Cycle 1
Health 2024-10-29 · Fire 2024-10-29
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Abilene, TX
Northern Oaks Living & Rehabilitation Center
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2722 Old Anson Rd, Abilene, TX
(325) 676-1677
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1991-07-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing
LPN hours / resident day
0.63
Licensed practical nurse staffing
Aide hours / resident day
1.84
Nurse aide staffing
Weekend hours
2.59
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
97.1%
1 pts worse
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
97.9%
4.4 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
18.9%
6.7 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
10.8%
3 pts worse
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.0% |
15.4%
11.4 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
16.1%
8.1 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
15.0%
3.3 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.2%
2.9 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
89.7%
10.5 pts worse
|
81.7%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
12.0%
8.7 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
88.0%
1.3 pts worse
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
25.9%
9.3 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-29 · Fire 2023-08-29
13 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
6 health deficiencies
Top issue: Administration (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
2024-10-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-29
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-29
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-11-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Not marked corrected
C · Minimal harm
2026-01-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Not marked corrected
D · Potential for more than minimal harm
2025-11-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-08
E · Potential for more than minimal harm
2025-03-07
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 2025-03-08
E · Potential for more than minimal harm
2024-10-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-22
E · Potential for more than minimal harm
2023-09-20
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 2023-10-12
E · Potential for more than minimal harm
2023-09-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-08-29
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-08-29
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 2023-09-22
E · Potential for more than minimal harm
2023-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-29
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 2023-09-22
E · Potential for more than minimal harm
2023-08-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-29
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 2023-09-22
E · Potential for more than minimal harm
2023-08-29
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-29
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 2023-09-22
E · Potential for more than minimal harm
2023-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-29
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 2023-09-22
D · Potential for more than minimal harm
2023-08-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-22
C · Minimal harm
2023-08-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-06-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-22
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-06-23
E · Potential for more than minimal harm
2022-06-23
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 2022-06-24
D · Potential for more than minimal harm
2022-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-24
Penalties and ownership
What sits behind the stars
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burleson, Rhonda
Operational/Managerial Control · Individual
Burnam, Soon
Operational/Managerial Control · Individual
Northern Oaks Healthcare, Inc.
Operational/Managerial Control · Organization
Wright, Laban
Corporate Officer · Individual
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#3
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