Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Ridgeview Rehabilitation And Skilled Nursing during CMS and state inspections, most recent first.
The facility did not obtain a physician's order for a resident's indwelling urinary catheter and failed to ensure that catheter bags for three residents were consistently covered with privacy bags, as required by facility policy. Observations and interviews confirmed that catheter bags were often left uncovered both inside and outside resident rooms, and that documentation for catheter care was missing in at least one case.
Four residents with indwelling urinary catheters did not have their catheter use or care documented in their comprehensive care plans, despite evidence from assessments, physician orders, and staff observations. Staff provided catheter care based on observation and standard practice rather than individualized, documented plans, and residents' psychosocial needs related to catheter use were not addressed in care plans.
A resident with mental health diagnoses was not referred for a PASRR Level II evaluation due to an incorrect Level I screening. The MDS Nurse did not complete a new screening or send required documentation, and there was no oversight from the DON or Administrator.
The facility failed to implement comprehensive care plans for two residents. One resident, with chronic pain, did not have a care plan addressing pain management despite receiving medication. Another resident, initially with an indwelling catheter, had the catheter removed but the care plan was not updated, risking neglect in incontinence care. Interviews revealed a lack of communication and oversight in updating care plans, compromising resident care.
A resident was misdiagnosed with schizoaffective disorder, leading to inappropriate treatment. Despite having severe cognitive impairment and a history of dementia, the resident's records inaccurately included schizoaffective disorder due to an error in documentation. Facility staff, including the MDS Nurse and Medical Director, confirmed the misdiagnosis, but the error was not corrected in the resident's records. The facility's policy on antipsychotic medication use was not followed, resulting in the deficiency.
A facility failed to maintain an effective infection control program when an LVN did not clean a blood pressure cuff after using it on a resident under enhanced barrier precautions and used it on another resident. The absence of signage and PPE outside the resident's room contributed to the oversight. Interviews with the ADON and DON revealed a lapse in ensuring proper signage and PPE availability, contrary to the facility's infection control policy.
Failure to Ensure Physician Orders and Privacy for Indwelling Catheters
Penalty
Summary
The facility failed to ensure proper treatment and services for residents with indwelling urinary catheters, as evidenced by the lack of a physician's order for one resident's catheter and the absence of privacy covers on catheter bags for three residents. Specifically, one resident did not have a physician's order for her indwelling urinary catheter, nor was there any indication of catheter care in her care plan, despite her medical record and MDS assessment indicating catheter use. The Director of Nursing confirmed that no orders or care plan documentation could be found for this resident's catheter. Additionally, observations revealed that three residents with indwelling catheters had their catheter bags uncovered while in and outside their rooms. One resident was seen wheeling down the hallway with her catheter bag visible and reported that a privacy cover was almost never used. Another resident's family member corroborated that the catheter bag was typically not covered during visits. A third resident was observed with an uncovered, nearly full catheter bag in her room. Staff interviews confirmed that privacy covers were available and intended to maintain resident dignity, but were not consistently used. The facility's policy required catheter drainage bags to be covered at all times.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Urinary Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents who had indwelling urinary catheters. Despite documentation in the Minimum Data Set (MDS) assessments and physician orders indicating the presence of catheters, the residents' care plans did not reflect this critical aspect of their care. For example, one resident's initial care plan did not mention her indwelling catheter, even though her MDS assessment and direct observation confirmed its use. Another resident's care plan, closed upon discharge, also lacked any reference to her catheter, despite hospital records and physician orders indicating its necessity and ongoing use. Observations and interviews further revealed that staff were aware of the residents' catheters through direct care and visual cues, but this information was not formally documented in the care plans. One resident was observed moving through the hallway with her catheter bag visible and without a privacy cover, and she reported that this was a common occurrence. Another resident expressed confusion and distress about her catheter, frequently asking staff for its removal, yet her care plan did not address her catheter use or her psychosocial needs related to it. Staff interviews confirmed that catheter care was provided based on standard practice and observation rather than individualized, documented care plans. The lack of documentation and individualized care planning for catheter use was consistent across multiple residents, as evidenced by the absence of catheter-related goals, interventions, or measurable objectives in their care plans. This omission was noted despite facility policy requiring comprehensive, person-centered care plans that include measurable objectives, timeframes, and descriptions of services to meet each resident's needs. The failure to include catheter care in the care plans placed residents at risk of not having their needs for assistance met and increased their susceptibility to urinary tract infections (UTIs).
