Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Settlers Ridge Care Center during CMS and state inspections, most recent first.
Incomplete Person-Centered Care Plans: The facility failed to develop complete, person-centered care plans for 5 residents with significant cognitive and medical needs. Care plans did not include measurable goals, timeframes, or key issues such as refusal of care, mental health needs, or discharge planning options. Residents had diagnoses including dementia, Alzheimer’s disease, diabetes, dysphagia, malnutrition, depression, anxiety, and hospice status, and MARs showed repeated refusals of meds and vital sign checks for some residents.
Food storage and labeling practices were not followed in the kitchen. Surveyors observed 12 unlabeled and undated maroon bowls with unsecured lids in the dry pantry and a clear plastic container with a cracked, unsealed lid in the walk-in refrigerator. On return visits, the same bowls remained in place. The DON and Dietitian were interviewed, and the facility policy required opened food to be kept in airtight containers and all food in the refrigerator to be covered, labeled, and dated.
Kitchen refrigeration equipment was not maintained in operating condition when the walk-in refrigerator coolant fan was observed actively dripping water onto shelving and food items, and the walk-in freezer coolant fan had ice buildup and later leaked a clear liquid into a container below. The DON, Dietitian, and Maintenance Director were present during observations and interviews, and the Maintenance Director stated he had to drain the refrigerator fan every 2 to 3 days and handled refrigeration repairs himself rather than using contract commercial maintenance.
Incorrect Diet Served to Resident with Dysphagia: A resident with dysphagia, malnutrition, and respiratory diagnoses was ordered a puree diet, but during lunch she was served a regular consistency dessert instead of the ordered puree item. RN, dietary, housekeeping, and DON interviews confirmed the tray was not properly checked against the diet order, and the facility policy required tray verification for correct diet orders.
Medication Not Observed Until Swallowed: A resident with moderate cognitive impairment and diagnoses including CAD, HTN, and PAD was given medication, but the RN left the room before visually confirming he swallowed it. The resident said the nurse usually stays but did not this time, and the DON stated there were no orders allowing unsupervised medication administration. Facility policy required staff to observe the resident after administration to ensure the dose was completely ingested.
A resident with Alzheimer’s disease, DM2, and moderate cognitive impairment had Glipizide 10 mg unsecured in his room, with a pill found on the floor between his bed and his roommate’s bed. The resident said the pill had been there for several days and was probably his, and he was unsure whether he had missed a dose. RN identified the pill as the resident’s Glipizide, and the DON stated there were no orders allowing unsecured meds or self-administration.
Surveyors found that two shower rooms were not properly cleaned or sanitized, with overflowing soiled linen and trash bins, visible bodily waste, and dirty surfaces. Residents and staff reported that CNAs were responsible for cleaning after each use, but lapses led to unsanitary conditions. The facility lacked a written policy on shower room cleanliness.
A resident with severe cognitive impairment and a history of falls was found to have a new facial injury of unknown origin at discharge, which staff failed to recognize as separate from a previous fall. The injury was not immediately reported to the physician or family, and was not documented or treated as a new incident, resulting in a delay in medical intervention.
A resident with severe cognitive impairment and multiple comorbidities was found to have an unexplained facial wound at discharge. Staff assumed the injury was related to a previous fall and did not recognize it as a new injury, resulting in failure to report the incident to the state agency within the required timeframe. Multiple staff and clinical interviews confirmed the wound was not present during prior assessments, and the facility's reporting policy was not followed.
The facility failed to maintain an effective Infection Prevention and Control Program, with observed incidents of cross-contamination during medication administration and resident care. A medication aide cross-contaminated a resident's medication, another aide failed to sanitize equipment and touched medication with bare hands, and a CNA did not change gloves during incontinence care. Additionally, a Treatment Nurse did not use required PPE for a resident on enhanced barrier precautions.
A resident with a history of bloodstream infection due to a central venous catheter was at risk due to a failure in sterile technique during a PICC line dressing change. RN A did not change gloves after removing the old dressing, contrary to the facility's policy and training. The DON confirmed the expectation for proper sterile technique, which was not followed, potentially risking infection.
