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Complaint Investigation

Vista Ridge Nursing & Rehabilitation Center

Inspection Date: November 26, 2025
Total Violations 3
Facility ID 676036
Location LEWISVILLE, TX
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Inspection Findings

F-Tag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0604

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of three residents (Resident #3) reviewed for restraints. The facility failed to ensure Resident #3 had physician orders for the bolster mattresses on her bed. This failure could place residents at risk of not having an environment free from physical restraints.Findings included: Record review of Resident #3's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old male admitted to the facility on [DATE REDACTED]. Relevant diagnoses included lack of coordination and seizures (uncontrolled movements). Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 9 indicating moderate cognitive impairment.

The resident had active diagnoses of muscle weakness and seizures. Record review of Resident #3's Comprehensive Care Plan, dated 10/05/25, reflected a plan of care for risk of falls and seizures. None of

the care plans reflected an intervention for the use of a bolster mattress. For ADL care, it reflected the resident required total assistance Record review of Resident #3's physician orders, dated 10/07/25, reflected no physician order for the bolster mattress. In an observation on 10/07/25 at 8:26 AM, Resident #3 was observed with a bolster mattress on her bed. In an interview and observation on 10/07/25 at 8:30 AM, LVN I stated she was not sure if Resident #3 had physician orders for the bolster mattress but would check.

LVN I checked and she stated the resident had the bolster mattress care planned but she did not have physician orders. In an interview on 10/07/25 at 8:45 AM, the Interim DON and LVN I stated they were not sure if Resident #3 needed physician orders for the bolster mattress on her bed. The DON stated hospice may have orders for the device. They stated they were not aware of any risk to the resident if she did not have the physician orders but would work on obtaining orders for the bolster mattress. The facility's policy, Physical Restraints Application, dated October 2010, reflected, The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Vista Ridge Nursing & Rehabilitation Center

700 E Vista Ridge Mall Dr Lewisville, TX 75067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0695

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0695 Level of Harm - Minimal harm or potential for actual harm

treatments. When asked the risk of not bagging the mask, the DON just stared at me and initially did not say anything. She then repeated her expectations and stated sometimes the residents removed the mask from the bag. Review of the facility's policy Oxygen Use (Respiratory Therapy) Prevention of Infection, dated November 2011, reflected, The purpose of this procedure is to guide prevention of infection associated with the respiratory tasks and equipment, including ventilators, among residents and staff.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Vista Ridge Nursing & Rehabilitation Center

700 E Vista Ridge Mall Dr Lewisville, TX 75067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0919

Environmental Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

of the resident when they made their rounds. She stated she could not predict if something would happen to the resident, so she did not know the risk of not having the call light within reach of the resident, however

the expectation was for the residents to have their call light within reach if they need anything. Record

review of the facility's policy on Answering Call Lights, dated September 2022, revealed, The purpose of

this policy is to assure timely responses to the resident's requests and needs. Ensure the call light is assessable to the resident when in bed.

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

VISTA RIDGE NURSING & REHABILITATION CENTER in LEWISVILLE, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LEWISVILLE, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VISTA RIDGE NURSING & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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