Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
A resident with Alzheimer’s disease, severe cognitive impairment, and dependence for several ADLs was observed in bed with her call light out of reach and the cord routed away from the bedside. Staff, including a CNA, RN, DON, CNO, and ADM, stated call lights should be within residents’ reach at all times, and the facility policy required the call light to be accessible when in bed, from the toilet, from the shower, and from the floor.
Inaccurate MDS Coding for High-Risk Medication: A resident with a history of CVA, hypotension, dehydration, weakness, and memory deficits had an MDS that incorrectly coded anticoagulant use instead of the ordered antiplatelet medication, Clopidogrel. The care plan also identified anticoagulant therapy and interventions for anticoagulant monitoring, while interviews with the DON, ADON, MDS staff, CNO, and ADM confirmed the MDS should have reflected the resident’s actual medication regimen.
Failure to include a resident’s puree diet and thickened liquids in the care plan. A resident with CVA-related dysphagia, memory deficits, and swallowing difficulty was assessed as needing a mechanically altered diet, and physician orders reflected pureed texture with nectar consistency. However, the care plan had no focus areas, goals, or interventions for nutritional status or swallowing needs. Staff interviews confirmed the altered diet should have been care planned, and the resident reported recent weight loss and dislike of the puree and thickened liquids.
Expired lab supplies and needles were found in the medication storage room, including culture swabs, lab tubes, and Precision Glide needles past their expiration dates. Staff, including RN A, LVN D, CNA E, MA G, and the CNO, stated expired supplies should be removed from circulation and not used because they may be unsafe or ineffective and could affect lab accuracy. The facility policy stated that outdated medications or biologicals should be handled through the dispensing pharmacy for return or destruction.
A kitchen staff member was observed adding water to spaghetti puree during lunch service instead of using an approved liquid such as broth, milk, or reserved liquid. The DS corrected the process and stated that pureed food recipes should be followed, while the ADM and CNO said staff were expected to use approved recipes. Facility guidelines listed appropriate liquids for puree preparation, and water was not included.
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.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure Resident #49’s call light was within reach. Resident #49 was a female admitted with diagnoses including Alzheimer’s disease, anxiety, insomnia, and peripheral vascular disease. Her quarterly MDS showed she was dependent on staff for showering, toileting, and personal hygiene, required partial/moderate assistance with eating, and had a BIMS score of 01, indicating severe cognitive impairment. Her care plan identified her as at risk for falls due to limited mobility, poor cognition, and poor safety awareness, and included the intervention to keep her call light within reach and encourage her to use it for assistance as needed. During an observation, Resident #49 was found in bed asleep and slightly awakened to her name, but her call light was not within reach and was lying with the cord routed under and away from the nightstand. The resident did not wake enough to follow directions or demonstrate whether she could reach it. A CNA stated the call light was not in a reachable location and believed it had fallen off the bed, and both the CNA and RN stated call lights should be within residents’ reach at all times. The DON, CNO, and ADM also stated it was their expectation that all residents’ call lights be within reach at all times. The facility policy titled Answering the Call Light stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Inaccurate MDS Coding for High-Risk Medication
Penalty
Summary
Resident #2’s assessment was not accurately coded on the MDS for high-risk medications. The resident was admitted with diagnoses including hypotension, dehydration, weakness, memory deficit following cerebral infarction, and other cerebral infarction due to occlusion or stenosis of a small artery. The physician’s orders included Clopidogrel (Plavix), an antiplatelet medication, and there was no anticoagulant medication ordered, although an order dated 11/25/2025 referenced monitoring anticoagulant medication. The MDS assessment dated [DATE] reflected a BIMS score of 11 and, in Section N-Medications, N0415 High Risk Drug Classes, indicated use and indication of anticoagulant medication, but did not indicate use or indication of antiplatelet medication. The care plan initiated on 11/25/2025 also identified the resident as being on anticoagulant therapy related to a history of CVA and included interventions for administering anticoagulant medications and monitoring for adverse reactions of anticoagulant therapy. During observation on 12/9/2025, Resident #2 was clean, comfortable, and without distress, and the resident expressed no concerns. Interviews with the DON, ADON, MDS A, MDS B, CNO, and ADM confirmed that the MDS should accurately reflect the resident’s medications and that antiplatelet medications should have been coded if ordered, while anticoagulant use should not have been coded if not ordered. MDS A stated that Resident #2’s MDS was coded incorrectly and that the error was an oversight.
