Cycle 1
Health 2025-07-24 · Fire 2025-07-24
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Austin, TX
Sedona Trace Health And Wellness Center
4-star overall rating with 4-star inspections with $11,168 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
8324 Cameron Rd., Austin, TX
(737) 241-0800
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2018-11-20
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,700
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.54
Baseline 20.24% · Performance 19.79% · Measure score 3.54 · Achievement 3.54 · Improvement 0.92
Healthcare-associated infections
2.78
Baseline 8.47% · Performance 7.33% · Measure score 2.78 · Achievement 1.69 · Improvement 2.78
Total nurse turnover
5.79
Baseline 55.56% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.57
Adjusted total nurse staffing
0.68
Baseline 2.88 hours · Performance 3.23 hours · Measure score 0.68 · Achievement 0.52 · Improvement 0.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 10.92% · Lower 95% interval 8.19% |
| Discharge to community | 49.26% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 41.67% · Lower 95% interval 40.65% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 70.27% |
95.27%
25 pts worse
|
Numerator 78 · Denominator 111 |
| Falls with major injury | 0.9% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 111 |
| Discharge self-care score | 51.95% |
53.69%
1.7 pts worse
|
Numerator 40 · Denominator 77 |
| Discharge mobility score | 50.65% |
50.94%
0.3 pts worse
|
Numerator 39 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 1.8% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 111 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 141 |
| Staff flu vaccination coverage | 21.53% |
42%
20.5 pts worse
|
Numerator 45 · Denominator 209 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 49 · Denominator 77 |
| Transfer of health information to provider | 87.5% |
95.95%
8.5 pts worse
|
Numerator 28 · Denominator 32 |
| Transfer of health information to patient | 96.61% |
96.28%
0.3 pts better
|
Numerator 57 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 2.86% |
25.2%
22.3 pts worse
|
Numerator 2 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
97.1%
2 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 95.9% · Q4 86.9% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
97.9%
4.2 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.7% · Q3 1.4% · Q4 1.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
2.7%
0.4 pts worse
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 4.4% · Q4 1.2% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
3.3%
1.8 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.5% · Q4 2.8% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
18.9%
8.3 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.7% · Q3 11.9% · Q4 12.8% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
10.8%
7.7 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 5.4% · Q4 4.8% · 4Q avg 3.1% · 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 | 44.9% |
15.4%
29.5 pts worse
|
16.3%
28.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.3% · Q2 46.0% · Q3 36.9% · 4Q avg 44.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.7% |
16.1%
14.6 pts worse
|
14.9%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 30.6% · Q3 37.3% · Q4 26.5% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
15.0%
6.4 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 19.8% · Q3 14.8% · Q4 19.3% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.2%
0.6 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 3.6% · Q4 5.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
89.7%
0.5 pts worse
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 95.5% · Q3 93.1% · Q4 77.5% · 4Q avg 89.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.2% |
12.0%
8.8 pts better
|
12.0%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.2% · Observed 3.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
88.0%
7.5 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
25.9%
1.5 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 20.4% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-14 · Fire 2024-06-14
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-14
F · Potential for more than minimal harm
2024-06-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-20
F · Potential for more than minimal harm
2024-06-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-01
F · Potential for more than minimal harm
2024-06-14
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-04-30
E · Potential for more than minimal harm
2024-06-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-19
D · Potential for more than minimal harm
2024-06-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-26
D · Potential for more than minimal harm
2024-06-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-21
D · Potential for more than minimal harm
2024-06-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-06-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-07-15
D · Potential for more than minimal harm
2024-06-24
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-07-16
J · Immediate jeopardy
2024-06-14
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-06-15
E · Potential for more than minimal harm
2024-06-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-15
E · Potential for more than minimal harm
2024-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-14
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 2024-06-15
D · Potential for more than minimal harm
2024-06-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-06-15
D · Potential for more than minimal harm
2024-06-14
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 2024-06-15
E · Potential for more than minimal harm
2023-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-05-11
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 2023-06-02
D · Potential for more than minimal harm
2023-05-11
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 2023-06-02
C · Minimal harm
2023-05-11
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-06-02
Penalties and ownership
What sits behind the stars
$11,168
2024-06-14
Fine
Fine · fine $11,168
Fine
Ownership
Guadalupe County Hospital Board
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Gann, Kody
Corporate Officer · Individual
Hurley, Rachael
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Mustang Ridge Healthcare, Inc.
Operational/Managerial Control · Organization
Rathi, Anil
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Legend Oaks Healthcare And Rehabilitation - North
Austin, TX
2-star overall rating with 2-star inspections with abuse icon flag with $41,890 in total fines with 9 recent health deficiencies
#2
Coral Rehabilitation and Nursing of Austin
Austin, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $376,390 in total fines with 41 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Oakcrest Nursing And Rehabilitation Center
Austin, TX
2-star overall rating with 2-star inspections with $31,959 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out