Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Pointe Health And Wellness Center during CMS and state inspections, most recent first.
A resident with a history of repeated falls and multiple comorbidities had a care plan and Kardex that called for a fall mat at bedside and a low bed as fall-prevention interventions. Surveyors observed the resident in bed with no fall mat present and the wheelchair at bedside with brakes unlocked, despite staff interviews confirming that fall prevention practices included use of fall mats and locking wheelchair brakes. After a prior fall in which the resident attempted to get to the wheelchair, the IDT discussed the event, but the comprehensive care plan was not updated to include locking wheelchair brakes when the resident was not in the wheelchair, demonstrating a failure to fully develop and implement a comprehensive, person-centered fall-prevention care plan.
A resident with a history of repeated falls, vascular dementia, and dependence for transfers was care planned to have a fall mat at bedside and locked wheelchair brakes as fall-prevention interventions. On the survey day, the resident was observed in bed with the bed in low position and a wheelchair at the bedside, but without a fall mat and with both wheelchair brakes unlocked, despite these requirements being documented in the care plan and Kardex. Multiple CNAs, an RN, an LVN, the DON, ADON, and ADM all acknowledged that fall prevention for this resident included a bedside fall mat when in bed and locked wheelchair brakes when the wheelchair was at bedside, yet these measures were not in place at the time of observation.
A facility failed to ensure timely brief changes and ADL assistance for several residents who needed help with hygiene and toileting. Residents reported waiting too long between checks, including over 2 to 3 hours in some cases, and one resident was observed with a moderately wet brief and redness with excoriation on the buttock. Staff interviews showed inconsistent expectations for brief-change timing, and the DON stated there was no specific ADL care policy on brief changes.
The facility failed to maintain food safety standards in the kitchen and nourishment rooms. Observations found mold-like buildup inside the ice machine, along with multiple unlabeled and undated food items in the kitchen, walk-in cooler, freezer, and nourishment rooms, including leftovers, prepared foods, and frozen items. Staff interviews showed inconsistent understanding of who was responsible for labeling, dating, and cleaning, despite facility policies requiring food to be dated on receipt or preparation and the ice machine to be kept clean.
Call Light Left Out of Reach A resident with diagnoses including muscle weakness, gait and mobility abnormalities, and traumatic brain injury had a call light care plan directing staff to keep the device within reach. During observation, the call light was found on the floor out of reach while the resident was in bed and unable to retrieve it. The resident stated staff had not been placing it near him in his new room. Staff and leadership stated call lights should be within easy reach and that nursing staff were responsible for ensuring access.
Expired Insulin Glargine Administered During Med Pass: An LVN gave a resident with type 1 DM insulin glargine after checking the blood sugar but without verifying the medication’s expiration date. The vial had been opened beyond the 28-day limit, and the MAR showed multiple doses of expired insulin were given. The LVN said she knew she was responsible for checking expiration dates, while the DON stated staff were expected to check med cart expiration dates before administration.
A facility failed to ensure a resident received necessary treatment for pressure ulcers, leading to an increase in the size and severity of the ulcers. The staff did not place an order for a low air loss (LAL) mattress as prescribed, and the resident's condition worsened. Interviews revealed that the wound care nurse acknowledged the oversight, and the mattress was only ordered after the resident was hospitalized.
Failure to Implement and Update Fall-Prevention Care Plan Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple diagnoses, including schizoaffective disorder, COPD, repeated falls, vascular dementia, muscle wasting, and anxiety disorder. The resident’s quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented that he required partial/moderate assistance for bed mobility and was dependent for chair/bed transfers, with a history of falls without injury. The care plan dated 01/21/2026 documented falls on 01/17/2026 and 01/20/2026 and included an intervention, dated 01/19/2026, to implement a fall mat at the bedside and keep the bed in the lowest position, and the Kardex also reflected a fall mat intervention under the safety section. Despite these documented interventions, observations on 01/23/2026 at 2:29 PM and 3:20 PM showed the resident in bed with the bed in a low position, his wheelchair placed at the bedside with both brakes unlocked, and no fall mat present on either side of the bed. The incident report for the 01/17/2026 fall indicated the resident was found on the floor after attempting to get to his wheelchair, and that the IDT met and added fall mats as an intervention and updated the care plan. However, the comprehensive care plan was not updated to include locking the wheelchair brakes when the resident was not in the wheelchair, even though this was a relevant intervention following the fall where the resident attempted to reach his wheelchair. Interviews with CNAs and nursing staff confirmed that fall prevention practices at the facility included keeping beds in low position, ensuring call lights were within reach, locking wheelchair brakes when the wheelchair was at bedside, and using fall mats next to the bed when residents were in bed. Staff reported that they determined fall risk and interventions, such as fall mats, from the Kardex and care plan. The DON and ADM stated that the resident had an increase in falls and that fall mats were an intervention for this resident, and that the Kardex was triggered by the care plan. However, on the day of observation, staff interviews and room observations showed that the fall mat intervention documented in the care plan and Kardex was not implemented, and the specific intervention to ensure wheelchair brakes were locked when the resident was not in the wheelchair was not added to the resident’s comprehensive care plan after the fall on 01/17/2026, resulting in a failure to fully develop and implement a comprehensive person-centered care plan consistent with identified needs.
