Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Sagebrook Nursing And Rehabilitation during CMS and state inspections, most recent first.
Staff failed to consistently knock before entering the rooms of three residents, including individuals with both intact and impaired cognition. Observations and interviews confirmed that a PTA and an RN entered rooms without knocking, despite facility policy and staff training requiring this action to respect resident privacy and dignity. Residents and a POA noticed the lack of knocking, and staff acknowledged the policy but could not explain the lapses.
Staff failed to follow infection control protocols, including hand hygiene between residents during meal tray delivery, glove changes and hand hygiene during peri-care, and use of gowns for Enhanced Barrier Precautions during medication administration and care of residents with enteral feeding tubes and Foley catheters. These lapses occurred despite staff training and involved residents with significant medical needs.
A resident with severe cognitive impairment reported being raped to her Hospice caretaker, who informed the facility three days later. The facility delayed reporting the incident to the State Agency, exceeding the required two-hour window for abuse allegations. Interviews revealed the ADM and DON initially deemed the allegation non-reportable but later recognized the need to report it. Staff were aware of reporting protocols, but the delay suggests a lapse in adherence to facility policies.
A resident with cognitive impairment and a history of falls experienced an unwitnessed fall due to malfunctioning wheelchair brakes. Despite previous complaints, the facility failed to address the issue, leading to the resident falling while unsupervised in the bathroom. Observations revealed a lack of staff presence and inadequate documentation of the incident, highlighting deficiencies in supervision and maintenance protocols.
A resident with moderate cognitive impairment reported bruising on her wrist, believed to have occurred during a transfer by a CNA. The incident was not reported to the facility administrator until several days later, resulting in a delayed report to the state agency. Staff interviews revealed awareness of reporting procedures, but the incident was not escalated appropriately, indicating a breakdown in communication and protocol adherence.
Two residents were found living in unsanitary conditions, with unclean bedding and air mattresses. Despite staff being trained on resident rights, there was a lack of accountability and clear policy, leading to oversight in maintaining a clean environment.
A facility failed to develop a comprehensive care plan for a resident with dementia, diabetes, stroke, and hypertension, who exhibited psychiatric behaviors such as wandering and agitation. The care plan did not address these behaviors, focusing only on medication administration. Despite documented incidents of wandering and disorientation, the care plan was not updated to include these behaviors, contrary to the facility's policy requiring ongoing assessments and revisions.
Failure to Knock Before Entering Resident Rooms Violates Resident Rights
Penalty
Summary
Surveyors identified that staff at the facility failed to consistently honor residents' rights to privacy and dignity by not knocking before entering residents' rooms. Observations revealed that both a Physical Therapy Assistant (PTA) and a Registered Nurse (RN A) entered the rooms of three residents without knocking. These incidents were directly observed on multiple occasions, involving residents with varying cognitive abilities, including one resident with severe cognitive impairment and others with intact cognitive responses. Interviews with the affected residents and a resident's Power of Attorney (POA) confirmed that staff did not always knock before entering. One resident expressed that while it did not upset her, she would prefer staff to knock. Another resident stated that she would like staff to knock, as it could be irritating when they did not, and she sometimes had to remind them. The POA for a resident with severe cognitive impairment noted that nurses mainly did not knock but did not feel it was necessary. These interviews highlight that the practice of not knocking was noticed by residents and their representatives. Staff interviews, including those with the PTA, RN A, the Director of Nursing (DON), and the Administrator (ADM), confirmed that facility policy requires staff to knock before entering any resident's room, except in emergencies. Staff acknowledged awareness of this policy and the importance of respecting residents' privacy. Despite this, staff could not explain why the policy was not consistently followed, and monitoring was reportedly done through rounds and spot checks. The facility's written policy also affirms residents' rights to dignity, courtesy, and privacy.
Failure to Maintain Infection Control Practices During Resident Care and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to required infection control practices during resident care and meal service. Observations revealed that a CNA did not perform hand hygiene between each resident when passing lunch trays to several residents. The CNA admitted to forgetting to use hand sanitizer between residents, despite having received training on hand hygiene and infection control. During peri-care for a resident, another CNA did not change gloves or perform hand hygiene when moving from the front to the back, which is a breach of standard infection control procedures. Additionally, an RN failed to wear a gown while administering medications via an enteral feeding tube to a resident on Enhanced Barrier Precautions, stating she forgot due to feeling nervous, even though she had been trained on the protocol. Another RN did not perform hand hygiene with each glove change while providing Foley catheter and wound care to a resident with a urinary tract infection and pressure ulcer. Interviews with the DON and Administrator confirmed their expectations for staff to follow proper hand hygiene, glove changes, and Enhanced Barrier Precautions as outlined in facility policy. The residents involved had significant medical conditions, including Alzheimer's disease, Down's syndrome, gastrostomy status, neuromuscular dysfunction, and pressure ulcers, making adherence to infection control protocols critical during their care.
