Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
A resident with CKD stage 5 and dependence on renal dialysis had repeated dialysis communication forms left incomplete after return from treatment, with blank post-dialysis vitals and assessment sections for multiple trips. The resident’s care plan did not include dialysis-specific goals or interventions, and staff interviews confirmed the return assessments and vitals were expected to be documented but were not consistently completed.
Medication administration errors exceeded the allowed rate, with late doses given to multiple residents receiving anticonvulsant, analgesic, and anti-Parkinsonian meds. One resident with epilepsy and chronic pain, one resident with dementia and epilepsy, and one resident with Parkinson’s disease and chronic pain all had morning meds administered outside the ordered time windows, and staff reported that two MAs were responsible for about 90 residents during the day shift.
A facility failed to maintain infection control during G-tube site care and blood pressure monitoring. An LVN repeatedly wiped a resident’s gastrostomy stoma with the same moistened gauze during site care, and two MAs used blood pressure monitors and cuffs on multiple residents without sanitizing the equipment between uses. The affected residents had diagnoses including dementia, dysphagia, gastrostomy tube status, hypertension, hypotension, heart failure, and cerebrovascular disease.
A CNA entered a resident's room without knocking or announcing herself before answering the call light and changing the resident's brief. The resident had stroke-related deficits, moderate cognitive impairment, contractures, and required extensive assistance with ADLs. Interviews with the resident, CNA, DON, and ADM confirmed that staff were expected to knock and announce themselves before entering to protect privacy and dignity.
Soiled linens and urine odor were found in a resident’s room, with the resident observed lying in a urine-soiled bed and the sheets still present later in the day. The resident had severe cognitive impairment, was incontinent of urine, and required substantial to maximal assistance with ADLs. A CNA stated she forgot to remove the soiled sheets after assisting the resident, and an LVN and the DON stated residents were checked every 2 hours and soiled linens were not normally left in rooms.
PRN Psychotropic Order Lacked Required 14-Day Limit: A resident with vascular dementia, severe cognitive impairment, and anxiety had a PRN Ativan order for agitation with no stop date. The chart also included a pharmacy note stating CMS requires evaluation of PRN psychotropic orders beyond 14 days, while the DON and ADM stated PRN psychotropic meds should be reviewed every 14 days and acknowledged the order was not reviewed and corrected.
Care Plan Missing Dialysis and Ostomy Interventions: A resident with CKD stage 5, dialysis dependence, and an ileostomy had a care plan that addressed the ostomy only in general terms and did not include dialysis goals, measurable interventions, or pre-dialysis ostomy checks. Records showed the resident had missed completion of dialysis after an ostomy accident, and staff interviews confirmed dialysis and ostomy needs should have been reflected in the care plan.
Failure to Provide Timely Bathing and Honor Shower Preference: A resident who required extensive assistance with bathing was not showered soon after admission and instead received a bed bath despite asking for a shower. The resident stated she had not been bathed since admission and felt unclean until staff finally provided a bed bath. Staff gave differing explanations, including uncertainty about transfer status and shower scheduling, while the DON and ADON stated new admissions were generally expected to receive prompt bathing and that the resident’s shower preference could have been accommodated.
Unlocked Medication Cart Left Unattended on Hallway: A medication cart on the 400 hall was observed unlocked and unattended while RN B stepped away to a resident room. The cart contained accessible insulin, antidepressants, Carbidopa Levodopa, breathing treatments, wound care supplies, needles, and lancets, and multiple residents, CNAs, an LVN, and a visitor passed by while it remained unsecured. RN B, LVN A, the DON, and the ADM all stated carts are expected to be locked when staff are not with them.
Survey Results Binder Not Readily Accessible: The facility failed to keep the survey results binder in a readily accessible location for residents, families, and visitors. The AD and ADM could not initially locate the binder, staff at the central nurses station did not know where it was, and residents stated they did not know where to find it. When the binder was found, it was missing multiple recent 2567s from survey and complaint/incident investigation visits, despite staff stating the binder was meant to provide access to survey results and complaints.
Nurse staffing information was not posted in a readily accessible location for residents and visitors. Surveyors found the daily staffing posting placed high on a wall behind a potted tree, making it difficult to read and not accessible to someone in a wheelchair. The ADM said there was no policy for the posting requirement, and the DON stated residents or visitors might have to ask someone if they could not read it.
A resident receiving continuous O2 therapy had the humidifier bottle and nasal cannula/tubing not changed as ordered each Sunday. The care plan and MD order required weekly changes, but MAR review, observation, and staff interviews showed the equipment had not been replaced as scheduled, and one RN documented intending to do the task but forgot after not wanting to disturb the sleeping resident. The ADON stated the equipment should be replaced per order and documented only after completion.
