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
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
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
Staffing
RN hours / resident day
0.32
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.24
Nurse aide staffing
Weekend hours
3.18
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
33%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
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
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2022-07-10
Inspection history
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-05
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-25
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-07-10
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
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
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
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-10
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 3-star inspections with $21,648 in total fines with 9 recent health deficiencies
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