Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sagecrest Alzheimers Care Center during CMS and state inspections, most recent first.
The facility failed to develop comprehensive person-centered care plans for several residents with dementia and severe cognitive impairment. Care plans for multiple residents did not include the dementia diagnosis, and one resident’s plan also omitted hearing aids despite documented hearing loss and hearing aid use. RN, MDS, and DON interviews confirmed the plans were intended to guide staff care, but the dementia diagnoses were not included and the hearing aids should have been care planned.
A resident with COPD and severe cognitive impairment was receiving ordered oxygen therapy when the oxygen concentrator’s air filter was observed to have dust collected on it. Staff gave conflicting accounts of who was responsible for checking and cleaning concentrator filters, especially for a hospice-owned unit, and the facility had no policy regarding oxygen concentrators.
A CNA did not follow proper infection control procedures while providing incontinence care to a resident who was dependent for most ADLs and had a history of COVID-19 and other health issues. The CNA handled clean items with soiled gloves and did not perform hand hygiene at required intervals, contrary to facility policy. The CNA later acknowledged the lapse and the risk of cross-contamination.
A facility failed to provide safe respiratory care for a resident with COPD, as the nasal cannula was not stored properly when not in use, risking infection. Observations showed the cannula was left uncovered and on the floor, contrary to professional standards and care plans. Interviews confirmed the need for proper storage to prevent cross-contamination.
A facility failed to maintain an effective infection prevention and control program when a CNA did not change gloves or perform hand hygiene during incontinence care for a resident with a history of urinary tract infection and chronic kidney disease. The facility's policy, aligned with CDC guidelines, emphasizes hand hygiene to prevent infection spread, which was not followed, potentially leading to cross-contamination.
Care Plans Missing Dementia and Hearing Aid Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for Residents #2, #3, #6, #8, and #14. Record review showed each of these residents had a diagnosis of dementia or Alzheimer’s disease, with severe cognitive impairment documented on MDS assessments, but their care plans did not include the dementia diagnosis. Resident #2’s care plan also did not include hearing aids, even though the MDS documented hearing difficulty and the use of hearing aids. Resident #2’s record showed a history of dementia and hearing loss, with a BIMS score of 0 and MDS findings that the resident had moderate difficulty hearing and used hearing aids. Resident #3’s record showed a diagnosis of dementia and a BIMS score of 03, but the care plan did not address dementia. Resident #6’s record showed a diagnosis of Alzheimer’s dementia and a BIMS score of 03, but the care plan did not indicate anything about dementia. Resident #8’s record showed a diagnosis of dementia and a BIMS score of 3, but the care plan did not include dementia. Resident #14’s record showed a diagnosis of dementia and an inability to complete the BIMS, but the care plan did not include dementia. During interviews, RN A, the MDS nurse, and the DON stated that care plans were intended to guide staff in providing resident care and were reviewed quarterly and revised as needed. The MDS nurse stated the facility did not include the dementia diagnosis in the care plans and relied on BIMS/cognitive loss entries instead, and she acknowledged that Resident #2’s hearing aids should have been added to the care plan so staff would be aware of them and monitor them. The facility policy stated that the comprehensive care plan should identify problem areas and interventions needed to meet the resident’s needs and be revised as information and condition changes.
Dirty Oxygen Concentrator Filter Not Addressed
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who was receiving oxygen therapy. Resident #9 had a diagnosis of COPD, severe cognitive impairment, and a physician order for oxygen twice daily via nasal cannula at 2-4 liters per minute for shortness of breath and comfort. The care plan identified a potential for distressed respiratory effort and included oxygen administration as ordered. During an observation, the resident’s oxygen concentrator was operating and the air filter appeared to have dust collected on it. Interviews with the Plant Manager, RN, ADON, DON, and Administrator showed conflicting understanding of who was responsible for cleaning and checking oxygen concentrator filters, especially for a concentrator supplied by a hospice agency. The Plant Manager stated facility maintenance cleaned facility-owned concentrators every 30 days and did not check outside-company units. The RN and DON stated nurses checked the oxygen setting, tubing, and humidifier, but not the filters, while the ADON stated maintenance was responsible for cleaning the air filter and that there had been no formal training on checking oxygen concentrator filters. The Administrator stated there was no policy regarding oxygen concentrators.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to adhere to proper infection prevention and control practices while providing incontinence care to an 86-year-old male resident with a history of COVID-19, acute upper respiratory infection, constipation, and mobility issues. During the observed care, CNA A initially washed her hands and donned gloves, but after removing a soiled brief and cleaning the resident, she continued to handle clean items, such as a new brief, without changing her visibly soiled gloves or performing hand hygiene. She only washed her hands before exiting the resident's room, contrary to the facility's hand hygiene policy, which requires hand hygiene after removing gloves and before handling clean items. The resident was dependent on staff for most activities of daily living and was frequently incontinent of bowel and bladder. CNA A acknowledged during an interview that she did not follow standard precautions and recognized the risk of cross-contamination by mixing clean and dirty tasks without proper glove changes or hand hygiene. The Director of Nursing confirmed expectations for staff to follow infection control protocols, including hand washing and glove changes as needed during care, and noted that staff receive regular infection control training.
Failure to Ensure Safe Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required such care, consistent with professional standards of practice and the resident's comprehensive person-centered care plan. Specifically, the facility did not ensure that the resident's nasal cannula was kept in a bag while not in use, which could place the resident at risk for infections and transmission of communicable diseases. Observations revealed that the resident's nasal cannula was uncovered and hanging over the bed rail and concentrator in the resident's room, with the nose prongs on the floor. The resident involved was an elderly male with severe cognitive impairment and a history of chronic obstructive pulmonary disease (COPD), requiring continuous oxygen therapy to maintain oxygen saturation above 90%. Despite physician orders and care plans indicating the need for oxygen therapy, the facility did not have a policy for the prevention of infection related to respiratory therapy. Interviews with the Director of Nursing (DON) and the Administrator confirmed that nasal cannulas should be stored in a plastic bag when not in use to prevent cross-contamination and infection, but this was not done.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinence care for Resident #11. Resident #11, a cognitively intact female with a history of urinary tract infection, essential hypertension, and chronic kidney disease, required partial/moderate assistance with activities of daily living and was frequently incontinent. During an observation, CNA A was seen performing incontinence care without changing gloves or performing hand hygiene after handling soiled materials, which is a breach of infection control practices. Interviews with CNA A, the Director of Nursing (DON), and the Administrator confirmed the expectation for staff to follow infection control policies, including proper hand hygiene. The facility's hand hygiene policy, aligned with CDC guidelines, emphasizes the importance of handwashing to prevent infection spread. The failure to adhere to these guidelines by CNA A could lead to cross-contamination and infection, as acknowledged by both the DON and the Administrator.
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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 San Angelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Arbor Terrace | 1 mi | ★★★★★ | 16 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 8 | 0 |
| Park Plaza Nursing And Rehabilitation Center | 3.5 mi | ★★★★★ | 3 | 0 |
| St. Juanita Retirement And Rehab | 4.7 mi | — | 5 | 0 |
| Avir At Meadow Creek | 5.9 mi | ★★★★★ | 3 | 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 August 2026) and official state health department websites.