False Documentation of Oxygen Equipment Changes: A resident on continuous O2 therapy with respiratory failure and other chronic conditions had an order for weekly tubing and humidifier bottle changes. An RN and an agency LVN documented the oxygen equipment as changed even though the task was not completed as recorded, and observation later found the humidifier bottle empty and the cannula still dated from an earlier week. Interviews confirmed the equipment had not been changed as documented and that the RN signed the MAR before actually completing the task.
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.
Missing Post-Dialysis Assessments and Incomplete Dialysis Care Documentation
Penalty
Summary
The facility failed to ensure that a resident who required dialysis received dialysis-related care and documentation consistent with the resident’s care needs and the facility’s own communication process. Resident #2 was admitted with diagnoses including chronic kidney disease stage 5, renal osteodystrophy, acquired absence of kidney, and dependence on renal dialysis. The resident’s MDS reflected intact cognition, an ostomy, and dialysis treatments. The record also showed orders for a renal diet, dialysis on a set schedule, monitoring of the AV shunt/fistula in the left upper extremity each shift, and no blood pressure or venipuncture on the dialysis access extremity. The resident’s care plan addressed the ileostomy, but it did not include a care plan focus for dialysis treatment, dialysis goals, or dialysis-related interventions. It also did not include interventions for assessing the ostomy appliance before dialysis treatments or a care plan focus for the renal diet order. The facility’s dialysis communication forms for multiple dialysis trips were reviewed, and the post-dialysis assessment and vitals section to be completed by nursing staff after the resident returned to the facility was left blank on forms dated 04/27/26, 06/23/26, 06/27/26, 07/02/26, 07/07/26, and 07/08/26. Those blank sections included documentation for vitals, temperature changes, edema checks, access type and assessment, shunt/thrill and bruit presence, perma cath check, and other problems or concerns. During interview, LVN A stated the dialysis communication form was used to assess the dialysis site and document vitals before the resident left and again when the resident returned, and she stated she did not believe she was completing the last section of the form for the resident’s return assessment and vitals. The DON stated it was her expectation that nursing staff complete the dialysis communication forms, including the final return assessment with vitals and upload it into the system. The ADM stated assessments were expected to be completed and documented appropriately. The facility policy for charting and documentation stated that all services provided, progress toward care plan goals, and changes in condition shall be documented in the medical record, including assessment data and unusual findings, tolerance of treatment, and notification of family or physician if indicated.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors found a medication error rate of 25.93% based on 7 errors out of 27 opportunities, involving three residents reviewed for medication administration. The errors involved late administration of scheduled analgesic, anticonvulsant, and anti-parkinsonism medications during the period reviewed. Resident #76 was admitted with diagnoses including epilepsy, polyneuropathy, chronic pain syndrome, contracture, and tremor, and had a BIMS score of 15 indicating intact cognition. Her orders included clonazepam, gabapentin, levetiracetam, primidone, and buspirone, with several medications scheduled for the morning medication pass and others at specific times such as 7:00 a.m. and 8:00 a.m. During observation, the resident was receiving her morning medications at 10:45 a.m. Record review showed that her morning medications on multiple days were administered after 10:45 a.m. Resident #101 had diagnoses including type 2 diabetes, epilepsy, hypertensive heart disease, dementia, chronic kidney disease, and shortness of breath, with a BIMS score of 11 indicating moderate cognitive impairment. His orders included levetiracetam, acetaminophen, and pregabalin, with morning medications scheduled for the morning medication pass and specific times. During observation, his morning medications were being administered at 11:15 a.m. Record review showed that his morning medications on multiple days were given between 11:00 a.m. and 12:45 p.m. Resident #39 had diagnoses including dementia, COPD, Parkinson’s disease, neurocognitive disorder with Lewy bodies, and chronic pain syndrome, with a BIMS score of 12 indicating moderate cognitive impairment. His orders included amantadine, morphine sulfate, and gabapentin, with morning medications scheduled for the morning medication pass. Record review showed that his morning medications on multiple days were administered after 10:30 a.m. Staff interviews indicated that only two medication aides were responsible for approximately 90 residents on day shift, and both aides stated that morning medication administration was often delayed because of the workload and the number of residents assigned.