A resident with moderate cognitive impairment and a history of dementia and coronary artery disease was placed on supplemental oxygen without a physician's order specifying the amount. Despite the care plan indicating the need for respiratory treatments, there was no documented order for oxygen therapy. Nursing staff assumed a standing order existed but failed to verify or document it, leading to the resident receiving oxygen therapy without the necessary physician's order.
A resident in a long-term care facility, who required moderate assistance with personal hygiene, was found with long and dirty fingernails, indicating a lack of proper nail care. The CNA responsible did not check the resident's nails, and the DON acknowledged the potential infection control issues. Facility policy required nail care during bathing, which was not followed.
A resident with an indwelling urinary catheter was at risk for a urinary tract infection due to improper care by an LVN. During wound care, the LVN placed the catheter drainage bag above the bladder level, causing urine backflow. Despite the LVN's proficiency in catheter care, this action violated the facility's policy, which requires drainage bags to be below the bladder to prevent infection.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 5 of 5 residents reviewed for care planning. The care plans for Residents #33, #57, #10, #65, and #16 did not include measurable objectives and timeframes that addressed the residents’ identified medical, nursing, mental, and psychosocial needs. The report states that the care plans were incomplete and did not reflect the residents’ goals, needs, strengths, or discharge planning options where applicable. Resident #33 had severe cognitive impairment, chronic heart failure, type 2 diabetes, Alzheimer’s disease, anxiety disorder, and depression, and was admitted to hospice. Her care plan included only 3 goals related to activities, personal preferences, and advance directive preference. Resident #57 had severe cognitive impairment, adult failure to thrive, dysphagia, dementia, and bipolar disorder; the MAR showed repeated refusals of medication and vital sign checks, but the care plan did not address refusal of care or discharge planning/options. Resident #10 had severe cognitive impairment, Alzheimer’s disease, dysphagia, and moderate protein-calorie malnutrition; the MAR also showed repeated refusals of medication and some vital sign checks, and the care plan did not address refusal of care or discharge planning/options. Resident #65 had severe cognitive impairment, cerebral infarction, vascular dementia, major depressive disorder, and anxiety disorder; physician orders included a psychiatry consult and alprazolam for anxiety, but the care plan did not address mental health needs for depression and anxiety or discharge planning/options. Resident #16 had moderate cognitive impairment, Alzheimer’s disease, type 2 diabetes, and depression, and the care plan did not address discharge planning or options. The MDS nurse stated she was behind on completing care plans and was auditing them, completing 1 to 2 per day. The DON acknowledged Resident #33’s care plan was not complete and stated the facility had opened a new part-time care plan position that had not yet been filled; she also acknowledged that the refusal of care for Residents #57 and #10 should have been addressed in the care plans.
Food Storage and Labeling Deficiencies in Kitchen Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observations in the dry pantry on 3/31/26, surveyors found 12 plastic round maroon bowls with plastic lids that were not securely sealed, were exposed to the air, and were not labeled or dated. In the walk-in refrigerator, surveyors also observed 1 clear plastic container with a red cracked lid that was unsealed and exposed to the air. During interviews, the Director of Nutritional Services stated the facility has 1 kitchen and 1 main dining room, and the Dietitian comes weekly on Tuesdays and is responsible for resident assessments, therapeutic menus, and kitchen in-services. On return visits to the kitchen on 4/1/26 and 4/2/26, the same 12 unlabeled and undated bowls with unsecured lids remained in the dry pantry. Record review of the facility’s Food Storage policy stated opened packages of food are to be stored in air-tight containers or bags, all containers are to be accurately labeled with the item and date opened, and all foods in the refrigerator are to be covered, labeled, and dated. The FDA Code reviewed also stated packaged food shall be labeled as specified in law and food shall be protected from contamination.