Delayed Reporting of Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident within the required timeframe. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, reported to her Hospice caretaker that she had been raped three times. The Hospice caretaker informed the facility of the allegation three days later, but the facility did not report the incident to the State Agency (SA) until two days after being notified, exceeding the mandated two-hour reporting window for abuse allegations. Interviews with the facility's Administrator (ADM) and Director of Nursing (DON) revealed that their initial reaction was to consider the allegation as non-reportable. However, upon further reflection, they recognized the need to report it. Both the ADM and DON acknowledged their responsibility to report such allegations within two hours to ensure resident safety and accurate portrayal of events. Despite this understanding, the report was delayed, potentially placing residents at risk of sexual abuse and substandard care. The facility's staff, including CNAs and an LVN, were interviewed and confirmed they had not received any reports of sexual abuse from the resident. They were aware of the importance of immediate reporting and had been recently in-serviced on abuse and neglect reporting procedures. The facility's policies and training materials emphasized the need for prompt reporting of abuse allegations, yet the delay in reporting this incident indicates a lapse in adherence to these protocols.
Inadequate Supervision and Maintenance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that Resident #2 received adequate supervision and assistance devices to prevent accidents, specifically regarding the malfunctioning wheelchair brakes. Resident #2, a male with a history of dementia, cognitive impairment, and repeated falls, experienced an unwitnessed fall due to the wheelchair brakes not properly locking. This incident occurred when Resident #2 attempted to use the bathroom unsupervised, resulting in soreness and pain. Despite previous incidents and complaints about the wheelchair brakes, the facility did not adequately address the issue, leading to the fall. Observations and interviews revealed that Resident #2 had previously reported issues with the wheelchair brakes to staff, but the maintenance staff did not promptly address the problem. The maintenance staff acknowledged adjusting the wheelchair brakes in the past but did not have a consistent system for documenting or following up on such repairs. On the day of the incident, Resident #2 was found on the bathroom floor, yelling for help, with no staff present in the hallway to assist him promptly. The call light was not activated, and Resident #2 expressed frustration over the lack of timely assistance from the staff. The facility's failure to maintain a safe environment and provide adequate supervision and assistance devices for Resident #2 was further compounded by the lack of proper documentation and follow-up on maintenance issues. The incident was not recorded in the facility's incident log, and there were no new orders or pain levels documented for Resident #2 on the day of the fall. Interviews with staff indicated a lack of clarity and consistency in following fall protocols and maintaining wheelchair safety, contributing to the deficiency in care provided to Resident #2.
Delayed Reporting of Alleged Neglect Incident
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident within the required timeframe. The resident, who had moderate cognitive impairment and required assistance for activities of daily living, reported bruising on her right thumb down to her wrist, which she believed occurred during a transfer by a CNA. The incident was not reported to the facility administrator until several days after it allegedly occurred, resulting in a delayed report to the state agency. The resident's allegation of neglect was made on an unknown date, but the facility did not report it to the state agency until three days after the resident was found with bruising. The facility's staff, including the LVN who documented the bruising, did not immediately report the incident to the administrator or director of nursing. The administrator and director of nursing were only made aware of the incident during a morning meeting, which led to a late report to the state agency. Interviews with facility staff revealed that they were aware of the procedures for reporting abuse and neglect but failed to follow them in this instance. The LVN reported the incident to a weekend supervisor but did not escalate it further, and the weekend supervisor did not report it to the administrator. The facility's incident log and in-service training records indicated that staff were trained on the abuse and neglect policy, but the failure to report the incident in a timely manner suggests a breakdown in communication and adherence to protocol.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents, as observed during a survey. Resident #1's room was found with a comforter and sheet on the floor, and the air mattress had visible food crumbs and smeared substances. Despite housekeeping efforts, the air mattress remained unclean, and the comforter was placed back on the bed without being cleaned. Interviews with staff revealed a lack of awareness and responsibility for ensuring the cleanliness of the residents' bedding and air mattresses. Resident #2's room was similarly neglected, with dried feces previously reported on the bed and floor. During the survey, a dried brown substance was observed on the bed, and the resident was found sleeping with dried food on the comforter. Staff interviews indicated that the CNAs and nursing staff were responsible for changing bedding and cleaning air mattresses, but there was a disconnect in executing these duties, as evidenced by the unclean conditions. The facility's Director of Nursing and Administrator acknowledged that staff were trained on resident rights, but there was no specific housekeeping policy in place. The lack of a clear policy and accountability led to the oversight in maintaining a clean environment for the residents, as staff were unsure why the bedding and air mattresses were not cleaned despite being aware of the hygiene expectations.
Failure to Implement Comprehensive Care Plan for Resident with Psychiatric Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with the resident's rights and includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, a male with unspecified dementia, type II diabetes, stroke, and hypertension, exhibited psychiatric behaviors such as wandering, insomnia, agitation, and anxiety. Despite these behaviors, the care plan did not address them, focusing only on the administration of antidepressant and anti-anxiety medications. The resident's psychiatric assessment indicated the need for psychotropic medication to manage symptoms and prevent relapse or hospitalization. Progress notes documented instances of wandering and disorientation, including an incident where the resident exited the building. Interviews with facility staff revealed that the care plan should have included the resident's behaviors, but it was not updated accordingly. The facility's policy requires ongoing assessments and revisions of care plans as residents' conditions change, which was not adhered to in this case.
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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) |
|---|---|---|---|---|
| Cedar Pointe Health And Wellness Center | 1.1 mi | ★★★★★ | 6 | 0 |
| The Springs Healthcare And Rehabilitation | 1.2 mi | ★★★★★ | 9 | 0 |
| New Hope Manor | 2.2 mi | ★★★★★ | 9 | 0 |
| The Center At Parmer | 4.8 mi | ★★★★★ | 18 | 0 |
| Ignite Medical Resort Round Rock, Llc | 5.9 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.