent hair from falling into the food. Food storage practices were also found to be inadequate. Items in the refrigerator and freezer, such as packages of bologna, ham, and raw celery, were not labeled with the date they were received from the vendor. Additionally, several items in the freezer, including bags of okra, waffles, and cookie dough, were improperly sealed, exposing them to airborne contaminants. The dry storage area also contained unlabeled packages of hamburger buns and tortillas. The facility's policy requires all stored food to be covered, labeled, and dated, but these standards were not met. Sanitation issues were evident in the kitchen, with the ice scoop holder showing brownish and white stains, and sugar and flour bins having dark dirt-like stains. Furthermore, food transported to resident rooms and the memory care unit was not properly covered, posing a risk of contamination. During a dining observation, uncovered desserts and green beans were seen on a food cart, and residents were observed standing over the trays. The Dietary Manager acknowledged these issues, noting that the ice scoop holder should be cleaned after every shift and that food should be covered during transport to prevent contamination.
Inadequate Infection Control During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinent care for two residents. For one resident, CNA A and CNA B did not change their gloves or perform hand hygiene after touching potentially contaminated surfaces and before handling clean items. Specifically, CNA A did not change gloves after placing a plastic bag in the trash can and before cleaning the resident's perineal area, nor after cleaning the resident's bottom and before touching a new brief. CNA B also failed to change gloves after handling a soiled brief and before assisting with a clean brief. In another instance, CNA B did not perform hand hygiene after leaving and re-entering a resident's room to retrieve wipes. Although she initially washed her hands upon entering the room, she failed to do so again after touching door knobs and other surfaces outside the room, which could have led to contamination. This oversight occurred during the provision of incontinent care for a resident diagnosed with cerebral infarction and incontinence. Interviews with the CNAs revealed a lack of awareness regarding the importance of changing gloves and performing hand hygiene to prevent cross-contamination and infection. The Director of Nursing and other staff acknowledged the importance of hand hygiene and glove changes in preventing infections, but the observed practices did not align with the facility's policies on hand hygiene and perineal care.
Failure to Maintain a Safe Environment Due to Presence of Scissors
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards, as evidenced by the presence of pointed scissors in the room of a resident with impaired cognition. The resident, who had a history of cerebrovascular disease and a cognitive communication deficit, was found to have a pair of large scissors with non-rounded ends stored in his wheelchair. The resident stated he used the scissors to cut the sides of a soiled brief, which posed a risk of injury to himself and others. The Director of Nursing (DON) was notified of the scissors, and it was acknowledged that the presence of such an item in the resident's room was unsafe. Interviews with staff revealed that the resident used the scissors for cutting paper, and there was no awareness among staff that the resident used them to cut briefs. The facility lacked a policy regarding residents or family members bringing sharp objects like scissors into rooms, and the DON admitted that such items posed a danger. The facility did not provide a policy about environmental hazards, and the DON emphasized the importance of staff being diligent about safety awareness. The absence of a policy and the lack of staff awareness contributed to the deficiency in maintaining a safe environment for the resident.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to secure confidential and personal medical records for two residents, leading to a breach of privacy and confidentiality. During medication administration to a resident diagnosed with neurocognitive disorder with Lewy bodies and hypertension, RN A left her laptop open, displaying sensitive information such as the resident's name, status, location, gender, date of birth, age, physician's name, latest vital signs, allergies, code status, emergency instructions, and medications. This information was visible from the hallway, exposing it to unauthorized individuals. RN A acknowledged the oversight, stating that she usually locks or minimizes the screen but forgot on this occasion. Similarly, while providing wound care to another resident diagnosed with dementia, RN A again left her laptop open, displaying the resident's personal and medical information, including the order for wound care. This information was also visible from the hallway. RN A admitted to repeating the mistake and recognized the importance of protecting residents' health information as per HIPAA regulations. Interviews with the ADON, DON, and Administrator confirmed the expectation that staff should ensure residents' information is not exposed, emphasizing the confidentiality and privacy of residents' medical records.
Failure to Secure Wound Care Cart
Penalty
Summary
The facility failed to ensure that a wound care cart was kept locked or under direct observation of authorized staff, which was accessible to residents. On the specified date, RN A was observed preparing to perform wound care and left the wound care cart unlocked in the hallway, with its drawers facing outward. The cart contained various medical supplies, including dressings, wound cleansers, ointments, and other items that could potentially be misused if accessed by residents. Interviews with RN A, the ADON, the DON, and the Administrator confirmed the expectation that carts should be locked when unattended to prevent residents from accessing potentially harmful items. RN A acknowledged forgetting to lock the cart and recognized the risk of residents accessing the contents. The ADON, DON, and Administrator all emphasized the importance of securing carts to prevent accidental ingestion or misuse of the items contained within.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA B during the provision of incontinent care to Resident #3. Resident #3, a female with chronic kidney disease and moderate cognitive impairment, was frequently incontinent for bowel and bladder. During the care process, CNA B did not perform hand hygiene before donning gloves, and failed to change gloves after touching potentially contaminated surfaces, such as the trash can and the resident's soiled bottom, before handling a clean brief. CNA B's actions were observed during an interview and care session, where she admitted to not washing her hands before starting the care and not changing gloves at appropriate times. She acknowledged that her gloves were soiled when she touched the new brief, which could lead to cross-contamination. Despite having received in-service training on incontinent care and hand hygiene, CNA B did not adhere to the expected protocols. Interviews with the ADON, DON, and Administrator confirmed that the facility's policy required hand hygiene before and after incontinent care and glove changes when transitioning from dirty to clean tasks. The facility's policies on hand hygiene and perineal care were reviewed, highlighting the importance of these practices in preventing infections and ensuring resident comfort.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pilot Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Pilot Point | 1.3 mi | — | 2 | 0 |
| Settlers Ridge Care Center | 11.3 mi | — | 1 | 0 |
| Whitesboro Health And Rehabilitation Center | 16.6 mi | — | 5 | 1 |
| Cottonwood Nursing And Rehabilitation | 16.7 mi | — | 3 | 0 |
| Denton Village By Purehealth | 16.8 mi | — | 15 | 1 |
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