Kitchen Refrigeration Equipment Not Maintained
Penalty
Summary
The facility failed to maintain essential kitchen equipment in operating condition by not maintaining the coolant fans in the walk-in refrigerator and walk-in freezer. During the initial kitchen tour, surveyors observed the walk-in refrigerator coolant fan actively dripping water onto shelving below, with drops landing in a clear container and on food items. The walk-in freezer coolant fan was also observed with ice buildup, and later the freezer fan was seen leaking a clear liquid substance into a clear plastic container placed on the shelf below the mechanical motor. The Director of Nutritional Services and the Dietitian were present during observations and interviews. The Dietitian stated she performed periodic kitchen walkthroughs and that the Maintenance Director had to drain the refrigerator coolant fan every 2 to 3 days. The Maintenance Director stated he had cleaned and blown out the drain on the coolant fan and said he would blow it out again. He also stated he did not call contract commercial maintenance for refrigeration and HVAC repairs and instead fixed things himself. The facility policy stated food must be stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination.
Incorrect Diet Served to Resident with Dysphagia
Penalty
Summary
The facility failed to provide a therapeutic diet that matched a resident’s physician-ordered puree consistency diet. The resident had been admitted with diagnoses including acute respiratory failure with hypoxia, pneumonia, pleural effusion, malnutrition, and dysphagia, and her assessment reflected difficulty swallowing, loss of food or liquids from the mouth, holding food in the mouth, and coughing or choking during meals or when swallowing medications. Her care plan identified her as at risk for weight changes due to poor oral intake, malnutrition, and failure to thrive, and directed staff to provide the diet as ordered. During lunch observation, the resident was served a puree meal, but the fruit cobbler was not pureed and was served in regular consistency. She ate a few bites of the regular dessert while RN E observed and confirmed it was not the ordered diet. RN E stated the resident was supposed to be on puree only and was at risk for choking if she ate a regular diet. The Regional Dietary Consultant, Dietary Aide, Housekeeper, and DON each stated staff were expected to check trays and tickets to ensure the meal matched the diet order, and the facility policy required each tray to be checked for the correct name, room number, and diet order.
Medication Not Observed Until Swallowed
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure Resident #26 swallowed his medication before the staff member left the room. Resident #26’s quarterly MDS assessment reflected he was a [AGE]-year-old male with a BIMS score of 11, indicating moderate cognitive impairment, and his diagnoses included coronary artery disease, hypertension, and peripheral artery disease. His care plan did not address self-administration of medications, and there were no physician orders allowing him to self-administer medications. During observation, Resident #26 was seen lying in bed, awake and alert, and stated he was finishing taking his medication. He was observed taking a drink and swallowing an unknown medication, and he reported that the nurse had brought the medication and left before watching him swallow it. The RN who administered the medication stated she stepped out of the room because someone was calling for her in the hallway and did not witness the resident swallow the medication. The DON stated there were no allowances or orders for unsupervised medication administration and that facility policy required staff to stay with the resident until the medication was swallowed and visually confirm ingestion. The facility policy also stated the resident is always observed after administration to ensure the dose was completely ingested.
Unsecured Glipizide Found in Resident Room
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments for one resident reviewed for medication storage. Resident #16, a male with Alzheimer’s disease, type 2 diabetes, and depression, had a BIMS score of 8 indicating moderate cognitive impairment. His care plan did not address any goals or interventions related to medication at bedside or self-administration, and his active physician’s orders included Glipizide 10 mg by mouth twice daily with no order for self-administration. During observation, a round white pill was found on the floor between Resident #16’s bed and his roommate’s bed, and the resident stated it had been on the floor for several days and was probably his. He said he took his medication that morning and was not sure if he had missed a dose recently. RN F identified the pill as Glipizide belonging to Resident #16 and stated she was responsible for administering his medications. The DON later stated there were no allowances or orders for Resident #16 to have medication unsecured in his room. The facility policy on storage of medication stated staff will store medications in accordance with standard practice guidelines.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment in two of five shower rooms reviewed. Observations revealed that one shower room had a strong odor of urine, overflowing soiled linen and trash bins, a toilet bowl with visible feces and urine, dried red spots on the floor, and a dirty shoe insole left on the sink counter. Another shower room had five brown smudges of varying sizes on the tiled floor of one shower. These unsanitary conditions were confirmed by both the Director of Environmental Services and staff interviews. Interviews with CNAs and residents indicated that CNAs were responsible for cleaning the shower rooms after each use, including removing any bodily fluids or soiled materials, and notifying housekeeping for further sanitization. However, residents reported that the shower rooms were often messy, with dirty towels left on the floor and, in some cases, feces observed in the shower. Staff acknowledged the risk of infection and contamination if the showers were not properly cleaned between uses, and described their process for cleaning and notifying housekeeping, though lapses in this process were evident. Further, the Director of Environmental Services and the DON stated that while housekeeping cleaned the shower rooms daily, CNAs were expected to clean up after each use. The Administrator confirmed that CNAs were required to keep the showers sanitary and clean immediately after use. Despite these expectations, the facility did not have a written policy regarding the cleanliness of the facility or shower rooms, and no such policy was provided upon request by surveyors.
