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Sagebrook Nursing and Rehabilitation

901 Discovery Blvd, Cedar Park, TX 78613 · For profit - Corporation · 124 certified beds · (512) 259-9993 Medicare & Medicaid certified

Call the home — (512) 259-9993 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 2024Resident-funds citation (F0567)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
900 Discovery Blvd · (512) 337-1089 · Call to confirm hours
Pharmacy
4601 183A Toll Rd · (512) 690-9083 · Call to confirm hours
Grocery
Aldi0.5 mi
850 N Bell Blvd, Suite 210, Suite 210
Park
614 Stallion Dr · (512) 401-5500 · Typically dawn to dusk
Place of worship
715 Discovery Blvd · (512) 945-4167

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased24.3%15.8%15.4%worse
Long-stay residents who lose too much weight7.8%3.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.1%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.7%3.3%3.3%better
Long-stay residents whose ability to walk worsened32.3%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.5%18.0%18.9%better
Long-stay residents given the seasonal flu vaccine85.7%98.0%95.3%worse
Long-stay residents with pressure ulcers5.1%3.8%4.7%typical
Long-stay residents with worsening bladder/bowel control18.3%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine75.6%88.0%79.4%typical
Short-stay residents rehospitalized after admission26.8%25.7%22.6%worse
Short-stay residents with an outpatient ER visit8.4%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.202.171.67better
Long-stay outpatient ER visits per 1,000 resident days0.982.061.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.2%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
43.3%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 43.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.2%CMS range 36.9–58.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.4–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge43.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified22.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 3.7–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.45
RN hours/ resident / day
0.78
LPN hours/ resident / day
1.96
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.32
RN hoursweekends
50.7%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 124 beds and averages 93.3 residents a day — about 75% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.28 on weekdays — 10% thinner on weekends. RN hours go from 0.50 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-05-14)
10
at the previous standard inspection (2024-03-28)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Ecited before2025-05-14 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #71, Resident #191, and Resident #194) reviewed for rights. The facility failed to ensure PTA and RN A knocked on Resident #71, Resident #191, and Resident #194's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #71's Face Sheet dated 05/14/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71's diagnoses included kidney failure, muscle wasting, muscle weakness, difficulty walking, cognitive communication deficit (problems with communication), need for assistance with personal care, respiratory failure, type 2 diabetes…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 of 10 residents (Resident #10, Resident #32, Resident #35, Resident #76, Resident #52, Resident #22, Resident #15 and Resident #193) reviewed for infection control. 1. CNA A did not conduct hand hygiene between each resident when passing lunch trays on the 400 Hall to Residents #10, #35, #76, #52, #22, and #15. 2. During peri-care, CNA B did not sanitize her hands or change gloves when going from the front to the back for Resident #10. 3. RN A did not wear a gown for Enhanced Barrier Precautions when administering medications to Resident #193, who had an enteral feeding tube. 4. RN B did not conduct hand hygiene with glove changes when providing Foley catheter care and wound care to Resident #32. These failures…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report within 2 hours to the SA after Resident #1 alleged sexual abuse to her Hospice caretaker on 12/13/24, who subsequently notified the facility on 12/16/24. The facility did not report Resident #1's allegation to the SA until 12/18/24. This failure could place residents at risk of sexual abuse and receiving substandard quality of care.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 5 residents reviewed for unwitnessed falls. The facility failed to adjust Resident #2's wheelchair brakes so they locked in place. On 12/19/24, Resident #2 went to the bathroom unsupervised and fell due to wheelchair brakes not properly locking, subsequently leading to soreness and pain. This failure could place residents at risk of falls, bruises, skin tears, fractures, and hospitalizations. Findings include: Review of Resident #2's admission record, dated 12/19/24, reflected he was a [AGE] year old male who was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, mild cognitive impairment of uncertain or unknown etiology, pain in right hip, generalized muscle weakness, difficulty in walking, unsteadiness on feet, unspecified lack of coordination, fracture