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Cedar Ridge Rehabilitation and Healthcare Center
1700 N Washington St, Pilot Point, TX 76258 · CMS Certification Number (CCN) 455930
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 34 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 19 from complaints)
- Fire safety citations
- 5
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- April 1, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 2.7 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 1, 2026 | 10 | 9 | 2 |
| Cycle 2 | January 16, 2025 | 21 | 8 | 17 |
CMS weighted health inspection score: 75 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
34 health citations across 8 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
April 1, 2026: 9 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| E | F-0680 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/02/2026 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/02/2026 |
November 25, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/01/2025 |
June 20, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 06/21/2025 |
April 30, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/05/2025 |
January 16, 2025: 8 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/17/2025 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/17/2025 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/17/2025 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/17/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/17/2025 |
| E | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/17/2025 |
| E | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/17/2025 |
| E | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 01/17/2025 |
December 17, 2024: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/18/2024 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/18/2024 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/18/2024 |
November 30, 2023: 8 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/15/2023 |
| E | F-0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/15/2023 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/15/2023 |
| F | F-0801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/15/2023 |
| D | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/15/2023 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/15/2023 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/15/2023 |
| E | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 12/15/2023 |
September 14, 2023: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2023 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2023 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/18/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
5 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 04/01/2026 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/15/2026 |
| 01/16/2025 | F | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 01/22/2025 |
| 01/16/2025 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/22/2025 |
| 11/30/2023 | F | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 12/15/2023 |
| 11/30/2023 | D | K-0300 | Meet other general requirements that are deficient. Egress Deficiencies | Deficient, Provider has date of correction Corrected 12/15/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.57 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.3 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.04 | Not published | Not published |
| Nurse aide hours per resident per day | 2.24 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.39 | Not published | Not published |
| RN hours per resident per day, weekends | 0.17 | Not published | Not published |
| Total nursing staff turnover (%) | 49.5 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 71.4 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Nexion Health at Pilot Point, INC.
- Ownership type
- For profit - Corporation
- Chain
- Nexion Health (51 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 108
- Average residents per day
- 81.7
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- July 18, 1991
- County/parish
- Denton
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
19 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| NEXION HEALTH OF OHI INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| NEXION HEALTH LEASING, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| NEXION HEALTH, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| BOLT, BRETTON | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| KIRLEY, FRANCIS | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| ROWAN, TERRY | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HERDRICH, WILLIAM | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KIRLEY, FRANCIS | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| REID, JOHN | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RINER, MEERA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FALLON, JOHN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KIRLEY, FRANCIS | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LEE, BRIAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RINER, MEERA | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NEXION HEALTH LEASING, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NEXION HEALTH OF OHI INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NEXION HEALTH, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| KIRLEY, FRANCIS | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RINER, MEERA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Cedar Ridge Rehabilitation and Healthcare Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.