Failure to Notify Physician and Family of New Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when a significant change in the resident's physical status was discovered. Specifically, a resident with severe cognitive impairment and multiple complex diagnoses, including Alzheimer's disease, dementia, and a history of falls, was found to have an injury of unknown origin on her face at the time of discharge. The injury, described as a linear abrasion with open skin and signs of blunt force trauma, was not present earlier in the day and was not reported to the physician or family as a new injury. Staff interviews and record reviews revealed that the injury was discovered by a family member at discharge, who then raised concerns about the resident's care. Facility staff, including the DON and RN, assumed the injury was related to a previous, witnessed fall that had occurred several days earlier and had already been reported. As a result, the new injury was not recognized as a separate incident, and no immediate notification or medical intervention was provided. The physician confirmed that she was not notified of the new wound and stated that it should have been treated and reported as a new injury of unknown origin. Documentation showed inconsistencies in staff observations, with some staff noting only a bruise and others unaware of the open wound. The facility also failed to report the injury of unknown origin to the state agency within the required timeframe. The lack of immediate recognition and notification of the new injury led to a delay in appropriate medical assessment and intervention for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required by regulation. Specifically, an injury of unknown origin was discovered on a female resident who was receiving respite care and had multiple diagnoses, including Alzheimer's disease, dementia, Parkinson's disease, and a history of falls. The injury, a linear abrasion with clotted, bright red skin on the right cheek, was observed by the family at the time of discharge, but was not reported to the state agency within the required 24-hour timeframe. Staff interviews and record reviews revealed that the resident had a witnessed fall several days prior to the discovery of the injury, but at the time of the fall, no injuries were noted. Multiple staff members, including the DON, wound care nurse, and RN, stated that they had seen only a light bruise on the resident's face prior to discharge and were unaware of any open wound or new injury. The DON and other staff assumed that the family's concern was related to the earlier fall and its resulting bruise, not recognizing that a new injury had occurred. The physician and wound care nurse confirmed that the wound seen in the family’s video and photograph was not present during their last assessments and that it appeared to be a recent, open wound. The facility's policy requires that all injuries of unknown origin be reported to the administrator and, if reportable, to the state agency within 24 hours. However, the injury discovered at discharge was not reported as required. The failure to recognize and report the new injury was due to staff assuming it was related to the previous fall, leading to inaccurate communication with the family and a lack of timely notification to the appropriate authorities.
Infection Control Deficiencies in Medication and Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observed incidents involving medication administration and resident care. During a medication observation, a medication aide (MA C) was seen cross-contaminating Resident #23's medication by touching a dropped pill with bare hands and handing it back to the resident. This action was acknowledged by MA C, who admitted to realizing the cross-contamination risk and the need to dispose of the contaminated medication. Another incident involved MA B, who failed to sanitize a blood pressure cuff between uses on Residents #22 and #72. Additionally, MA B was observed touching medication with bare hands while preparing Resident #72's medication, which was against the facility's infection control practices. MA B admitted to forgetting to sanitize the equipment and acknowledged the importance of not touching medications with bare hands to prevent the spread of germs. Further deficiencies were noted in the care provided to Resident #64. CNA D did not change gloves or perform hand hygiene after handling a soiled brief before applying a clean one, which she recognized as a cross-contamination risk. Additionally, the Treatment Nurse did not use the required personal protective equipment (PPE) while performing wound care on Resident #64, who was on enhanced barrier precautions due to a venous access device and wounds. The Treatment Nurse misunderstood the requirements for PPE use, thinking the resident's condition did not necessitate enhanced precautions.
