Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Vista Ridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, aphasia, severe mental illness, and significant ADL deficits told a psychologist that a family member was touching her inappropriately in a sexual manner. The psychologist informed the Admin, who acknowledged that reporting abuse allegations to the state was her responsibility. Despite a written Abuse Prevention Program requiring immediate reporting of all alleged abuse to the state agency and submission of written investigative findings, the Admin did not file an incident in TULIP or notify the state, stating she did not believe it was abuse because the resident said the family member always did it and thought it was funny and did not explicitly say it was without consent.
A resident with moderate cognitive impairment, aphasia, depression, and anxiety reported to a psychologist that a family member had been touching her vaginal area under her clothing without consent. The psychologist informed the SW, who documented the allegation and notified APS, police, and facility leadership, including the DON and administrator. Staff interviews confirmed awareness of the allegation and that supervised visitation was implemented, but review of the state TULIP system showed no report submitted. The administrator, who acknowledged responsibility for state reporting, stated she investigated but did not consider the incident abuse and therefore did not report it, despite facility policy requiring immediate reporting of all alleged abuse to the state agency.
A resident with aphasia, moderate cognitive impairment, severe mental illness, and multiple ADL deficits reported to a psychologist that a family member had been touching her vaginal area under her clothing without consent. The psychologist informed the SW, who documented the allegation and notified APS and police, and the resident requested supervised visitation rather than criminal charges. The RN, SW, psychologist, ADON, and DON all acknowledged awareness of the allegation, and the facility’s abuse policy required immediate reporting of alleged abuse and submission of written investigation findings within five working days. The administrator conducted an internal investigation but, based on her belief that the conduct was not abuse, did not submit an incident report or the investigation findings to the State Survey Agency, resulting in a failure to report as required.
Surveyors found that several residents with cognitive impairment, muscle weakness, and fall risk did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Observations showed call lights placed on the floor, on chairs, or otherwise out of reach, and staff interviews confirmed the expectation that call lights should be accessible and checked during rounds.
A resident with cognitive impairment, muscle weakness, and seizures was found with a bolster mattress on the bed without a physician order or care plan intervention for its use. Staff, including an LVN and the Interim DON, were unaware of the need for a physician order, and facility policy required such orders for physical restraints.
Three residents requiring respiratory care had their nebulizer and CPAP masks improperly stored unbagged when not in use, despite care plans and physician orders specifying respiratory therapy. Nursing staff acknowledged responsibility for ensuring proper storage but admitted to lapses, and the DON confirmed expectations for bagging masks were not consistently met.
A resident with severe cognitive impairment, a history of aspiration pneumonia, and a physician-ordered pureed diet was left unsupervised during a meal and ate a regular cookie offered by another cognitively impaired resident. Despite multiple staff being present in the dining room, no one intervened or noticed the resident eating outside her prescribed diet, leading to coughing episodes. The resident's care plan required assistance and supervision with eating, but these interventions were not followed, and staff were unclear about their monitoring responsibilities.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the handling and maintenance of respiratory equipment. A resident with chronic pulmonary embolism had a nasal cannula improperly stored and not changed weekly, and lacked an 'Oxygen in Use' sign. Another resident with COPD had a nasal cannula not bagged when not in use. A third resident with sleep apnea had a BiPAP mask that was not cleaned or bagged properly, increasing the risk of contamination.
A facility failed to review and update a resident's care plan quarterly, as required. The resident, who was cognitively intact and had multiple health conditions, had not been involved in a care plan meeting since the previous year. Staff interviews revealed that a system changeover prevented access to previous records, and the facility's policy on involving residents in care planning was not followed.
A resident, who was cognitively intact and had multiple diagnoses, was not included in his care plan conference, and his involvement was not documented. Interviews revealed that the resident had not participated in a care plan meeting since the previous year, despite expressing concerns about his medication and discharge plan. Facility staff cited a system changeover as the reason for the lack of access to previous records, and the facility's policy encourages resident participation in care plan development.
A CMA left a computer unlocked and unattended on a medication cart, exposing resident information on Hall 300. The lapse occurred while the CMA assisted a resident, allowing others to potentially view sensitive data. The CMA admitted awareness of the policy to lock the computer but forgot in this instance.