of superior rim of right…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 (Resident #1) of 4 residents reviewed for incidents. The facility staff failed to inform the ADM of Resident #1's allegation of neglect from 10/19/24 until 10/22/24, subsequently making the ADM's report late to the SA. This failure could place residents at risk of neglect and receiving substandard quality of care. Findings include: Review of Resident #1's admission record, dated 11/21/24, reflected she was an [AGE]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment for 2 of 4 (Resident #1 and Resident #2) residents reviewed for environmental concerns. The facility failed to ensure that the Resident #1 and Resident #2's bedding, and Resident #1's air mattress were clean and free of dirt and dried food. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Record review of Resident #1's admission Record dated 10/09/2024 revealed the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's medical diagnoses included Alzheimer's disease (brain disorder that gets worse over time), dementia (memory, thinking, difficulty), muscle weakness, lack of coordination, weakness, morbid obesity, type 2 diabetes mellitus without complications (high blood sugar), protein-calorie malnutrition, kidney disease,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's psychiatric behaviors such as wandering, insomnia, aggitation, and anxiety. This failure could place residents at risk of not having their individualized needs met, a delay in services, and not receiving adequate care. Findings included: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type II diabetes , stroke, and hypertension (high blood pressure). Record review of Resident #1's quarterly…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-28 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 6 (Resident #7, Resident #46, Resident #52 Resident #58, 139 and Resident #188) residents in 1 of 1 dining room. The facility failed to promote Resident #7, 46, 52, 58, 139 and 188's dignity while dining when staff did not serve the resident their lunch tray at the same time as other residents at the same table. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #7 Face Sheet dated 03/26/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, type 2 diabetes, Aphasia, delusional disorder, Parkinson's disease, high blood pressure, blockage in the artery, kidney failure, iron…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-28 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to manage the personal funds of the resident deposited with the facility for 3 (Resident #2, Resident #4, and Resident #20) of five residents reviewed for trust funds. The facility failed to ensure Resident #2, 4, and 20 had ready access to his personal funds on the weekends. This failure could place twenty-seven residents whose funds are managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings Included: Interview on 03/27/2024 at 9:00 AM in the Resident Group Meeting revealed Resident #2, Resident #4, and Resident #20 did not have access to their funds on the weekend or after 5 pm. Resident #2 stated that the residents can only get their money when the business office manager was there. Resident #4, and Resident #20 both stated that they had trouble getting their money because they had a lot of turnovers in the office, and there was not a business office manager to give them…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-28 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents had the right to participate, discontinue or refuse to participate in experimental research for 4 of 4 residents (Resident #2, Resident #16, Resident #65 and Resident #67) reviewed for participation in experimental research. The facility failed to review and maintain in residents' chart signed consents for a sleep study for Residents #2, #16, #65, and #67 This failure placed residents at risk of not knowing how their personal information was used and being unaware of their right to refuse to participate in the study. Findings included: A record review of Resident #2's face sheet dated 3/27/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of unspecified dementia, chronic obstructive pulmonary disease (lung disease), type 2 diabetes (uncontrolled blood sugar), epilepsy (seizure disorder), hypertension (high blood pressure), chronic diastolic (congestive) heart failure, chronic kidney disease,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2024-03-28 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident rights for personal privacy for 7 of 7 residents (Resident # 4, Resident # 18, Resident #36, Resident # 44, Resident #50, Resident #65, Resident #68, and Resident #69) reviewed for personal privacy. The facility posted personal incontinent information on the inside of Resident #4, 36, 44,50,65, and 68's closet. The facility posted Resident #69's incontinent information on the outside of his bathroom door that was visible by anyone walking past the resident's room. The deficient practice could affect all residents in the facility who are incontinent and could result in the resident being humiliated and cause embarrassment to the residents. Findings included: Review of Resident #4 