Failure to Follow Sterile Technique in CVC Dressing Change
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous fluids for a resident, specifically in the context of changing a central venous catheter (CVC) dressing. During an observation, RN A did not adhere to sterile technique while changing the dressing for a resident with a PICC line. The resident, a male with intact cognition, had a history of bloodstream infection due to a central venous catheter, respiratory failure, and pneumonia. The resident's care plan required a dressing change every seven days, but during the procedure, RN A did not change gloves after removing the old dressing and before cleaning the line exit site, which is a breach of sterile technique. RN A acknowledged the importance of changing gloves and performing hand hygiene when transitioning from dirty to clean tasks during the dressing change. The Director of Nursing (DON) confirmed that the expectation for staff was to follow proper sterile techniques, including changing gloves and performing hand hygiene. The facility's policy also required strict sterile technique for dressing changes. Despite receiving training on sterile dressing changes both during RN A's education and annually at the facility, the failure to follow these procedures could place residents at risk for infections.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, identified as Resident #64, who required supplemental oxygen. The deficiency was identified through observation, interviews, and record reviews. Resident #64, an elderly female with moderate cognitive impairment and a history of dementia, fractured hip, and coronary artery disease, was noted to have been placed on supplemental oxygen without a physician's order specifying the amount to be delivered. Despite the resident's care plan indicating the need for respiratory treatments and oxygen as ordered, there was no documented order for oxygen therapy from the physician, which is a requirement for administering such care. The deficiency was further highlighted by the fact that nursing staff, including LVN F and LVN G, assumed the existence of a standing order for oxygen administration but failed to verify or document it in the electronic medical records. This oversight led to the resident receiving oxygen therapy without the necessary physician's order, placing her at risk of receiving an incorrect amount of oxygen. The facility's policy on oxygen therapy requires that licensed staff provide oxygen therapy as prescribed by a physician and document it accordingly, which was not adhered to in this case.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The deficiency was observed in a male resident who required moderate assistance with personal hygiene due to his medical conditions, including a fracture, obstructive uropathy, and Alzheimer's disease. During an observation, it was noted that the resident had long fingernails with a black substance underneath and around the nail beds, indicating a lack of proper nail care. Interviews with staff revealed that nail care was typically performed during shower times, and since the resident was not diabetic, CNAs were responsible for this task. However, the CNA assigned to the resident admitted to not checking his nails on the morning of the observation. The Director of Nursing confirmed that nail care should be provided as needed and acknowledged the potential infection control issues associated with neglecting this aspect of care. The facility's policy on bathing included performing hand hygiene and nail care, which was not adhered to in this instance.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a risk of urinary tract infection. The resident, a female with multiple sclerosis, a stage 4 pressure ulcer, and neuromuscular dysfunction of the bladder, required extensive assistance and had a moderately impaired cognition. During a wound care procedure, a Licensed Vocational Nurse (LVN) placed the resident's urinary catheter drainage bag on the bed above the bladder level, causing urine to flow back toward the bladder. This action was contrary to the facility's policy, which mandates that gravity drainage bags be positioned below the bladder to prevent infection. The LVN acknowledged the mistake, stating that the catheter bag and tubing should be kept below the bladder to prevent urine backflow and potential infection. The Director of Nursing (DON) confirmed that the improper positioning of the catheter bag placed the resident at risk for a urinary tract infection. Despite the LVN's proficiency in catheter care as per a recent competency check, no additional training was provided following the incident. The facility's policy on urinary catheter infection prevention clearly states that drainage bags should be positioned below the bladder, highlighting a lapse in adherence to established protocols.
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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 Celina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belterra Health & Rehab | 10.2 mi | ★★★★★ | 10 | 0 |
| Baybrooke Village Care And Rehab Center | 11.1 mi | ★★★★★ | 26 | 0 |
| Cedar Ridge Rehabilitation And Healthcare Center | 11.3 mi | ★★★★★ | 11 | 0 |
| Avir At Pilot Point | 11.7 mi | ★★★★★ | 2 | 0 |
| Park Manor Of Mckinney | 11.7 mi | ★★★★★ | 0 | 0 |
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