Health inspection·November 21, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room. The facility reported Resident #1's neglect allegation to the SA on 10/22/24 at 1:10pm. There were no alleged perpetrators and witnesses. Resident #1 alleged a CNA hurt her arm and thumb during repositioning for care on either 10/16/24 or 10/18/24. Resident #1 was assessed head to toe on 10/19/24 at 1:25 PM by LVN A. LVN A found bruising to Resident #1's right thumb down to her wrist. The facility initiated safe surveys and skin checks for all residents on Resident #1's hall and found there were no other signs of abuse/neglect. The facility also initiated education on abuse/neglect and proper methods of repositioning during care. Resident #1 was unable to remember when the incident occurred and give a description of the CNA that performed the care. Resident #1 was consistent that the CNA was providing service and used her arm to reposition her. Resident #1 stated she didn't feel pain during the care and noticed her thumb was sore and some slight bruising. Resident #1 kept repeating the incident happened either on 10/16/24 or 10/18/24. Resident #1's bruising looked consistent with someone locking hands in a helping manner around Resident #1's lower wrist and thumb area. Resident #1 repeated during all her interviews that the incident happened while a CNA was providing care and didn't feel that the action was done intentionally. The facility interviewed all staff that were assigned to Resident #1's room on the alleged days except for an Agency CNA that would not return calls and had not been to the facility since. All other interviewed staff stated they didn't use Resident #1's hand to reposition Resident #1, but used a draw sheet. The investigation findings were unconfirmed. During an interview on 11/21/24 at 8:56 AM, the DON stated Resident #1 didn't immediately report her alleged neglect incident. The DON stated she didn't know when Resident #1 initially reported her alleged neglect incident. During an interview on 11/21/24 at 9:30 AM, CNA B stated he was in-serviced on abuse and neglect. CNA B stated he knew the ADM was the abuse and neglect coordinator. CNA B stated he would immediately report abuse and neglect. During an interview on 11/21/24 at 9:43 AM, CNA C stated she worked at the facility for 21 years. CNA C stated she was given orientation training on abuse and neglect. CNA C stated she knew the ADM was the abuse and neglect coordinator. CNA C stated she would immediately report abuse or neglect. An attempt to interview Resident #1 was made on 11/21/24 at 9:48 AM. Resident #1 was sleeping in her room. During an interview on 11/21/24 at 9:50 AM, LVN A stated he worked at the facility for 3.5 years. LVN A stated he was given orientation training on abuse. LVN A stated he knew to notify the ADM, who was the abuse and neglect coordinator, on abuse and neglect. LVN A stated he would immediately report abuse or neglect. LVN A stated he was not working when Resident #1 alleged neglect. During an interview on 11/21/24 at 9:54 AM, the ADON stated she knew the ADM was the abuse and neglect coordinator. The ADON stated she would immediately report abuse and neglect. The ADON stated she was not working when Resident #1 alleged neglect. An attempt to interview Resident #1 was made on 11/21/24 at 10:00 AM. Resident #1 was sleeping in her room. During an interview on 11/21/24 at 10:52 AM, LVN A stated he reported what he wrote in his progress note on 10/19/24 to the weekend supervisor. LVN A stated he couldn't recall who the WS was. LVN A stated he knew it was important to immediately report abuse or neglect to ensure it didn't happen to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 2 of 3 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 11/21/2024 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anyone else. LVN A stated he didn't report directly to the DON and ADM because it wasn't something that he saw, Resident #1 didn't have right mindset with her memory, and he just reported it to the weekend supervisor. During an interview on 11/21/24 at 10:56 AM, the ADM stated he couldn't recall when and who reported Resident #1's alleged neglect incident. The ADM stated on 10/21/24, during a morning meeting, it was brought up about Resident #1's alleged neglect incident. The ADM stated he considered Resident #1's alleged incident as neglect and followed the neglect reporting procedures outlined in the provider letter for reporting neglect to the SA. The ADM stated he went by the within 24 hour timeframe for reporting neglect. The ADM stated all staff were responsible for immediately reporting abuse and neglect to him so he could report to the SA. During an interview on 11/21/24 at 11:22 AM, the DON stated she was notified on 10/21/24 during morning meeting about Resident #1's alleged neglect incident. The DON stated she initiated the neglect reporting protocol because it wasn't suspected abuse and because Resident #1 didn't state that the incident was abuse. The DON stated neglect was reported to the SA within 24 hours. The DON stated neglect was reported to the SA within two hours if staff suspected abuse. The DON stated she knew it was important to report abuse and neglect to the SA because staff can remove the alleged staff member from the resident, ensure resident safety, ensure other residents were not harmed, and initiate an investigation. The DON stated residents could be harmed if staff were not reporting within the required timeframes. The DON stated as soon as she's notified of allegations or suspicions of abuse and neglect, she would report right away. The DON stated she did not know why the WS and LVN A, who wrote the progress notes on 10/19/24, didn't report Resident #1's alleged neglect incident to her and the ADM. The DON stated she believed the WS didn't immediately report because the WS didn't think Resident #1 was in immediate danger. An attempt to contact the WS was made on 11/21/24 at 11:32 AM. A voicemail and call back number were left. The WS didn't return the call before exit. Review of the facility's incident log, from 10/01/24 through 11/21/24, reflected Resident #1's bruise incident was on 10/19/24 at 1:20 PM. Review of the facility's in-services, from 10/01/24 through 11/21/24, reflected staff were trained on the abuse and neglect policy and procedure on 10/03/24. Staff were trained on reporting immediately to the ADM of any allegations and suspicions of abuse and neglect. Review of the SA's provider letter for reporting neglect to the SA, issued 08/29/24, reflected: A facility must report to the SA the following types of incidents, in accordance with applicable state and federal requirements: Neglect Do Report: An incident that does not result in serious bodily injury but that involves any of the following: Neglect: Immediately, but not later than 24 hours after the incident occurs or is suspected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675937 If continuation sheet Page 3 of 3