Infection Control Failures During G-tube Care and Blood Pressure Monitoring
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 5 of 9 residents reviewed for infection control. During observation, LVN C provided gastrostomy tube site care for a resident with unspecified dementia, protein-calorie malnutrition, dysphagia, and gastrostomy tube status. The resident required extensive assistance with personal care and received most nutritional intake through the gastrostomy tube. While cleansing the gastrostomy stoma, LVN C repeatedly wiped back and forth across the stoma using the same moistened 4 x 4 gauze pad instead of using a clean portion of the gauze or replacing it as needed. The report also documented that MA E and MA F did not sanitize blood pressure equipment between residents while obtaining blood pressures for four residents with diagnoses including dementia, hypertension, orthostatic hypotension, heart failure, and cerebrovascular disease. MA E used an upper arm blood pressure monitor and cuff on one resident, then used the same cuff on another resident without sanitizing it, and returned the cuff to the basket without cleaning it. MA F used a wrist blood pressure monitor on two other residents without sanitizing the monitor between uses and returned it to the medication cart without sanitizing it. Both MAs stated they had not sanitized the equipment during the day and acknowledged the importance of sanitizing blood pressure cuffs between residents. Record review showed the resident receiving gastrostomy care had an order for site cleansing with normal saline, pat dry, and split gauze every evening, and the care plan included gastrostomy tube site care and monitoring for infection. The facility’s policy on ostomy care stated the peristomal skin should be cleansed gently and not scrubbed, and the policy on cleaning and disinfection of resident-care items and equipment stated reusable items are to be cleaned and disinfected between residents. The in-service records reviewed from 01/04/26 to 07/15/26 showed no in-services on cleaning medical equipment.
Failure to Knock and Announce Before Entering Resident Room
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when CNA A entered Resident #35's room without knocking or announcing herself before entering to answer the resident's call light and change her brief. Resident #35's record showed she was an older female admitted to the facility with diagnoses including stroke, high blood pressure, neurogenic bladder, hemiplegia/hemiparesis, depression, and chronic pain. Her BIMS score was 12, indicating moderately impaired cognition. Her care plan reflected that she required substantial assistance from one staff member to turn and reposition in bed, had contractures of both legs and her left arm, and required two staff for transfers. During observation, CNA A walked into Resident #35's open room without knocking on the door or wall and without announcing herself. In interview, Resident #35 stated staff typically knocked and spoke before entering, and that if someone walked in without saying anything she would wonder what they were doing and feel apprehension. CNA J stated staff were supposed to knock or announce themselves before entry to provide privacy and let residents know they were there to help and not harm them. The DON and ADM both stated the facility policy was to always knock and announce oneself before entering a resident's room, and the DON stated that failing to do so could embarrass the resident and invade privacy.
Soiled Linens and Urine Odor Left in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #17 by leaving urine-soiled bed linens in the resident’s room and failing to remove them promptly. Resident #17’s quarterly MDS reflected severe cognitive impairment with a BIMS score of 6, substantial to maximal assistance needed for dressing, grooming, and toileting hygiene, and that he was always incontinent of urine. His care plan addressed bladder incontinence with disposable briefs, changing briefs as needed, and cleansing the perineal area with each episode of incontinence. During observation, Resident #17 was found lying in a soiled bed with a strong urine odor in the room, and yellow-brown urine rings were present on both the top and bottom sheets. At a later observation, the bed remained covered with urine-soiled sheets and the urine odor was still present. CNA D stated she had assisted the resident with a shower and getting up but forgot to remove the soiled sheets from the room, and she acknowledged that leaving them there was not homelike. LVN C and the DON stated residents were checked every two hours and as needed, soiled linens were not normally left in rooms, and CNAs were responsible for removing them.
PRN Psychotropic Order Lacked Required 14-Day Limit
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication order for Resident #17 was limited to 14 days or otherwise documented by the prescriber as appropriate for extension beyond 14 days. Resident #17 was a male with diagnoses including vascular dementia, hyperlipidemia, anxiety disorder, and chronic pain, and his MDS reflected a BIMS score of 6 with severe cognitive impairment. He required substantial to maximal assistance with dressing, grooming, and toileting hygiene, was always incontinent of urine, and his care plan identified use of anti-anxiety medications for anxiety disorder with monitoring for adverse reactions. Record review showed an order for Ativan 0.5 mg by mouth every 12 hours as needed for agitation, initiated on 6/12/26, with no stop date. A pharmacy review dated 6/16/26 noted that CMS requires evaluation of PRN psychotropic orders greater than 14 days and recommended review of the continued use of the PRN Ativan order and documentation of a short-term duration of therapy. In interviews, the DON stated ADONs were responsible for reviewing new orders each morning to ensure diagnosis and stop dates were in place for psychotropic medications, but she was not sure why the order was not reviewed and corrected when received. The ADM stated PRN psychotropic medications should be reviewed every 14 days and that he did not know why the nurses did not review and correct the order.