A resident with dementia and chronic kidney disease was found with urine-stained sheets that had not been changed, leading to an unsanitary living condition. The resident reported that staff typically did not change his sheets, and he had to wait for them to dry before using the bed. Interviews revealed that the CNA was unaware of the need to change the linens, and the facility's policy required linens to be changed if soiled to prevent infection control issues.
A medication cart on Hall 300 was left unlocked and unattended, allowing easy access to medications while a CMA assisted a resident. Despite knowing the protocol, the CMA forgot to lock the cart, which was against the facility's policy. This incident occurred in the presence of residents and a housekeeper, posing a risk of unauthorized access.
The facility failed to maintain an infection control program, leading to inadequate PPE usage and hand hygiene by two CNAs. This placed residents at risk of infection, as the CNAs did not follow proper protocols while caring for COVID-19 positive residents.
Failure to Report Alleged Sexual Abuse According to Facility Policy
Penalty
Summary
The facility failed to implement and follow its written abuse prevention policies and procedures when a resident reported sexual abuse by a family member. A psychologist reported to the Administrator that the resident stated her family member was touching her inappropriately in a sexual manner. The resident had a BIMS score of 10, indicating moderate cognitive impairment, unclear speech, and usually understood others, and required substantial/maximal assistance with ADLs including oral hygiene, toileting hygiene, showering, dressing, personal hygiene, and bed mobility. The resident’s care plan, initiated the day after the reported outcry, documented that she had voiced concerns to staff about the conduct of her family member during visits, and included care areas such as ADL deficit, severe mental illness with antidepressant and anti-anxiety medications, communication problems (aphasia), fall risk, and mood and psychosocial problems with APS and psychological services involved. Despite the facility’s Abuse Prevention Program policy, which required all alleged violations involving abuse to be immediately reported (within two hours for abuse) to the state licensing/certification agency and thoroughly investigated with written findings submitted within five working days, the Administrator did not report the allegation to the state. The Administrator stated that she considered it her responsibility to call the state regarding allegations of abuse or neglect, acknowledged that the psychologist had reported the resident’s allegation to her, and stated she did not report it because the resident said the family member always did this and thought it was funny, and the resident did not tell her it was without consent. The Administrator reported that she conducted an investigation but did not think it was abuse, so she neither reported the allegation nor submitted the investigation to the state. Record review of TULIP showed no incident report related to this allegation, confirming the failure to report as required by the facility’s policy and federal requirements.
Failure to Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the State Survey Agency as required by federal regulations and the facility’s own Abuse Prevention Program. A female resident with a history of aphasia following cerebral infarction, dysphagia, major depressive disorder, and generalized anxiety disorder, and with a BIMS score of 10 indicating moderate cognitive impairment, reported that her family member (FM) had been touching her vaginal area. According to the police report, the resident stated the FM placed his hand under her clothing, making direct contact with her vaginal area without her consent. The resident’s care plan documented that she had voiced concerns about the FM’s conduct during visits and that visits were to be supervised in common areas during daytime hours when administration was present. Record review showed that on the date of the allegation, the psychologist was informed by the resident that the FM was touching her inappropriately and the psychologist notified the social worker (SW), police, and Adult Protective Services (APS) the same day. Progress notes documented that the SW met with the resident to clarify concerns, that APS and police were notified, and that the SW informed the DON, administrator, and charge nurse. Interviews with the RN, SW, psychologist, ADON, DON, and administrator confirmed that facility leadership was aware of the allegation of inappropriate sexual touching by the FM and that internal steps were taken to ensure supervised visitation and to notify law enforcement and APS. However, review of the TULIP reporting system showed no incident report submitted to the State Survey Agency (HHSC) regarding this allegation. The administrator acknowledged in interviews that she was responsible for reporting allegations of abuse or neglect to the state and that she did not report this allegation. She stated she had conducted an investigation but did not believe the situation constituted abuse because the resident told her the FM “always did this and he thought it was funny” and did not explicitly state to her that it was without consent. The facility’s Abuse Prevention Program policy required that all alleged violations involving abuse be reported immediately, but not later than two hours, to the state licensing/certification agency and other appropriate agencies, and that all reports of resident abuse be promptly reported to local, state, and federal agencies and thoroughly investigated. Despite this policy and staff recognition that such allegations should be reported to the state, the allegation involving this resident was not reported to the State Survey Agency.