Failure to Care Plan Altered Diet and Dysphagia Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #5 that included measurable objectives and time frames to address his identified nutritional needs. Resident #5 was admitted with diagnoses including osteomyelitis of the left ankle and foot, memory deficit following cerebral infarction, dysphagia following cerebral infarction, and oropharyngeal dysphagia. His comprehensive MDS assessment showed a BIMS score of 14 and documented signs of a swallowing disorder, including holding food in the mouth, coughing or choking during meals or with medications, and complaints of difficulty or pain with swallowing. The assessment also indicated that he was on a mechanically altered diet with pureed food and thickened liquids on admission and while a resident. Physician orders reflected a regular diet with pureed texture and nectar consistency, and later an order for speech therapy to re-evaluate for possible diet advancement. However, the care plan report reviewed on 12/11/2025 contained no focus areas, goals, or interventions/tasks related to the resident’s nutritional status, swallowing disorder, or mechanically altered diet. During observation and interview, Resident #5 stated he had been on a puree and thickened liquid diet since admission and expressed concern about recent weight loss, which he attributed to the puree diet, and said he did not care for thickened liquids. Staff interviews confirmed that the altered diet should have been included in the care plan. RN C stated that altered diets and thickened liquids need to be in the care plan so staff do not provide unsafe items such as regular water with medications. The ADON acknowledged that Resident #5’s diet and supplements were not care planned and should have been. The DON, CNO, and ADM stated that care plans should accurately reflect the resident’s clinical picture and care needs, and the facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables that incorporated identified problem areas and risk factors.
Expired Lab Supplies and Needles Found in Medication Storage Room
Penalty
Summary
Drugs and biologicals were not stored properly in the medication storage room. During observation of the medication storage room, expired lab supplies and needles were found, including 5 culture swabs, 2 blue top lab tubes, 1 lab transport tube, 4 gold top lab tubes, 4 red top lab tubes, and 10 Precision Glide needles, all past their expiration dates. The report identified this as the only medication storage room reviewed for drug storage. Staff interviews confirmed that expired supplies should be removed from circulation and discarded. RN A, LVN D, CNA E, MA G, and the CNO each stated that expired lab tubes, lab swabs, and needles should not be used because they may not be safe or effective and could affect lab accuracy. The facility policy stated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and that outdated medications or biologicals should be handled through the dispensing pharmacy for return or destruction.
Pureed Food Prepared With Water Instead of Approved Liquids
Penalty
Summary
The facility failed to prepare pureed foods by methods that conserve nutritive value and flavor for 1 of 1 kitchen reviewed for food and nutrition services. During lunch service, DS B was observed pouring water into spaghetti noodles and sauce to help achieve the proper puree consistency. Another observation showed DS A correcting DS B and instructing her to use broth instead of water, while also checking the consistency of the puree and directing DS B to continue using the food processor until a smooth consistency was reached. In interviews, DS B stated that using water instead of milk, broth, or melted butter was a mistake and that she understood water removes nutritive value from the food. DS A stated that pureed food recipes should be followed and that broth should be used to preserve nutritive value and taste. The ADM and CNO stated that staff were expected to follow approved recipes for pureed foods, and the facility's Pureed Foods Guidelines stated to add appropriate liquid such as reserved liquid, broth, juice, or milk if needed; water was not listed.
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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Nursing homes near Cleburne
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 | ★★★★★ | 4 | 0 |
| Colonial Manor Nursing Center | 3.1 mi | ★★★★★ | 3 | 0 |
| Town Hall Estates Keene, Inc. | 7.7 mi | ★★★★★ | 0 | 0 |
| Alvarado Meadows Nursing & Rehabilitation | 13.9 mi | ★★★★★ | 4 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 14 mi | ★★★★★ | 13 | 1 |
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