Cycle 1
Health 2024-10-17 · Fire 2024-10-17
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cedar Park, TX
Cedar Pointe Health and Wellness Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies
1301 Cottonwood Creek Trail, Cedar Park, TX
(737) 757-3100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
110
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2017-10-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,535
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.63% · Performance 21.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.57% · Performance 7.74% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7
Baseline 50.00% · Performance 35.07% · Measure score 7 · Achievement 7 · Improvement 5.44
Adjusted total nurse staffing
1
Baseline 3.17 hours · Performance 3.36 hours · Measure score 1 · Achievement 1 · Improvement 0.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 9.66% · Lower 95% interval 7.61% |
| Discharge to community | 44.99% |
50.57%
5.6 pts worse
|
Worse than the National Rate · Eligible stays 191 · Observed rate 39.79% · Lower 95% interval 39.7% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.5% |
95.27%
3.2 pts better
|
Numerator 131 · Denominator 133 |
| Falls with major injury | 1.5% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 133 |
| Discharge self-care score | 58.16% |
53.69%
4.5 pts better
|
Numerator 57 · Denominator 98 |
| Discharge mobility score | 31.63% |
50.94%
19.3 pts worse
|
Numerator 31 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 3.01% |
2.29%
0.7 pts worse
|
Numerator 4 · Denominator 133 · Adjusted rate 2.82% |
| Healthcare-associated infections requiring hospitalization | 7.74% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 8.53% · Lower 95% interval 4.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 164 |
| Staff flu vaccination coverage | 26.29% |
42%
15.7 pts worse
|
Numerator 51 · Denominator 194 |
| Discharge function score | 43.88% |
56.45%
12.6 pts worse
|
Numerator 43 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 17.91% |
25.2%
7.3 pts worse
|
Numerator 12 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
97.9%
1.2 pts worse
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.5% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
2.7%
1.6 pts worse
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 1.4% · Q3 3.8% · Q4 6.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 2.7% · Q4 4.1% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
18.9%
2.1 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 18.4% · Q3 17.3% · Q4 13.3% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
10.8%
4.1 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.6% · Q3 7.9% · Q4 6.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.3% |
15.4%
8.9 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
16.1%
5.3 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 20.6% · Q3 22.0% · Q4 23.0% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
15.0%
4.6 pts worse
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 17.1% · Q3 14.5% · Q4 20.9% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.2%
1.3 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.1% · Q3 3.2% · Q4 1.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
89.7%
8.3 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 96.2% · Q3 99.4% · Q4 97.3% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
12.0%
2.3 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 9.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
88.0%
8.3 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
25.9%
4.1 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 20.2% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-10 · Fire 2022-06-10
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-06-10
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2022-07-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-26
D · Potential for more than minimal harm
2026-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-26
G · Actual harm
2024-03-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-08-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-25
D · Potential for more than minimal harm
2022-06-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-07-10
D · Potential for more than minimal harm
2022-06-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-07-10
D · Potential for more than minimal harm
2022-06-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-07-10
D · Potential for more than minimal harm
2022-06-10
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-10
Penalties and ownership
What sits behind the stars
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Apple Springs Healthcare, Inc.
Operational/Managerial Control · Organization
Baldwin, Shaun
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Hooper, Grady
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Philip, Anjana
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Springs Healthcare And Rehabilitation
Cedar Park, TX
5-star overall rating with 4-star inspections with $8,193 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Sagebrook Nursing And Rehabilitation
Cedar Park, TX
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
New Hope Manor
Cedar Park, TX
4-star overall rating with 3-star inspections with $21,648 in total fines with 9 recent health deficiencies
Jump out