Care Plan Missing Dialysis and Ostomy Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident with dialysis needs and an ileostomy. Resident #2 was admitted with diagnoses including chronic kidney disease stage 5, renal osteodystrophy, acquired absence of kidney, and dependence on renal dialysis. The admission assessment reflected intact cognition, and the record also showed that the resident had an ostomy and was receiving dialysis treatments. The resident’s care plan, last revised on 04/27/26, included a focus on the ileostomy with interventions to change the ostomy appliance as needed and to report illness, inflammation, or drainage at the ostomy site. However, the care plan did not include a focus on dialysis treatment, goals, or interventions, and it did not include interventions to assess the ostomy appliance before dialysis treatments. The care plan also did not include a focus on the resident’s renal diet order. Orders in the record included dialysis schedules, monitoring of the AV shunt/fistula in the left upper extremity, no blood pressure or venipuncture on that extremity, ileostomy care every shift and as needed, and ileostomy wafer and bag changes every 3 days and as needed. A nursing note documented that the resident had an accident with the ostomy in dialysis and was not able to complete dialysis treatment, with dialysis rescheduled for another day. During interview, the resident stated she sometimes had issues with her ostomy bag not being intact and that the dialysis center would not provide treatment if she arrived that way. Staff interviews reflected that dialysis and ostomy needs should be included in the care plan and that missing these items meant the resident’s care picture was not accurate. The facility policy stated that comprehensive care plans must include measurable objectives and timetables and reflect current recognized standards of practice for identified problem areas and conditions.
Failure to Provide Timely Bathing and Honor Shower Preference
Penalty
Summary
The facility failed to ensure that a resident who required extensive assistance with bathing received necessary hygiene services after admission. The resident’s baseline care plan, initiated on 07/10/2026, identified her as alert and oriented with intact short- and long-term memory, and documented that she required extensive assistance with transfers, bed mobility, and showering with 1 staff member. Her shower task and bathing task entries were marked “Not Applicable” for several days after admission. During an observation and interview on 07/14/2026, the resident stated that she had not been showered since admission and wanted a shower because she was not used to wearing briefs. Her hair appeared greasy and somewhat disheveled. In a follow-up interview, she stated that staff gave her a bed bath instead of a shower, that CNA I told her she was getting a bed bath, and that when she asked to go to the shower she was told no. She also stated that her shower days had not yet been established and that she felt filthy until she was “semi-cleaned” on Tuesday. Staff interviews showed differing explanations for the delay and the bathing method used. CNA I stated she gave the resident a bed bath because the resident’s transfer status had not yet been fully assessed and she wanted to prevent an accident; she also stated the resident reported limited hip movement after a recent fall/hospitalization. Other staff stated that new admissions were generally expected to receive a shower on admission day or the next day if admitted later, and that residents could be assisted with a shower even if transfer status was uncertain. The DON and ADON stated that residents admitted from a hospital were generally expected to receive a shower promptly, that bathing preferences should be communicated through the care plan or report, and that the resident could have been assisted with a shower if requested. The facility policy on supporting ADLs stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, including hygiene such as bathing.
Unlocked Medication Cart Left Unattended on Hallway
Penalty
Summary
The facility failed to keep a medication cart locked and secured when it was not in use on the 400 hall. During an observation, the 400-hall medication cart was seen unlocked at 2:15 PM, and RN B was later observed retrieving wound care supplies from the bottom drawer while the cart remained unlocked. RN B then returned to a resident's room and left the cart unattended and out of view in the middle of the hall until the surveyor brought it to her attention at 2:32 PM. During that time, two residents wandering the hall, two CNAs, one LVN, and one visitor passed by the cart. The unlocked cart contained accessible items including insulin, antidepressant medication, Parkinson's medication (Carbidopa Levodopa), breathing treatments, wound care supplies, needles, and lancets. RN B stated she had been trained to secure the cart but forgot to lock it. LVN A, the DON, and the ADM each stated it was the facility expectation that medication carts be locked when staff step away from them. The facility policy stated the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide and that all outward sides must be inaccessible to residents or others passing by.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to have the results of the most recent survey posted in a place readily available to residents, family members, and legal representatives. During observation and interview, the AD stated she did not know where the survey binder was located, and the AD and surveyors searched the facility without finding the binder containing prior 2567s. The ADM also attempted to locate it and asked nursing staff at the central nurse’s station, but no one knew where it was. Later, a black binder titled survey results was found sitting at the central nurse’s station, but it did not contain the most recent 2567s from multiple survey and complaint/incident investigation visits, including visits dated 07/02/25, 07/17/25, 08/06/25, 03/12/26, 05/07/26, and 07/02/26. During confidential interviews, 13 of 13 residents stated they did not know where the survey binder was located or that the information was available to them. An LVN stated the binder was meant to let residents, families, and visitors know what was going on in the facility and that it should be located somewhere in the front and available to everyone. The DON stated the binder was intended to keep complaints and past surveys accessible and should have been placed in a central location, such as the central nurses station. The ADM later stated he found the binder in an office near the front lobby and acknowledged it should have been easily accessible. The facility policy on Resident Rights stated residents have the right to examine survey results.
