Cycle 1
Health 2024-09-19 · Fire 2024-09-19
7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cleburne, TX
Ridgeview Rehabilitation And Skilled Nursing
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
206 Walls Dr, Cleburne, TX
(817) 645-0668
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
134
Certified beds
Average residents
101
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Dallas County Hospital District
Operator or chain grouping
Approved since
2008-09-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 2 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,370
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.55
Baseline 21.39% · Performance 20.71% · Measure score 1.55 · Achievement 1.55 · Improvement 1.04
Healthcare-associated infections
5.33
Baseline 7.37% · Performance 6.24% · Measure score 5.33 · Achievement 5.33 · Improvement 4.25
Total nurse turnover
3.46
Baseline 80.26% · Performance 58.33% · Measure score 3.46 · Achievement 1.31 · Improvement 3.46
Adjusted total nurse staffing
1.63
Baseline 3.37 hours · Performance 3.54 hours · Measure score 1.63 · Achievement 1.63 · Improvement 0.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.61% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 12.88% · Lower 95% interval 7.47% |
| Discharge to community | 56.78% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 53.1% · Lower 95% interval 49.53% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 104 · Denominator 106 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 106 |
| Discharge self-care score | 46.91% |
53.69%
6.8 pts worse
|
Numerator 38 · Denominator 81 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 36 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 106 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 3.96% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 5 · Denominator 110 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.62% |
56.45%
5.8 pts worse
|
Numerator 41 · Denominator 81 |
| Transfer of health information to provider | 98% |
95.95%
2 pts better
|
Numerator 49 · Denominator 50 |
| Transfer of health information to patient | 94.29% |
96.28%
2 pts worse
|
Numerator 33 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 14.81% |
25.2%
10.4 pts worse
|
Numerator 8 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 1.7% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.5% |
2.7%
4.8 pts worse
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 13.3% · Q3 1.9% · Q4 3.4% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.3%
0.9 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.0% · Q3 3.8% · Q4 3.4% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
18.9%
2.2 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 15.1% · Q3 16.4% · Q4 15.9% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
10.8%
2.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.1% · Q3 8.2% · Q4 8.8% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 35.7% |
15.4%
20.3 pts worse
|
16.3%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.1% · 4Q avg 35.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
16.1%
2.2 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 28.9% · Q3 17.1% · Q4 13.2% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
15.0%
6.9 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 21.7% · Q3 16.5% · Q4 21.9% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
4.2%
3.9 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
89.7%
6.6 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 96.6% · Q3 95.5% · Q4 95.5% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
12.0%
3.4 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 15.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
88.0%
9.9 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
25.9%
4.4 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 20.0% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-31
F · Potential for more than minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-07-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-07-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-30
F · Potential for more than minimal harm
2023-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-05-16
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-05-17
E · Potential for more than minimal harm
2025-05-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-17
D · Potential for more than minimal harm
2024-09-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
F · Potential for more than minimal harm
2023-07-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-07-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-17
E · Potential for more than minimal harm
2023-07-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-18
Penalties and ownership
What sits behind the stars
Ownership
Bradley, Shannan
Corporate Director · Individual
Bradley, Shannan
W-2 Managing Employee · Individual
Castaneda, Edmundo
Corporate Officer · Individual
Castaneda, Edmundo
W-2 Managing Employee · Individual
Cerise, Frederick
Corporate Director · Individual
Dallas County Hospital District
Operational/Managerial Control · Organization
J-S Cleburne Operations LP
Operational/Managerial Control · Organization
Porter, Chris
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Heritage Trails Nursing And Rehabilitation Center
Cleburne, TX
4-star overall rating with 4-star inspections with $67,124 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Colonial Manor Nursing Center
Cleburne, TX
4-star overall rating with 3-star inspections with $35,539 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Town Hall Estates Keene, Inc.
Keene, TX
3-star overall rating with 3-star inspections with $78,402 in total fines with 8 recent health deficiencies
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