Cycle 1
Health 2025-05-14 · Fire 2025-05-14
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cedar Park, TX
Sagebrook Nursing And Rehabilitation
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
901 Discovery Blvd, Cedar Park, TX
(512) 259-9993
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Caraday Healthcare
Operator or chain grouping
Approved since
2002-11-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,948
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.66
Baseline 17.46% · Performance 19.74% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Healthcare-associated infections
2.48
Baseline 5.02% · Performance 7.09% · Measure score 2.48 · Achievement 2.48 · Improvement 0
Total nurse turnover
1.28
Baseline 50.75% · Performance 58.46% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.41 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 7.06% · Lower 95% interval 6.39% |
| Discharge to community | 48.24% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 42.62% · Lower 95% interval 36.9% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 16.13% |
95.27%
79.1 pts worse
|
Numerator 5 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 13 · Denominator 20 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 6 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 33% |
8.2%
24.8 pts better
|
Numerator 33 · Denominator 100 |
| Staff flu vaccination coverage | 41.18% |
42%
0.8 pts worse
|
Numerator 35 · Denominator 85 |
| Discharge function score | 45% |
56.45%
11.5 pts worse
|
Numerator 9 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 3 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
97.1%
3.3 pts worse
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 93.8% · Q3 95.7% · Q4 88.5% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.7% |
97.9%
12.2 pts worse
|
95.5%
9.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 1.4% · Q4 1.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
2.7%
0.8 pts worse
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 3.0% · Q4 5.5% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
3.3%
4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.7% · Q3 9.4% · Q4 6.2% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
18.9%
10.3 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.7% · Q3 10.7% · Q4 7.8% · 4Q avg 8.6% |
| 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 7.3% · Q2 7.5% · Q3 6.4% · Q4 5.5% · 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 | 60.9% |
15.4%
45.5 pts worse
|
16.3%
44.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 61.5% · 4Q avg 60.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 57.6% |
16.1%
41.5 pts worse
|
14.9%
42.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 56.0% · 4Q avg 57.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.5%
0.6 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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 | 26.9% |
15.0%
11.9 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 35.8% · Q3 15.6% · Q4 20.3% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 12.9% |
4.2%
8.7 pts worse
|
5.1%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 20.6% · Q3 9.8% · Q4 7.6% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.3% |
89.7%
13.4 pts worse
|
81.7%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 74.7% · Q3 73.2% · Q4 77.0% · 4Q avg 76.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.0%
2.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.4% · Expected 11.4% · 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 0.0% · Q2 0.9% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.6% |
88.0%
12.4 pts worse
|
79.7%
4.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
25.9%
2.6 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 21.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
15 health deficiencies
Top issue: Resident Rights (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-23
E · Potential for more than minimal harm
2024-03-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-15
D · Potential for more than minimal harm
2024-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-16
D · Potential for more than minimal harm
2023-01-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2024-12-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-19
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-06-06
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 2024-06-07
E · Potential for more than minimal harm
2024-03-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-28
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-28
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-28
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 2024-04-19
E · Potential for more than minimal harm
2024-03-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-19
D · Potential for more than minimal harm
2023-08-23
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 2023-09-18
D · Potential for more than minimal harm
2023-08-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-01-26
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Caraday Sagebrook LLC
Operational/Managerial Control · Organization
Chumley, Richard
Corporate Officer · Individual
Granite Sagebrook Health Center, LLC
5% Or Greater Mortgage Interest · Organization
Moore, Gregory
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cedar Pointe Health and Wellness Center
Cedar Park, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
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
#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
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