Nurse Staffing Posting Not Readily Accessible
Penalty
Summary
Nurse staffing information was not posted daily in a manner that was readily accessible to residents and visitors. On 07/15/2026 and 07/16/2026, surveyors observed a paper with the facility name, date, census, and total number and actual hours worked per shift for licensed staff responsible for resident care posted on the right-side wall behind the second set of entry doors, but it was approximately 5 feet up the wall and positioned behind a potted indoor tree. The surveyor had to maneuver around the tree to read the posting, and it was not at eye level for someone in a wheelchair or viewable from behind the tree. During interview, the ADM stated the facility did not have a policy on nurse staffing postings and said they could move the tree and move the posting down the wall. The DON stated she had been helping with the posting requirement and that the ADON handled it as well, but the tree had been placed in that area during remodeling. She also stated the postings might not be readily accessible to someone in a wheelchair and that residents or visitors would have to ask someone about the staff posting if they could not read it. The ADM stated nurse managers were responsible for compliance, that the posting had always been located high on the hall, and that the expectation was for it to be updated daily and visible to residents, staff, and visitors.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that a resident receiving continuous oxygen therapy had the humidifier water bottle and oxygen cannula changed every Sunday as ordered by the physician and reflected in the care plan. The resident was an older female admitted with acute respiratory failure with hypoxia, hypertensive heart disease, obesity, adult failure to thrive, and difficulty walking. Her MDS indicated a BIMS score of 13, showing intact cognition, and she was documented as receiving oxygen therapy for respiratory issues. The resident’s care plan directed continuous oxygen at 3 liters via nasal cannula, titration to maintain SPO2 above 92%, and weekly changes of the oxygen tubing and water every Sunday. The physician’s order also required the oxygen tubing and water to be changed every week on Sunday and as needed. Review of the June and July 2026 MARs showed the tubing and humidifier bottle were documented as changed on 06/28/26 and again on 07/05/26. However, during observation on 07/06/26, the humidifier bottle had no water in it and the date written on the oxygen cannula was 06/21/26. During interviews, the resident stated she needed oxygen throughout the day and said staff were usually diligent about changing the equipment, but that an agency nurse had been present the prior Sunday and did not change it. An LVN later stated the oxygen tube and water bottle had not been changed for 15 days and that she changed them immediately when she discovered this. An RN stated she had intended to change the components on the Sunday night shift but did not do so because the resident was sleeping and she later forgot. The ADON stated the equipment should be replaced as ordered and that nurses should document the task only after it had been completed.
False Documentation of Oxygen Equipment Changes
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident receiving continuous oxygen therapy. The resident was an older female admitted with acute respiratory failure with hypoxia, hypertensive heart disease, obesity due to excess calories, adult failure to thrive, and difficulty walking. Her care plan and physician’s order required continuous oxygen at 3 liters via nasal cannula and that the oxygen tubing and water be changed every Sunday and as needed. Record review showed that RN B documented the oxygen tubing and humidifier bottle as changed on 06/28/26, and LVN C documented the same task as completed on 07/05/26. However, during observation on 07/06/26, the resident was on continuous oxygen therapy, the humidifier bottle had no water in it, and the oxygen cannula was dated 06/21/26. During interview, the resident stated staff were normally diligent about changing the water bottle and oxygen cannula every week, but last Sunday an agency nurse was present and did not change them. During interview, LVN A stated the oxygen tubing and water bottle had not been changed since 06/21/26 and that she changed them immediately after learning this. RN B stated she was the Sunday night nurse on 06/28/26, did not complete the task because the resident was sleeping and she became busy with other duties, and acknowledged that she documented the task in the MAR before actually performing it. The ADON stated that humidifier bottles, tubing, and nasal cannulas should be replaced as ordered and that nurses are supposed to document only after the task has been completed.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 347 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 10 | 0 |
| New Hope Manor | 2.2 mi | ★★★★★ | 8 | 0 |
| The Center At Parmer | 4.8 mi | ★★★★★ | 18 | 0 |
| Ignite Medical Resort Round Rock, Llc | 5.9 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.