Ridgecrest Healthcare and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 2 of 10 (Residents #1 and #2) reviewed for abuse. The facility did not ensure the Abuse Coordinator implemented their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 11/09/25 between Resident #1 and Resident #2. This deficient practice could place residents at risk of unreported abuse, neglect, and a decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 10 (Residents #1 and #2) residents reviewed for reporting. The facility did not report the resident-to-resident altercation between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of been notified on 11/09/25. This failure to report could place the residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to have evidence alleged violations were thoroughly investigated for 1 of 18 (Resident #1) residents reviewed for abuse and neglect. The facility did not provide evidence of immediate corrective actions implemented according to the Provider Investigation Report of a Resident to Resident verbal altercation that occurred on 11/21/25 to include evidence that staff were provided and received the in-service training on abuse and neglect and the facility failed to provide evidence that Resident # 1 was monitored for 1:1 supervision for 1 of 5 (11/23/25) days. This failure could place residents at risk for abuse or neglect in that that facility did not thoroughly investigate the alleged violations and take appropriate corrective action as a result of the investigation findings.

Inspectors wroteBased on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 7 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure a pulse and blood pressure was not recorded for Resident #1 on 3/26/26 when she was discharged to the hospital on 3/25/26 and had not returned to the facility. The facility failed to ensure the ADON charted the correctly dated vital signs on skilled nursing notes for Resident #1 on 3/22/26, 3/23/26, and 3/24/26. The facility failed to ensure the ADON did not chart skilled nursing notes on Resident #1 on 3 days (3/26/26, 3/27/26, and 3/28/26) after she had been admitted to the hospital. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and appetizing temperature for the lunch meal on 7/29/25. The facility failed to follow puree recipe for carrots served on 7/29/25 (lunch meal). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, 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 for dietary services, in that: 1) The Dietary staff failed to label and date all food items. 2) Dietary staff failed to effectively reseal, label and date frozen and refrigerated food items. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, for 1 of 8 residents (Resident #9) reviewed for abuse and neglect reporting. The facility failed to report to HHSC within 2 hours when Resident #9 alleged Resident #57 hit her on 06/17/2025. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 28 residents (Resident #11) reviewed for MDS assessment accuracy. The facility failed to accurately document Resident #11's tobacco use. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment was completed for 1 of 4 residents (Resident #7) reviewed for PASRR Level I screenings. The facility failed to complete the PASRR level 1 screening for Resident #7 who was admitted on [DATE] and had a diagnosis of Schizophrenia on admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment PE (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Resident #123 and Resident #127) of 22 residents reviewed for baseline care plans. The facility failed to address Resident #123's vascular dementia diagnosis on her baseline care plan. The facility failed to ensure Resident #127's baseline care plan was completed within 48 hours of admission. These deficient practices could affect residents who are admitted to the facility with specialized needs and result in missed care. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 28 residents (Residents #5 and Resident #112) reviewed for care plans. 1. The facility failed to ensure Resident #5's care plan included her fall on 07/19/25 and the use of the non-strip strips and cervical collar (a collar used around the neck to support the neck and spinal cord after an injury) that should always remain in place. 2. The facility failed to update Resident #112's care plans for nectar thick liquids on 06/27/25. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 28 residents (Resident #110) reviewed for ADLs. The facility failed to provide Resident #10's showers as scheduled for the month of July 2025. These failures could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life.

Inspectors wroteBased on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #123) The facility failed to begin neurological checks when Resident #123 had an unwitnessed fall on 07/30/25 at 3:10 PM. These failures could place residents at risk of a delay in treatments for the resident's conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure Resident #11 did not smoke a cigarette in the facility on 12/08/2024 and 07/11/2025. The facility failed to ensure Resident #11 was provided supervision while smoking on 07/29/2025. These failures could place residents at risk of accidents, injuries, or burns.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents reviewed for respiratory care. (Resident #42) The facility failed to administer Resident #42's oxygen as ordered on 07/28/25, 7/29/25, and 7/30/25. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications. (Resident #123) The facility failed to ensure Resident #123 had a diagnosis or adequate indication for quetiapine (Seroquel) (An antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). The facility failed to ensure the proper consent form 3713 was completed prior to administering the medication quetiapine (Seroquel). This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 6 residents (Resident #60) and 1 of 3 medication carts (300-Hall nurse medication cart) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #60's medication labels for her amlodipine, carbidopa-levodopa, clopidogrel, and hydralazine matched her physician order. 2. The facility failed to ensure LVN D secured the 300-Hall nurse medication cart when it was not in use and unattended on 07/29/2025. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #7) reviewed for hospice services. The facility failed to maintain Resident #7's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, and physician recertification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #22 and Resident #53) and 2 of 2 staff (Treatment Nurse and Laundry Supervisor) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse changed her gloves when she removed Resident #22's dirty dressing on 07/29/25. 2. The facility failed to ensure the Treatment Nurse used proper PPE when providing wound care for Resident #53 on 07/30/25. 3. The facility failed to ensure the Laundry Supervisor was aware of Resident #53 being under contact isolation. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E wore PPE while providing catheter care on Resident #2 on 03/26/25. 2. The facility failed to ensure LVN A wore the proper PPE (gown and gloves), changed her gloves, and performed hand hygiene while performing wound care on Resident #1 on 03/25/25. These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. Findings Include: 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 10 residents (Resident #1) reviewed for developing and implementing abuse policies. The facility failed to follow its policy to report to the Texas Health and Human Services Commission (HHSC) when Resident #1 alleged that LVN B did not do her treatment on 03/21/25 and she felt neglected. The facility staff did not report to the state agency that Resident #1 felt neglected by her missed wound treatment on 03/21/25. This failure could place residents at risk of neglect, abuse, mental anguish, and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 (Resident #1) residents reviewed for quality of care. The facility failed to ensure that LVN B did Resident #1's left axilla wound treatment as ordered on 03/21/25. This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report to the state agency Resident #1's bruising to left brow, temple, and behind right knee on 9/22/24. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 (Resident #1) residents reviewed for quality of care. The facility failed to ensure Resident #1's right heel arterial wound treatment orders were updated in the electronic medical records. This failure could result in residents with wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1's pressure wounds to her sacrum (a triangular bone at the base of the spine) and left calf were treated as ordered by the Wound Care Physician. These failures could place residents at risk for worsening of existing pressure injuries, infection, pain, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 1 of 4 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had orders for oxygen therapy. This failure could place residents at risk of not receiving a therapeutic level of oxygen therapy .

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse), and 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while performing wound care on Resident #1 and Resident #2 These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to ensure the ice machine, located in the facility's kitchen, was cleaned. The facility failed to ensure the tea dispenser was covered after being used. The facility failed to ensure kitchen equipment (food storage bins) were cleaned and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 (Resident #7, #26, #40, #76, #86, and#150) of 20 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #7's, #26's, #40's, #76's, #86's, and#150's rooms were cleaned and sanitized . This deficient practice could place residents at risk of living in an unclean and unsanitary environment.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Residents #26, #76 and #112) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #26's, #76's and #112's breathing masks were stored in a sanitary manner when they were not being used by the residents. The facility failed to ensure that Resident #76's CPAP mask properly fit the resident and ensured the resident's CPAP machine operated properly. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #11) of 1 resident reviewed for Care Plans. The facility failed to ensure Resident #11 was care planned for Dialysis. This failure could place the resident at risk of needs not being met.