Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Pointe Health And Wellness Center during CMS and state inspections, most recent first.
A resident with a history of repeated falls and multiple comorbidities had a care plan and Kardex that called for a fall mat at bedside and a low bed as fall-prevention interventions. Surveyors observed the resident in bed with no fall mat present and the wheelchair at bedside with brakes unlocked, despite staff interviews confirming that fall prevention practices included use of fall mats and locking wheelchair brakes. After a prior fall in which the resident attempted to get to the wheelchair, the IDT discussed the event, but the comprehensive care plan was not updated to include locking wheelchair brakes when the resident was not in the wheelchair, demonstrating a failure to fully develop and implement a comprehensive, person-centered fall-prevention care plan.
A resident with a history of repeated falls, vascular dementia, and dependence for transfers was care planned to have a fall mat at bedside and locked wheelchair brakes as fall-prevention interventions. On the survey day, the resident was observed in bed with the bed in low position and a wheelchair at the bedside, but without a fall mat and with both wheelchair brakes unlocked, despite these requirements being documented in the care plan and Kardex. Multiple CNAs, an RN, an LVN, the DON, ADON, and ADM all acknowledged that fall prevention for this resident included a bedside fall mat when in bed and locked wheelchair brakes when the wheelchair was at bedside, yet these measures were not in place at the time of observation.
A facility failed to ensure a resident received necessary treatment for pressure ulcers, leading to an increase in the size and severity of the ulcers. The staff did not place an order for a low air loss (LAL) mattress as prescribed, and the resident's condition worsened. Interviews revealed that the wound care nurse acknowledged the oversight, and the mattress was only ordered after the resident was hospitalized.
Failure to Implement and Update Fall-Prevention Care Plan Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple diagnoses, including schizoaffective disorder, COPD, repeated falls, vascular dementia, muscle wasting, and anxiety disorder. The resident’s quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented that he required partial/moderate assistance for bed mobility and was dependent for chair/bed transfers, with a history of falls without injury. The care plan dated 01/21/2026 documented falls on 01/17/2026 and 01/20/2026 and included an intervention, dated 01/19/2026, to implement a fall mat at the bedside and keep the bed in the lowest position, and the Kardex also reflected a fall mat intervention under the safety section. Despite these documented interventions, observations on 01/23/2026 at 2:29 PM and 3:20 PM showed the resident in bed with the bed in a low position, his wheelchair placed at the bedside with both brakes unlocked, and no fall mat present on either side of the bed. The incident report for the 01/17/2026 fall indicated the resident was found on the floor after attempting to get to his wheelchair, and that the IDT met and added fall mats as an intervention and updated the care plan. However, the comprehensive care plan was not updated to include locking the wheelchair brakes when the resident was not in the wheelchair, even though this was a relevant intervention following the fall where the resident attempted to reach his wheelchair. Interviews with CNAs and nursing staff confirmed that fall prevention practices at the facility included keeping beds in low position, ensuring call lights were within reach, locking wheelchair brakes when the wheelchair was at bedside, and using fall mats next to the bed when residents were in bed. Staff reported that they determined fall risk and interventions, such as fall mats, from the Kardex and care plan. The DON and ADM stated that the resident had an increase in falls and that fall mats were an intervention for this resident, and that the Kardex was triggered by the care plan. However, on the day of observation, staff interviews and room observations showed that the fall mat intervention documented in the care plan and Kardex was not implemented, and the specific intervention to ensure wheelchair brakes were locked when the resident was not in the wheelchair was not added to the resident’s comprehensive care plan after the fall on 01/17/2026, resulting in a failure to fully develop and implement a comprehensive person-centered care plan consistent with identified needs.
Failure to Maintain Fall Mat and Locked Wheelchair Brakes for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices to prevent accidents for one resident. The resident was an adult male with schizoaffective disorder, COPD, repeated falls, vascular dementia, muscle wasting and atrophy, and anxiety disorder. His quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented that he required partial/moderate assistance for bed mobility and was dependent for bed-to-chair transfers. He had a documented history of falls without injury, including falls on 01/17/2026 and 01/20/2026, after which the care plan and Kardex were updated to include a fall mat at bedside, bed in lowest position, and maintaining a clear pathway free of obstacles due to his fall risk related to vascular dementia and incontinence. On the survey date, observations at 2:29 PM and 3:20 PM showed the resident in bed with the bed in a low position and his wheelchair placed at the left side of the bed, but with both wheelchair brakes unlocked and no fall mat present on either side of the bed, despite the care plan and Kardex requiring a fall mat at bedside when he was in bed. During interview, the resident reported he had falls in the past and now asked for help to get in and out of bed. Review of the Kardex dated 01/23/2026 confirmed that a fall mat was to be implemented at bedside for safety. Multiple staff interviews confirmed that facility practice and resident-specific interventions required a fall mat at bedside when the resident was in bed and that wheelchair brakes should be locked when the wheelchair was at bedside. CNAs and nursing staff (CNA A, RN B, LVN C, CNA D, CNA E) described fall prevention as including bed in low position, call light within reach, use of fall mats at bedside for residents identified as fall risks, and locking wheelchair brakes to prevent the chair from moving if a resident attempted to sit or transfer. The DON, ADON, and ADM all stated that the resident had an increase in falls, that fall mats were an intervention in place for him, that this was communicated via the care plan and Kardex, and that the resident should have a fall mat whenever he was in bed and wheelchair brakes locked at bedside. Despite these documented interventions and staff knowledge, the resident was observed in bed without a fall mat and with wheelchair brakes unlocked on the day of survey.
Failure to Provide Necessary Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services for pressure ulcers, consistent with professional standards of practice. Specifically, the facility staff did not place an order for a low air loss (LAL) mattress in the resident's electronic health records, nor did they order the mattress as prescribed by the wound care specialist. This oversight led to the resident's pressure ulcers increasing in size and severity. The resident, an elderly female with severe cognitive impairment, dementia, Parkinson's disease, and other medical conditions, was at high risk for developing pressure ulcers. Despite having a care plan that included monitoring skin status and nutritional status, the resident developed multiple pressure ulcers. The wound care specialist had recommended specific treatments, including the use of a LAL mattress, frequent turning, and protein supplements. However, the order for the LAL mattress was not entered into the system, and the mattress was not provided. Interviews with facility staff revealed that the wound care nurse acknowledged the failure to place the order for the LAL mattress, citing no particular reason for the oversight. The Director of Nursing (DON) and other staff confirmed that the mattress was only ordered after the resident was sent to the hospital due to an increase in temperature and heart rate. The resident's condition, including weight loss and reluctance to reposition, further complicated the situation. Despite efforts to manage the resident's condition, the lack of the prescribed LAL mattress contributed to the deterioration of the resident's pressure ulcers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Healthcare And Rehabilitation | 0.2 mi | — | 9 | 0 |
| Sagebrook Nursing And Rehabilitation | 1.1 mi | — | 0 | 0 |
| New Hope Manor | 2.9 mi | — | 8 | 0 |
| The Center At Parmer | 4.3 mi | — | 2 | 0 |
| Park Valley Inn Health Center | 5.4 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.