Failure to Conduct PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASRR Level II evaluation, which is required for residents with serious mental disorders or intellectual disabilities. The resident in question had diagnoses including dementia, schizoaffective disorder, and bipolar disorder, yet the PASRR Level I screening incorrectly indicated no history of mental illness. This oversight was not corrected, and the resident did not receive the necessary PASRR services. Interviews revealed that the MDS Nurse responsible for PASRR assessments did not complete a new Level I screening when the initial one was found to be incorrect. The nurse also did not send the necessary documentation to the mental health authority, believing it was unnecessary. The Director of Nursing and the Administrator were unaware of the PASRR requirements and did not oversee the nurse's work, leading to a lack of checks and balances in the process.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #19 and Resident #22, as identified during a survey. Resident #19, an elderly male with chronic obstructive pulmonary disease and a BIMS score indicating no cognitive impairment, was receiving scheduled and as-needed pain medication. Despite this, the facility did not include a care plan addressing her pain management needs. Interviews with the MDS Nurse and the Director of Nursing (DON) revealed a lack of awareness regarding the absence of a pain management care plan for Resident #19, which posed a risk of increased pain due to inadequate care planning. Resident #22, an elderly male with multiple diagnoses including neurogenic bladder, was initially documented to have an indwelling catheter. However, after an incident where the catheter was accidentally removed, the resident no longer required it. Despite this change, the care plan was not updated to reflect the removal of the catheter. Interviews with the CNA, DON, and MDS Nurse indicated a lack of communication and oversight in updating the care plan, which could lead to neglect in incontinence care and potential harm due to skin breakdown. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timely updates to reflect changes in residents' conditions. However, the failure to update Resident #22's care plan and the absence of a pain management plan for Resident #19 highlight deficiencies in adhering to these policies. The lack of proper documentation and communication among staff members contributed to these oversights, potentially compromising the quality of care provided to the residents.
Misdiagnosis of Schizoaffective Disorder in a Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident who was misdiagnosed with schizoaffective disorder. This misdiagnosis was identified during a review of the resident's medical records, which included a quarterly MDS assessment and various health assessments. The resident, a female with severe cognitive impairment, was admitted with diagnoses including hip fracture, non-Alzheimer's dementia, and schizophrenia. However, her history and physical examination records indicated no history of borderline personality disorder or schizophrenia. The resident's comprehensive care plan included the use of psychotropic medications for behavior management related to schizoaffective/bipolar type and dementia with psychotic disturbance. However, a subsequent psychiatric assessment revealed no current symptoms of psychosis, and the resident was being treated for recurrent depressive disorders and dementia with agitation. Interviews with facility staff, including the MDS Nurse, Medical Director, and Psychologist, confirmed that the resident did not have a history of schizoaffective disorder, and the diagnosis was a result of an error in documentation. The facility's policy on antipsychotic medication use requires the identification and differentiation of acute psychiatric episodes from enduring psychiatric conditions. Despite this policy, the misdiagnosis was not corrected in the resident's records, and the MDS assessment was signed without a thorough review. The Director of Nursing acknowledged signing the MDS assessments but did not recall reviewing the specific assessment for the resident in question. This oversight in documentation and review processes led to the deficiency identified in the report.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not clean a blood pressure cuff after using it on a resident under enhanced barrier precautions and subsequently used it on another resident. LVN A, who was new to the facility but had prior experience as an agency nurse, was unaware that the first resident required enhanced barrier precautions due to the absence of signage and personal protective equipment (PPE) outside the resident's room. This oversight led to the potential risk of cross-contamination between residents. Additionally, the facility did not have proper signage indicating that the resident was on enhanced barrier precautions, which contributed to the oversight by LVN A. Interviews with the ADON and DON revealed that they were responsible for ensuring that signage and PPE were available for residents on enhanced barrier precautions. However, they were unaware of why the signage was missing, suggesting a lapse in the facility's infection control protocols. The facility's policy on infection control, dated November 2017, required standard and transmission-based precautions to prevent the spread of infections, which were not adequately followed in this instance.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Trails Nursing And Rehabilitation Center | 1.9 mi | — | 0 | 0 |
| Colonial Manor Nursing Center | 3.1 mi | — | 2 | 0 |
| Town Hall Estates Keene, Inc. | 7.7 mi | — | 0 | 0 |
| Alvarado Meadows Nursing & Rehabilitation | 13.9 mi | — | 0 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 14 mi | — | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.