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, morbid obesity, insomnia, overactive bladder, atrial fibrillation, breast cancer, major…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-28 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 6 of 8 residents (Resident #47, Resident #58, Resident #2, Resident #16, Resident #65, Resident #67) reviewed for comprehensive care plans. The facility failed to revise Resident #47's care plan to reflect interventions for her diagnosis of lymphedema. The facility failed to revise Resident #58's care plan to reflect interventions for her diagnosis of diabetes mellitus. The facility failed to revise Resident #2's, Resident #16's, Resident #65's, and Resident #67's care plan to reflect their participation in an experimental research study. These failures placed residents at risk of not having interventions in place to meet their needs. Findings included: A record review of Resident #47's face sheet dated 3/28/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, bipolar disorder (mood disorder), anxiety disorder, post-traumatic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-28 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal and oral hygiene for 3 of 8 (Resident #32, Resident #57 and Resident #58) residents reviewed for ADL's. The facility failed to ensure Resident #32 received nail care. The facility failed to ensure Resident #57 and Resident #58 received shaving care. These failures placed residents at risk of poor personal hygiene. Findings included: A record review of Resident #32's face sheet dated 3/28/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of dementia, muscle weakness, type 2 diabetes (uncontrolled blood sugar), cognitive communication deficit (difficulty communicating), hypertension (high blood pressure), cerebral infarction (stroke), and major depressive disorder (depression). A record review of Resident #32's annual MDS assessment dated [DATE] reflected a BIMS score of 9,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 7 residents (Resident #85 and Resident #26) reviewed for infection control, in that: 1. The facility failed to ensure Resident #26 received peri-care by not following infection control techniques such as handwashing and changing gloves, and 2. The facility failed to place a barrier between Resident #85's left heel wound and her mattress while providing wound care. These deficient practices placed residents at risk for infections and diminished quality of life. Findings include: A record review of undated face sheet for Resident #85 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Osteomyelitis, cognitive communication deficit, chronic obstructive pulmonary disease, diabetes mellitus type 2, chronic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate the needs and preferences of five of 24 residents (Residents #4, Resident #22, Resident #41, Resident #55, and Resident #64) reviewed for accommodation of needs. The facility failed to place Residents #4, 22, 41,55, and 64's call-lights within reach. This failure affected five residents and placed an additional twenty-five residents who reside at the facility at risk of not having their needs and preferences met and a decreased quality of life. Findings include: Review of Resident #4 Face Sheet dated 03/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnosis included dementia, morbid obesity, insomnia, overactive bladder, atrial fibrillation, breast cancer, major depressive disorder, anxiety disorder, COVID 19, adjustment disorder, high blood pressure. Review of Resident #4s Quarterly MDS assessment dated [DATE] revealed her BIMS score was seven. The MDS also revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to all residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #47) residents reviewed for edema care. The facility failed to obtain orders and provide treatment for Resident #47's lymphedema. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: A record review of Resident #47's face sheet dated 3/28/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, bipolar disorder (mood disorder), anxiety disorder, post-traumatic stress disorder, insomnia (difficulty sleeping), lymphedema (a condition that results in swelling of the leg or arm), hypertension (high blood pressure), gastroesophageal reflux disease (acid reflux), seborrheic dermatitis (skin disorder), and unspecified osteoarthritis (joint disease). A record review of Resident #47's admission MDS dated [DATE] reflected a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents received food that accommodated the resident's preferences for 1 of 8 (Resident #58) residents reviewed for food preferences. The facility served Resident #58 food items she disliked as reflected on her meal ticket. This failure placed residents at risk of decreased appetite and oral intake. Findings included: A record review of Resident #58's face sheet dated 3/28/2024 reflected an [AGE] year-old female readmitted on [DATE] with diagnoses of cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), type 2 diabetes (uncontrolled blood sugar), dysphagia (difficulty swallowing), anxiety disorder, hypertension (high blood pressure), primary insomnia (difficulty sleeping), hyperlipidemia (high