Failure to Report Sexual Abuse Allegation Investigation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report the results of an abuse investigation to the State Survey Agency within the required timeframe, as mandated by federal and state requirements and the facility’s own Abuse Prevention Program. A resident with aphasia following a stroke, dysphagia, major depressive disorder, generalized anxiety disorder, and moderate cognitive impairment (BIMS score of 10) reported concerns about the conduct of her family member (FM) during visits. Her care plan documented that she had voiced concerns about the FM’s conduct, that visits were to be supervised in common areas during daytime hours when administration was present, and that police had been notified. The care plan also reflected multiple care areas, including ADL deficits, severe mental illness with antidepressant and anti-anxiety medications, communication problems, fall risk, and mood/psychosocial problems with APS and psychological services involved. According to the police report and facility progress notes, the resident told the psychologist that the FM had been touching her vaginal area, placing his hand under her clothing and making direct contact with her vaginal area without her consent. The psychologist notified the social worker (SW), who then met with the resident to clarify concerns and documented that APS and the police department were notified. The resident stated she did not want to press criminal charges but wanted supervised visitation. Interviews with the RN, SW, psychologist, ADON, and DON confirmed that the resident had reported inappropriate touching by the FM, that law enforcement and APS were contacted, and that supervised visitation parameters were put in place. The DON and ADON both stated that allegations of abuse or neglect should be reported to the state and that the administrator was responsible for making such reports. Record review of the facility’s investigation showed that the administrator was notified by the SW of the allegations and that the administrator interviewed the resident. The administrator acknowledged that she conducted an investigation but did not report the allegation or the investigation findings to the State Survey Agency. She stated she did not think it was abuse because the resident told her the FM “always did this and he thought it was funny” and did not, in the administrator’s view, clearly state it was without consent. TULIP review showed no incident report submitted regarding this allegation. This inaction conflicted with the facility’s Abuse Prevention Program, which requires all alleged violations involving abuse to be reported immediately (within two hours if involving abuse) and that a written report of the investigation findings be provided to appropriate agencies within five working days of the incident.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for residents to call for staff assistance, as required. Observations on multiple halls revealed that the call lights in the rooms of seven residents were not within their reach. In several cases, the call lights were found hanging over chairs, on the floor, on top of wheelchairs, or behind beds, making it impossible for the residents to access them when needed. These findings were confirmed during observations conducted by surveyors on the same day. The residents affected had significant medical histories, including muscle weakness, lack of coordination, repeated falls, and varying levels of cognitive impairment as indicated by their BIMS scores. Their care plans specifically included interventions to ensure that call lights were within reach due to their high risk for falls and need for assistance with activities of daily living (ADLs). Despite these documented needs, the call lights were not positioned appropriately at the time of the survey. Interviews with nursing staff, including LVNs and RNs, confirmed that the expectation was for call lights to be within reach of residents and that staff were supposed to check this during their rounds. Staff acknowledged that call lights could be moved or knocked off by residents, but also stated that they had procedures, such as using clips, to keep them accessible. The interim DON reiterated the expectation for call lights to be within reach and for staff to check their placement during rounds. Review of the facility's policy also confirmed the requirement for call lights to be accessible to residents when in bed.
Failure to Obtain Physician Order for Bolster Mattress Used as Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. Specifically, a resident with a history of lack of coordination, muscle weakness, and seizures was observed with a bolster mattress on the bed. Review of the resident's care plan and physician orders revealed that there was no physician order for the use of the bolster mattress, and the care plan did not include this intervention. The resident required total assistance with activities of daily living and was at risk for falls and seizures, but the use of the bolster mattress was not documented as an intervention in the care plan. During interviews, staff members, including an LVN and the Interim DON, were unsure whether a physician order was required for the bolster mattress and confirmed that no such order was present. The facility's policy indicated that physical restraints should only be used when warranted by medical symptoms and with appropriate orders. The lack of a physician order for the bolster mattress constituted a failure to ensure the resident's environment was free from unnecessary physical restraints.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required respiratory equipment, as evidenced by improper storage of nebulizer and CPAP masks. Observations revealed that two residents had nebulizer masks left unbagged—one on a nightstand and another in a drawer—while a third resident's CPAP mask was also found unbagged on a nightstand. Interviews with nursing staff confirmed that it was their responsibility to ensure masks were bagged after use to prevent infection, but they admitted to forgetting or needing to remind residents to do so. The interim DON stated that masks should be air dried and then bagged, but acknowledged that sometimes residents removed the masks from the bags. Record reviews indicated that all three residents had relevant diagnoses requiring respiratory care, such as chronic cough, shortness of breath, COPD, and sleep apnea, and each had care plans and physician orders specifying the use of respiratory equipment. The facility's own policy on infection prevention for respiratory therapy equipment was not followed, as the masks were not properly stored when not in use, contrary to professional standards and the residents' care plans.