Failure to Maintain Fall Mat and Locked Wheelchair Brakes for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices to prevent accidents for one resident. The resident was an adult male with schizoaffective disorder, COPD, repeated falls, vascular dementia, muscle wasting and atrophy, and anxiety disorder. His quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented that he required partial/moderate assistance for bed mobility and was dependent for bed-to-chair transfers. He had a documented history of falls without injury, including falls on 01/17/2026 and 01/20/2026, after which the care plan and Kardex were updated to include a fall mat at bedside, bed in lowest position, and maintaining a clear pathway free of obstacles due to his fall risk related to vascular dementia and incontinence. On the survey date, observations at 2:29 PM and 3:20 PM showed the resident in bed with the bed in a low position and his wheelchair placed at the left side of the bed, but with both wheelchair brakes unlocked and no fall mat present on either side of the bed, despite the care plan and Kardex requiring a fall mat at bedside when he was in bed. During interview, the resident reported he had falls in the past and now asked for help to get in and out of bed. Review of the Kardex dated 01/23/2026 confirmed that a fall mat was to be implemented at bedside for safety. Multiple staff interviews confirmed that facility practice and resident-specific interventions required a fall mat at bedside when the resident was in bed and that wheelchair brakes should be locked when the wheelchair was at bedside. CNAs and nursing staff (CNA A, RN B, LVN C, CNA D, CNA E) described fall prevention as including bed in low position, call light within reach, use of fall mats at bedside for residents identified as fall risks, and locking wheelchair brakes to prevent the chair from moving if a resident attempted to sit or transfer. The DON, ADON, and ADM all stated that the resident had an increase in falls, that fall mats were an intervention in place for him, that this was communicated via the care plan and Kardex, and that the resident should have a fall mat whenever he was in bed and wheelchair brakes locked at bedside. Despite these documented interventions and staff knowledge, the resident was observed in bed without a fall mat and with wheelchair brakes unlocked on the day of survey.
Delayed Brief Changes and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received timely assistance with brief changes and personal hygiene for Resident #35, Resident #48, Resident #107, Resident #114, and Resident #117. Each of these residents had diagnoses and care plans reflecting a need for assistance or modified independence with bathing, hygiene, toileting, dressing, grooming, and other ADLs. Their records also showed cognitive scores ranging from BIMS 12 to 15, and their care plans directed staff to assist them with daily living care needs. During interviews, Resident #114 stated staff sometimes took too long to check and change her brief, explaining that she could be checked before she had wet the brief and then have to wait for the next round in two hours after she later voided. Resident #35 stated there were times staff took longer than every two hours to check briefs. Resident #48 stated it could be over three hours before her brief was changed and that this did not make her feel good. Resident #107 stated the timing was inconsistent, ranging from within five minutes to over one hour, and he did not like wearing a soiled brief. Resident #117 stated staff sometimes left during shift changes instead of changing his brief and that it could take the oncoming shift a long time to make rounds. An observation of Resident #48 showed her brief was moderately wet, her peri area appeared clean, and redness with top epidermal layer excoriation was present on the right buttock; she stated that area hurt when she laid on it. CNA G and CNA H stated they did not have barrier cream with them during the change, although they were trained to apply it during changes. The DON stated the facility did not have a specific ADL care policy on brief changes. Staff interviews reflected that ADL care and timely brief changing were expected to occur every 45 minutes to an hour or every two hours depending on the staff member interviewed, and that nursing staff, charge nurses, the DON, and the ADM were responsible for ensuring timely brief changes occurred. The facility’s ADL policy stated residents should receive assistance as needed with personal hygiene, grooming, dressing, toileting, transferring, ambulating, and eating, and that care plans and interventions should be based on resident needs, goals, and preferences.
Food Storage and Ice Machine Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and nourishment rooms. During observation, the ice machine in the kitchen had black and brown mold appearing substance growing on the inside, and the ice machine maintenance log showed the last recorded maintenance was dated 12/25. Staff interviews indicated the ice machine was expected to be cleaned daily by dietary aides and deep cleaned monthly by maintenance staff, but the observed condition did not reflect that standard. The facility also failed to label and date multiple food items in the kitchen, walk-in cooler, walk-in freezer, and nourishment rooms. Observations found undated and unlabeled bowls of cream of wheat or grits near the steam table, a saucepan of melted butter uncovered and unlabeled on the stove, and numerous refrigerated and frozen items without required preparation, open, discard, or use-by dates. These included oatmeal, chicken salad, pico de gallo, waffles, cheesy potatoes, vegetable blend, BBQ sauce, beans, chicken tenders, tuna salad, and grits. In the nourishment rooms, staff observed unlabeled and undated ice cream, popsicles, ice cream cones, frozen liquid in a to-go glass, and other food items stored in reusable and disposable shopping bags. Interviews with dietary, nursing, and administrative staff showed differing descriptions of who was responsible for labeling, dating, and cleaning the ice machine, although all stated that food items should be labeled and dated and that the ice machine should be cleaned routinely. The facility policies reviewed stated that food products should be dated within 30 minutes of receipt, leftovers must have a visible date reflecting the day prepared, stored leftovers must be used within 72 to 96 hours, and the ice machine should be clean inside and out. In-service records were also reviewed for cleaning lists and proper labeling and dating of food items.
