Health inspection·June 6, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's psychiatric behaviors such as wandering, insomnia, aggitation, and anxiety. This failure could place residents at risk of not having their individualized needs met, a delay in services, and not receiving adequate care. Findings included: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type II diabetes , stroke, and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment, dated 04/17/24, reflected a BIMS of 11, which indicated a moderate cognitive impairment. Section D (Mood) reflected he often felt lonely or isolated from those around him. Section E (Behavior) reflected he had no hallucinations, delusions, or physical/verbal behavioral symptoms directed towards others. Record review of Resident #1's quarterly care plan, revised 05/09/24, reflected he used antidepressant medication related to depression and anti-anxiety medications related to anxiety disorder with interventions of administering medications as ordered by the physician. There was no mention of psychiatric behaviors. Record review of Resident #1's physician order, dated 01/15/24, reflected Depakote Oral Tablet Delayed Release 125 MG - Give two tablets by mouth three times a day for behavioral disturbance. Record review of Resident #1's physician order, dated 03/18/24, reflected Zoloft Oral Tablet - Give 100 mg by mouth one time a day for anxiety/depression. Record review of Resident #1's physician order, dated 05/14/24, reflected Buspirone HCl Tablet 5 MG Give two tablets by mouth three times a day for anxiety. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675937 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagebrook Nursing and Rehabilitation 901 Discovery Blvd Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)