Inspection Report Summary
The most recent inspection on November 26, 2025, found deficiencies related to physical restraints, respiratory care, and call light accessibility. Earlier inspections showed a pattern of issues with respiratory care, care planning, infection control, and resident supervision, including a substantiated complaint involving inadequate supervision that led to an immediate jeopardy finding later removed. Inspectors cited problems such as lack of physician orders for restraints, improper storage and cleaning of respiratory equipment, inaccessible call lights, and failures in infection prevention and resident rights. Complaint investigations included substantiated cases of inadequate supervision and resident abuse, with staff termination and corrective actions taken. The facility’s inspection history shows recurring themes in respiratory care and resident safety, with some improvement noted between inspections but persistent challenges over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including the use of physical restraints, respiratory care, and the accessibility of call light systems in the facility.
Findings
The facility was found deficient in ensuring residents were free from unnecessary physical restraints, providing safe and appropriate respiratory care, and maintaining accessible call light systems for residents. Specific issues included lack of physician orders for physical restraints, improper storage of respiratory masks, and call lights being out of residents' reach.
Deficiencies (3)
Failed to ensure Resident #3 had physician orders for the bolster mattress used as a physical restraint.
Failed to ensure proper storage of nebulizer and CPAP masks for Residents #3, #8, and #10, increasing risk of respiratory infection.
Failed to ensure call light systems were accessible to seven residents (#1, #2, #4, #5, #6, #7, and #9), placing them at risk of not obtaining assistance.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN I | Interviewed regarding physician orders for bolster mattress and respiratory mask storage | |
| Interim DON | Director of Nursing | Interviewed regarding physician orders for bolster mattress, respiratory mask storage, and call light accessibility |
| LVN B | Interviewed regarding respiratory mask storage and call light accessibility | |
| RN S | Interviewed regarding call light accessibility |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and assistive devices to prevent accidents, specifically related to Resident #1 who was a known aspiration risk and was observed eating outside her prescribed pureed diet.
Complaint Details
The complaint investigation found that Resident #1 was not supervised during lunch on 04/01/25 and ate a non-pureed cookie offered by another resident, leading to coughing and risk of aspiration. The facility was cited for failure to provide adequate supervision despite multiple staff being present. An Immediate Jeopardy was identified and later removed after corrective actions, but the facility remained out of compliance.
Findings
The facility failed to ensure adequate supervision of Resident #1 during a lunch meal, resulting in the resident eating a non-pureed cookie which led to coughing and risk of aspiration. Multiple staff were present but did not intervene. The facility was found out of compliance with an Immediate Jeopardy identified and later removed, but remained out of compliance at a severity level of no actual harm with potential for more than minimal harm.
Deficiencies (1)
Failure to ensure adequate supervision and assistive devices to prevent accidents for Resident #1, a known aspiration risk, who ate outside her modified pureed diet.
Report Facts
Residents affected: 1
Date of Immediate Jeopardy identification: Apr 1, 2025
Date Immediate Jeopardy removed: Apr 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Assigned to check meal tickets and supervise residents during lunch; did not notice Resident #1 eating non-pureed cookie. |
| SDC D | Staff Development Coordinator | Responsible for monitoring residents' intake and supervision during meals; did not intervene when Resident #1 ate non-pureed cookie. |
| DON | Director of Nursing | Notified about the incident; described staffing and supervision plans; involved in corrective actions. |
| ADM | Administrator | Involved in family notification, waiver discussions, and implementation of corrective actions. |
| CNA B | Certified Nursing Assistant | Resident #1's CNA; provided observations about seating and supervision issues. |
| C-RN | Charge Registered Nurse | Contacted Resident #1's family about the incident and diet waiver. |
| SLP | Speech-Language Pathologist | Provided information on Resident #1's swallowing difficulties and diet requirements. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
The document is an annual inspection report for Vista Ridge Nursing & Rehabilitation Center conducted as part of regulatory oversight to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 5
Date: May 22, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with respiratory care standards for residents requiring oxygen therapy and related respiratory support.
Findings
The facility failed to ensure proper respiratory care for three residents, including improper storage and cleaning of nasal cannulas and BiPAP masks, failure to change equipment weekly, and lack of Oxygen in Use signage outside resident rooms, potentially placing residents at risk for respiratory infection.
Deficiencies (5)
Failure to ensure Resident #1's nasal cannula was stored properly.