Failure to Provide Adequate Supervision During Meal Service for Resident on Pureed Diet
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of aspiration pneumonia, oropharyngeal dysphagia, and a physician-ordered pureed diet was not provided adequate supervision during a lunch meal. The resident, who required assistance with eating and was known to be noncompliant with her diet due to her cognitive status, was seated at a table with another cognitively impaired resident who was on a regular diet. No staff were directly supervising or assisting her at the time, despite five staff being present in the dining room. During the meal, the resident was able to feed herself and was observed to take a regular sugar cookie offered by the other resident at her table. She ate the cookie, which was not consistent with her prescribed pureed diet, and began coughing several times before finishing it. Staff in the dining room did not notice the incident or intervene, and the resident was able to finish the cookie and her meal without further immediate incident. The resident's care plan and CNA Kardex both indicated she required assistance and supervision with eating, and her history included previous episodes of aspiration and pneumonia related to swallowing difficulties. Interviews with staff revealed that the resident was known to take food from others and from snack carts, and that staff had previously voiced concerns about her access to non-pureed foods. The seating arrangement in the dining room did not account for her supervision needs, and staff were unclear about their responsibilities for monitoring residents with special dietary requirements. The incident was not immediately recognized or addressed by staff present, and the facility did not have a specific policy on accident hazards related to dining supervision at the time of the event.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the handling and maintenance of respiratory equipment. Resident #1, a male with chronic pulmonary embolism, was observed with a nasal cannula improperly stored on the bed's grab bars and not bagged when not in use. The nasal cannula and humidifier had not been changed weekly as required, with the last change dated over a week prior. Additionally, there was no 'Oxygen in Use' sign outside the resident's door, which is necessary for safety precautions. Resident #2, a female with chronic obstructive pulmonary disease, was found with a nasal cannula not bagged when not in use, as it was left on the bed. The resident was unaware of the need to bag the nasal cannula to prevent contamination. This oversight in proper storage and handling of the nasal cannula could lead to potential respiratory infections. Resident #3, a female with sleep apnea, had a BiPAP mask that was not bagged and was found with a white substance on it, indicating it was not cleaned properly. The mask was stored in a drawer without a bag, increasing the risk of contamination. The resident sometimes refused to wear the BiPAP due to noise, and staff did not ensure the mask was cleaned and stored correctly after use.
Failure to Review and Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for one resident. This deficiency was identified during interviews and record reviews, which revealed that the care plan for an 86-year-old male resident with diagnoses including dementia, chronic kidney disease stage 3, and benign prostatic hyperplasia was not reviewed or updated quarterly. The resident, who was cognitively intact and required assistance for activities of daily living, had not been involved in a care plan meeting since the previous year, despite expressing concerns about his medication list and discharge plan. Interviews with facility staff, including the social worker, DON, and administrator, indicated that a system changeover had occurred, preventing access to previous resident records and care plan conferences. The social worker and DON were unsure of the exact date of the last care plan meeting, and the administrator acknowledged the inability to access records prior to the system change. The facility's policy on care planning emphasized the importance of involving the resident and their representatives in care plan development and revisions, but this was not adhered to in this case.