cholesterol), obstructive sleep apnea (breathing disorder), encephalopathy (disease of the brain), and unspecified atrial fibrillation (irregular heartbeat). A record review of Resident #58's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 residents reviewed for care plans. Resident #11 did not have a completed comprehensive care plan for several care areas. This failure could place residents at risk of not having their care needs met. Findings included: Review of the undated face sheet for Resident #11 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of history of urinary tract infections, cerebral infarction, expressive language disorder, muscle weakness, cognitive, communication deficit, type two diabetes mellitus, chronic, obstructive, pulmonary disease, asthma, aphasia, atherosclerotic, heart, disease, hyper lipidemia, unspecified, convulsions, repeated falls, depression, anxiety,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 10 residents reviewed for toileting and incontinent care. Resident #11 was not provided with incontinent care or assistance to the toilet on 8/23/23 from 01:51 AM to 10:55 AM. This failure could place residents at risk of urinary tract infection, skin breakdown, and indignity. Findings included: Review of the undated face sheet for Resident #11 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of history of urinary tract infections, cerebral infarction, expressive language disorder, muscle weakness, cognitive, communication deficit, type two diabetes mellitus, chronic, obstructive, pulmonary disease, asthma, aphasia, atherosclerotic, heart, disease, hyper lipidemia, unspecified, convulsions, repeated falls,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure that residents had a safe homelike environment for 2 (100-hall shower and 300-hall shower) of 2 shower rooms reviewed for environment. The facility failed to ensure the residents were provided with a safe, sanitary, and comfortable homelike environment . These failures placed residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation and interview on 01/24/23 at 10:52 AM, accommodated by CNA H, of the shower room between 100 and 200-hall revealed it had three cans of shaving creams, a bottle of body lotion, four bottle of deodorants, a razor, a toothpaste, a barrier cream ointment, a scissor on an open shelf unlocked and unattended . CNA H stated items should not have been left unattended and should have been taken out right after the resident showers and the door should have been locked. CNA H stated the reason for not leaving it unattended was to prevent cross-contamination. Observation and interview on 01/24/23 at 11:02 AM, accommodated by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents respiratory care consistent with professional standards of practice for 1 or 30 residents (Resident #25) reviewed for oxygen therapy. The facility failed to ensure Tthe oxygen tubing on Resident #25 was receiving oxygenwas dated with and a humidifier bottle on the oxygen concentrator was not empty for an unknown time. This failure placed residents at risk of nose and throat discomfort, dryness of nasal passagewayskin breakdown , inadequate respiratory care, and infection control. The findings included: Review of Resident #25's fFace Ssheet, dated 01/26/2,3 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of COPD ,( a lung disease that blocks airflow and make it difficult to breathe ,), asthma, ( a condition in which the airways become inflamed which makes it difficult to breathe), DM (, a disease that results in too much sugar in the blood), chronic cough, anemia (, a condition that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARADAY HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 4 of 53.8+0.2 vs chain
The other 7 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
STRATFORD HOSPITAL DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/01/2020
GRANITE SAGEBROOK HEALTH CENTER, LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 06/01/2020
CHUMLEY, RICHARDIndividualCORPORATE OFFICERsince 06/01/2020
CARADAY SAGEBROOK LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2020
MOORE, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2020
CHOI, MARYANNIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
CHOI, ROBERTIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
CUNNINGHAM, ERNESTIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
O'DONOGHUE-STALLARD, MAIREIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
STALLARD, THOMASIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
WOOD, STEPHENIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
ALCALA, CHRISTOPHERIndividualADP OF THE SNFsince 09/25/2023
KROL, MICHAELIndividualADP OF THE SNFsince 01/01/2020

CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.0M
Net patient revenuemost recent cost report
-7.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 67%Medicare 6%Other / private 28%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$283per resident / day
operating cost
$8,613per month
≈ monthly operating cost
$263per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675937. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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