Failure to ensure Resident #1's nasal cannula and humidifier were changed weekly.
Failure to ensure there was an Oxygen in Use sign outside Resident #1's door.
Failure to ensure Resident #2's nasal cannula was stored properly.
Failure to ensure Resident #3's BiPAP mask was cleaned and stored properly.
Report Facts
Oxygen flow rate: 2
BIMS score: 4
BIMS score: 14
BIMS score: 9
Weekly change interval: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Acknowledged BiPAP mask was not bagged and needed cleaning and replacement |
| LVN B | Licensed Vocational Nurse | Reported BiPAP mask was not bagged and should be cleaned and bagged after use |
| Administrator | Stated expectations for weekly changes of humidifier and nasal cannula and bagging of BiPAP mask | |
| DON | Director of Nursing | Explained importance of weekly changes and bagging of respiratory equipment and oxygen signage |
| ADON | Assistant Director of Nursing | Acknowledged missing Oxygen in Use sign and improper storage of nasal cannula and humidifier |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, privacy, environment, care planning, and medication storage at Vista Ridge Nursing & Rehabilitation Center.
Findings
The facility failed to ensure Resident #1's participation in care plan development, maintain confidentiality of resident information, provide a sanitary environment, update care plans timely, and secure medication storage. These failures posed risks of inadequate care, loss of privacy, unsanitary living conditions, unmet resident needs, and medication misuse.
Deficiencies (5)
Failed to allow resident to participate in the development and implementation of his person-centered plan of care.
Failed to protect confidentiality of personal health care information by leaving medication cart computer unlocked and unattended.
Failed to provide a sanitary environment by not ensuring resident's bed was made with clean linens and free of urine stains.
Failed to develop and revise comprehensive care plans timely and ensure interdisciplinary team review.
Failed to store all drugs and biologicals in locked compartments; medication cart left unlocked and unattended.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA B | Named in confidentiality and medication storage deficiencies for leaving computer and medication cart unlocked | |
| Administrator | Interviewed regarding system change affecting care plan access and acknowledged medication storage risks | |
| Social Worker | Interviewed about care plan meetings and system change affecting record access | |
| DON | Director of Nursing | Interviewed about care plan meetings and record access issues |
| CNA A | Interviewed regarding linen changing responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 3, 2024
Visit Reason
The inspection was conducted due to concerns about infection prevention and control practices, specifically related to COVID-19 precautions and PPE use by staff.
Complaint Details
The complaint investigation found that CNA A and CNA B did not wear required gowns, gloves, or face shields when caring for COVID-19 positive residents and failed to perform hand hygiene before and after resident contact and while delivering and picking up breakfast trays. The facility had seven COVID-19 positive residents at the time. Staff reported PPE shortages on the 300 hall and lack of communication about restocking. The Director of Nursing and other staff confirmed the infection control failures and risks to residents.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, resulting in staff not wearing adequate PPE or performing hand hygiene while caring for COVID-19 positive residents. This placed residents at risk for infection and potential health decline.
Deficiencies (3)
Failure to wear adequate PPE while repositioning COVID-19 positive Resident #1.
Failure to wear adequate PPE while delivering and setting up COVID-19 positive Resident #2's breakfast tray.
Failure to perform hand hygiene while delivering and picking up breakfast trays from residents on the 300 hall.
Report Facts
COVID-19 positive residents: 7
Deficiencies cited: 3
BIMS scores: 8
BIMS scores: 14
BIMS scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in infection control deficiencies for failing to wear adequate PPE and perform hand hygiene |
| CNA B | Certified Nursing Assistant | Named in infection control deficiencies for failing to wear adequate PPE and perform hand hygiene |
| LVN C | Licensed Vocational Nurse | Interviewed regarding PPE shortages and infection control awareness |
| DON | Director of Nursing | Interviewed regarding infection control policies and staff training |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, inadequate cleaning of resident rooms and handrails, lack of physician orders for oxygen supplementation upon admission, incomplete and inaccurate care plans for residents, failure to maintain residents' weight monitoring as ordered, improper respiratory care including unbagged nasal cannulas and overdue humidifier changes, and failure to properly sanitize blood pressure cuffs between residents.
Deficiencies (7)
Failure to ensure call light system was accessible to Resident #11.
Failure to provide a safe, clean, comfortable, and homelike environment including cleaning and sanitizing resident rooms and handrails.