Call Light Left Out of Resident's Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident #16 by not keeping the call light within reach while he was lying in bed. Resident #16 was a [AGE]-year-old male admitted with diagnoses including need for assistance with personal care, cognitive communication deficit, lack of coordination, abnormalities of gait and mobility, muscle weakness, and traumatic brain injury. His quarterly MDS reflected a BIMS score of 13, indicating he was cognitively intact. His care plan stated he required supervision and modified independence with bed mobility and other daily living care needs, and his call light care plan directed staff to ensure the call light was within reach and to encourage him to use it as needed. During observation on 01/06/2026 at 12:15 p.m., Resident #16's call light was found on the floor out of his reach. He was not able to reach it and appeared to struggle with getting it, and he was not able to get out of bed to retrieve it. At that time, he appeared well groomed and clean. In interview, Resident #16 stated staff had not put the call light near him since he moved to the new room. He stated not having the call light button next to him would stop him from getting assistance with things he may need and that he did not want to feel isolated by not having it nearby. Facility staff and leadership stated that call lights should be within residents' reach and that nursing staff were responsible for ensuring this. CNA A, LVN B, the DON, and the ADM each stated call lights should be placed within easy reach and that staff should monitor placement. The facility's call light policy stated it was the facility's policy to provide residents with a means of communication with nursing staff and to place the call device within the resident's reach before leaving the room. Despite this, the resident's call light was observed on the floor and out of reach.
Expired Insulin Glargine Administered During Medication Pass
Penalty
Summary
The facility failed to ensure residents remained free from significant medication errors for 1 of 6 residents reviewed, involving Resident #63. Resident #63 was an 85-year-old female with diagnoses including acute diastolic heart failure, anxiety disorder, chronic obstructive pulmonary disease, and type 1 diabetes mellitus. Her record showed she was ordered insulin glargine 10 units subcutaneously each morning, with instructions to discard the medication 28 days after first use, and her care plan identified that she was at risk for hyperglycemia and hypoglycemia related to diabetes medication. During the medication pass, an LVN checked Resident #63’s blood sugar, obtained a result of 203 mg/dL, and administered insulin glargine 10 units by subcutaneous injection without checking the expiration date of the medication. Observation of the insulin vial showed an open date of 12/7/2025, which exceeded the 28-day storage instructions for the medication after opening. The MAR showed Resident #63 received 4 doses of expired medication. The LVN stated she was trained on the medication administration policy, knew she was responsible for checking expiration dates, and believed the insulin expired after 30 days of opening while kept unrefrigerated on the nursing cart. The DON stated nursing staff were responsible for checking expiration dates on medication carts every day and before administering medications, and that the DON and ADONs spot checked carts while the pharmacist checked them monthly. The facility policy required medications to be administered in accordance with good nursing principles and practices, and the med pass policy required staff to check drug dose and expiration on all medications. The medication error report documented that the insulin glargine given to Resident #63 on 1/7/2026 had an open date of 12/07/2025 and should have been discarded after 28 days of being opened.
Failure to Provide Necessary Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services for pressure ulcers, consistent with professional standards of practice. Specifically, the facility staff did not place an order for a low air loss (LAL) mattress in the resident's electronic health records, nor did they order the mattress as prescribed by the wound care specialist. This oversight led to the resident's pressure ulcers increasing in size and severity. The resident, an elderly female with severe cognitive impairment, dementia, Parkinson's disease, and other medical conditions, was at high risk for developing pressure ulcers. Despite having a care plan that included monitoring skin status and nutritional status, the resident developed multiple pressure ulcers. The wound care specialist had recommended specific treatments, including the use of a LAL mattress, frequent turning, and protein supplements. However, the order for the LAL mattress was not entered into the system, and the mattress was not provided. Interviews with facility staff revealed that the wound care nurse acknowledged the failure to place the order for the LAL mattress, citing no particular reason for the oversight. The Director of Nursing (DON) and other staff confirmed that the mattress was only ordered after the resident was sent to the hospital due to an increase in temperature and heart rate. The resident's condition, including weight loss and reluctance to reposition, further complicated the situation. Despite efforts to manage the resident's condition, the lack of the prescribed LAL mattress contributed to the deterioration of the resident's pressure ulcers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Healthcare And Rehabilitation | 0.2 mi | ★★★★★ | 9 | 0 |
| Sagebrook Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| New Hope Manor | 2.9 mi | ★★★★★ | 9 | 0 |
| The Center At Parmer | 4.3 mi | ★★★★★ | 18 | 0 |
| Park Valley Inn Health Center | 5.4 mi | ★★★★★ | 10 | 0 |
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