Resident Excluded from Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident had the right to participate in the development and implementation of his person-centered plan of care. This deficiency was identified for a resident who was cognitively intact, as indicated by a BIMS score of 13, and had diagnoses including dementia, chronic kidney disease stage 3, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident was not included in his Care Plan Conference, and the most recent care plan did not document his involvement. Interviews revealed that the resident expressed a desire to obtain a copy of his medication list and discuss his discharge plan, as he had not been involved in a care plan meeting since the previous year. Interviews with facility staff, including the Social Worker, DON, and Administrator, indicated that there was uncertainty about the last care plan meeting date due to a system changeover that affected access to previous records. The Social Worker acknowledged that the resident had not had a care plan conference this year and planned to schedule one soon. The Administrator confirmed the inability to access previous records due to the system change and stated that they were working on completing care plans for the current quarter. The facility's policy encourages resident participation in care plan development, but this was not adhered to in this case.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to protect the confidentiality of personal health care information for residents on Hall 300. During an observation, it was noted that the computer on Medication Cart 1 was left unlocked and unattended by a Certified Medication Aide (CMA B) while she assisted a resident in a room. This lapse occurred for approximately two minutes, during which time residents and a housekeeper passed by the unlocked computer, which displayed the names and medication information of residents on the hall. CMA B, who had been employed at the facility for four months, acknowledged that she was aware of the requirement to lock the computer but forgot to do so in this instance. The facility's policy on resident rights, revised in October 2022, emphasizes the importance of privacy and confidentiality, which was compromised in this situation.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to provide a sanitary environment for a resident, who was one of four residents reviewed for environmental conditions. The resident, an 86-year-old male with diagnoses including dementia, chronic kidney disease stage 3, and benign prostatic hyperplasia, was found to have a bed with urine-stained sheets that had not been changed. The resident reported that he had wet the bed the previous night, and the sheets had not been changed, leaving the mattress wet and the sheets nearly dry. The resident expressed that staff typically did not change his sheets, and he often had to wait for them to dry before using the bed. Interviews with staff revealed that the certified nursing assistant (CNA) responsible for the resident's hall was unaware of the need to change the linens, as she had just started her shift. The facility's policy indicated that CNAs were responsible for changing linens on shower days or as needed if they were soiled. The administrator confirmed that linens should be changed if soiled to prevent infection control issues or skin breakdown. The facility's policy on resident rights emphasized the right to a dignified existence, which includes a safe, clean, and comfortable environment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments on Hall 300, as observed on April 16, 2024. Medication Cart 1 was found unlocked and unattended, with all drawers accessible, while a Certified Medication Aide (CMA) was assisting a resident in a nearby room. This lapse in protocol occurred despite the presence of residents and a housekeeper in the vicinity, posing a risk of unauthorized access to medications. The CMA involved had been employed at the facility for four months and acknowledged awareness of the requirement to lock the medication cart when not in sight. However, she admitted to forgetting to lock the cart while attending to a resident's needs. The facility's policy, revised in April 2019, clearly states that unlocked medication carts should not be left unattended, highlighting a breach in adherence to established procedures.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, which resulted in inadequate PPE usage and hand hygiene practices by two CNAs. CNA A and CNA B did not wear the necessary PPE while repositioning a COVID-19 positive resident and delivering breakfast trays to another COVID-19 positive resident. Additionally, CNA A did not perform hand hygiene while delivering and picking up breakfast trays from residents on the 300 hall, including both COVID-19 positive and negative residents. Resident #1, who had multiple diagnoses including dementia and respiratory failure, required substantial assistance with bed mobility. CNA A and CNA B entered her room with only N95 masks, failing to wear gowns, gloves, and face shields as required. They did not perform hand hygiene after repositioning her. Similarly, Resident #2, who was cognitively intact but required assistance with eating, was visited by CNA A who only wore a N95 mask and did not perform hand hygiene after delivering her breakfast tray and milk. The facility's Director of Nursing (DON) confirmed that staff were aware of the COVID-19 positive residents and the required PPE protocols. However, the PPE carts on the 300 hall were inadequately stocked, and the CNAs did not inform the nurses about the shortage. The DON acknowledged that the failure to wear proper PPE and perform hand hygiene placed residents at risk of infection. Interviews with the CNAs revealed they were aware of the PPE requirements and hand hygiene protocols but did not follow them due to the lack of supplies and oversight.
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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 Lewisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sandy Lake Rehabilitation And Care Center | 2.5 mi | ★★★★★ | 31 | 0 |
| Heritage Gardens Rehabilitation And Healthcare | 3.9 mi | ★★★★★ | 5 | 0 |
| Brookhaven Nursing And Rehabilitation Center | 5.1 mi | ★★★★★ | 5 | 1 |
| Carrollton Health And Rehabilitation Center | 5.3 mi | ★★★★★ | 10 | 0 |
| Lake Village Nursing And Rehabilitation Center | 5.6 mi | ★★★★★ | 14 | 0 |
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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 July 2026) and official state health department websites.