Failure to obtain physician orders for oxygen supplement for Resident #11 at the time of admission.
Failure to develop and implement comprehensive person-centered care plans including oxygen administration for Residents #11 and #22, malnutrition for Resident #7, and speech therapy for Resident #82.
Failure to assess Resident #7's weight weekly per physician orders, resulting in more than 5% weight loss in a month.
Failure to provide safe and appropriate respiratory care including unbagged nasal cannulas for Residents #11 and #64 and failure to change Resident #32's humidifier on oxygen concentrator within 7 days.
Failure to sanitize blood pressure cuff between Residents #3, #16, and #31.
Report Facts
Weight loss percentage: 5.5
Weight loss amount: 7.62
Physician order date: 2023
Humidifier change interval: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN O | Licensed Vocational Nurse | Interviewed regarding call light accessibility, oxygen supplement use, and nasal cannula handling for Resident #11. |
| CNA H | Certified Nursing Assistant | Interviewed regarding call light placement and nasal cannula handling. |
| CNA G | Certified Nursing Assistant | Interviewed regarding call light importance and nasal cannula handling. |
| LVN B | Licensed Vocational Nurse | Interviewed regarding call light importance, oxygen supplement care plans, and infection control. |
| ADON N | Assistant Director of Nursing | Interviewed regarding call light importance, physician orders, care plans, respiratory care, and infection control. |
| DON | Director of Nursing | Interviewed regarding call light importance, physician orders, care plans, respiratory care, and infection control. |
| Administrator | Facility Administrator | Interviewed regarding system failures, oversight, and quality assurance plans. |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding cleaning practices and staff training. |
| Housekeeper F | Housekeeper | Interviewed regarding cleaning practices. |
| MDS Nurse W | Minimum Data Set Nurse | Interviewed regarding care plan development and oversight. |
| MDS Nurse M | Minimum Data Set Nurse | Interviewed regarding care plan development and oversight. |
| Speech Pathologist | Speech Therapist | Interviewed regarding speech therapy care planning for Resident #82. |
| Social Worker | Social Worker | Interviewed regarding care plan meetings and documentation. |
| CNA C | Certified Medication Aide | Observed and interviewed regarding failure to sanitize blood pressure cuff between residents. |
| LVN A | Licensed Vocational Nurse | Interviewed regarding weight monitoring and oxygen concentrator care. |
| LVN C | Licensed Vocational Nurse | Interviewed regarding nasal cannula handling for Resident #64. |
| Regional Clinical Reimbursement | Regional Clinical Reimbursement (RCR) | Interviewed regarding care plan policies and weight monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to respect Resident #32's right to refuse glucose testing and to ensure the resident's rights were upheld.
Complaint Details
The complaint involved Resident #32 alleging that LVN B forcibly performed a blood glucose test despite the resident's refusal, twisting his finger and causing pain. The staff member was suspended pending investigation and later terminated for abuse. The facility conducted in-services on resident rights and abuse prevention following the incident.
Findings
The facility failed to honor Resident #32's right to refuse care, specifically glucose testing, resulting in minimal harm. The nurse forcibly performed a blood glucose test despite the resident's refusal, causing pain and emotional distress. The staff member involved was terminated. The facility implemented in-services on resident rights, abuse prevention, and respect/dignity.
Deficiencies (2)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, specifically refusal of glucose testing.
Failure to protect the resident from abuse, neglect, and exploitation, including physical abuse by twisting the resident's finger during glucose testing against his will.
Report Facts
Residents Affected: 1
BIMS score: 14
Admission date: May 2, 2017
Date of incident: May 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in the abuse finding for forcibly performing glucose testing against resident's refusal; employment terminated. |
| LVN A | Licensed Vocational Nurse | Assisted Resident #32 and provided statements regarding resident's right to refuse care. |
| CNA C | Certified Nursing Assistant | Provided interview statements about resident preferences and abuse in-service participation. |
| DON | Director of Nursing | Conducted injury assessment, ordered x-rays, suspended and terminated LVN B, and initiated staff in-services on resident rights and abuse prevention. |
| Administrator | Facility Administrator | Expected staff to respect resident rights and reported staff removal and termination following investigation. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
The document is an annual inspection report for Vista Ridge Nursing & Rehabilitation Center, summarizing the findings of the survey completed on 08/18/2022.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are both listed as unknown.
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