Cycle 1
Health 2025-05-08 · Fire 2025-05-08
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Keller, TX
Keller Oaks Healthcare Center
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
8703 Davis Blvd, Keller, TX
(817) 577-9999
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
134
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2004-06-14
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.57
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,789
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.18
Baseline 20.61% · Performance 19.49% · Measure score 4.18 · Achievement 4.18 · Improvement 2.62
Healthcare-associated infections
0
Baseline 8.38% · Performance 8.59% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 46.38% · Performance 66.67% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.21 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 | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 10.56% · Lower 95% interval 7.82% |
| Discharge to community | 54.56% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 50.93% · Lower 95% interval 45.7% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 106 · Denominator 106 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 106 |
| Discharge self-care score | 38.98% |
53.69%
14.7 pts worse
|
Numerator 23 · Denominator 59 |
| Discharge mobility score | 37.29% |
50.94%
13.6 pts worse
|
Numerator 22 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 106 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 8.59% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 10.59% · Lower 95% interval 6.02% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 10.55% |
42%
31.4 pts worse
|
Numerator 29 · Denominator 275 |
| Discharge function score | 45.76% |
56.45%
10.7 pts worse
|
Numerator 27 · Denominator 59 |
| Transfer of health information to provider | 38.1% |
95.95%
57.9 pts worse
|
Numerator 16 · Denominator 42 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 27 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.1%
2.5 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.1% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
97.9%
1.1 pts worse
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 13.0% |
2.7%
10.3 pts worse
|
11.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 18.6% · Q3 3.4% · Q4 6.8% · 4Q avg 13.0% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
3.3%
0.6 pts worse
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.2% · Q3 4.2% · Q4 3.9% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
18.9%
0.6 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 16.7% · Q3 17.5% · Q4 18.3% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
10.8%
7.6 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.3% · Q3 2.5% · Q4 3.7% · 4Q avg 3.2% · 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 | 8.9% |
15.4%
6.5 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 18.9% · Q3 7.5% · Q4 5.4% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
16.1%
5.7 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 36.4% · Q3 34.7% · Q4 11.0% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · 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 | 15.2% |
15.0%
0.2 pts worse
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 9.9% · Q3 13.2% · Q4 19.4% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.2%
2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.4% · Q3 2.1% · Q4 2.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
89.7%
5.8 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 99.2% · Q3 96.8% · Q4 88.3% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
12.0%
2.4 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 10.5% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.0% |
88.0%
8 pts better
|
79.7%
16.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
25.9%
5.4 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 30.5% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
5 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
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
2025-05-08
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-16
F · Potential for more than minimal harm
2024-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-03-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-08
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 2025-06-04
E · Potential for more than minimal harm
2025-05-08
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 2025-06-04
E · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-04
D · Potential for more than minimal harm
2024-10-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-10
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 2024-09-17
E · Potential for more than minimal harm
2024-04-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-03-28
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 2024-04-22
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 2024-04-12
D · Potential for more than minimal harm
2024-03-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-06
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 2024-04-01
E · Potential for more than minimal harm
2023-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-08-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-01-26
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 2023-02-14
D · Potential for more than minimal harm
2023-01-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-26
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2023-02-16
Penalties and ownership
What sits behind the stars
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Abitoye, Olutoyin
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Powderhorn Mountain Healthcare, Inc.
Operational/Managerial Control · Organization
Snyder, Ashlie
Operational/Managerial Control · Individual
Taylor, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Discovery Village At Southlake
Southlake, TX
4-star overall rating with 4-star inspections with $12,649 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
The Carlyle at Stonebridge Park
Southlake, TX
3-star overall rating with 2-star inspections with $125,895 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Oakmont Guest Care Center
Hurst, TX
1-star overall rating with 1-star inspections with $28,792 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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