Cycle 1
Health 2024-02-29 · Fire 2024-02-29
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Austin, TX
Onion Creek Nursing And Rehabilitation Center
1-star overall rating with 1-star inspections with $51,337 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1700 Onion Creek Pkwy, Austin, TX
(512) 291-4900
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
125
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2011-02-16
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
Staffing
Hours and turnover
RN hours / resident day
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,645
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.56
Baseline 20.77% · Performance 18.86% · Measure score 5.56 · Achievement 5.56 · Improvement 4.62
Healthcare-associated infections
3.36
Baseline 6.03% · Performance 6.83% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Total nurse turnover
1.68
Performance 56.82% · Measure score 1.68 · Achievement 1.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.26
Baseline 2.52 hours · Performance 3.43 hours · Measure score 2.26 · Achievement 1.22 · Improvement 2.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 11.11% · Lower 95% interval 6.65% |
| Discharge to community | 49.69% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 42.11% · Lower 95% interval 38.09% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 86.49% |
95.27%
8.8 pts worse
|
Numerator 64 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 57.78% |
53.69%
4.1 pts better
|
Numerator 26 · Denominator 45 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 20 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 2 · Denominator 74 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 6.25% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 1.12% |
42%
40.9 pts worse
|
Numerator 3 · Denominator 269 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 27 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 42 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.3 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
97.1%
0.7 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 96.7% · Q4 95.7% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
97.9%
2.9 pts worse
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.3%
2.9 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.4% · Q3 4.3% · Q4 4.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
2.7%
2 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 4.5% · Q4 10.5% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 6.0% · Q3 2.6% · Q4 1.3% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
18.9%
9.9 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 9.3% · Q3 8.6% · Q4 7.4% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
10.8%
0.7 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.2% · Q3 13.4% · Q4 9.4% · 4Q avg 10.1% · 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 | 18.4% |
15.4%
3 pts worse
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 19.5% · Q3 14.3% · Q4 11.0% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.3% |
16.1%
12.2 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 27.7% · Q3 28.9% · Q4 16.3% · 4Q avg 28.3% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
15.0%
11 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 28.5% · Q3 21.7% · Q4 20.5% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.2%
2.9 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.9% · Q4 0.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.9% |
89.7%
14.8 pts worse
|
81.7%
6.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.5% · Q2 70.1% · Q3 77.7% · Q4 79.9% · 4Q avg 74.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
12.0%
4.1 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.8% · Q3 0.9% · Q4 1.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.0% |
88.0%
29 pts worse
|
79.7%
20.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.9%
7.1 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 17.6% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-02 · Fire 2022-12-02
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-12
F · Potential for more than minimal harm
2021-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-01
E · Potential for more than minimal harm
2021-09-10
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 2021-10-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-03-03
E · Potential for more than minimal harm
2025-11-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-07-03
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 2025-07-26
D · Potential for more than minimal harm
2025-07-03
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-18
K · Immediate jeopardy
2025-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-21
J · Immediate jeopardy
2025-02-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-05
H · Actual harm
2024-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-07-01
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.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-07-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-02
F · Potential for more than minimal harm
2024-02-29
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 2024-03-08
E · Potential for more than minimal harm
2024-02-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-29
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 2024-03-15
D · Potential for more than minimal harm
2024-02-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-12-02
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 2022-12-09
E · Potential for more than minimal harm
2022-12-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-12-02
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 2022-12-09
D · Potential for more than minimal harm
2022-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-09
E · Potential for more than minimal harm
2021-09-10
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 2021-09-28
E · Potential for more than minimal harm
2021-09-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-09-28
E · Potential for more than minimal harm
2021-09-10
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 2021-09-28
E · Potential for more than minimal harm
2021-09-10
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 2021-09-28
D · Potential for more than minimal harm
2021-09-10
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 2021-09-28
D · Potential for more than minimal harm
2021-09-10
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 2021-09-28
Penalties and ownership
What sits behind the stars
$42,224
2025-04-05
Fine
Fine · fine $42,224
Fine
$9,113
2025-02-19
Fine
Fine · fine $9,113
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cooper, Brian
Operational/Managerial Control · Individual
Hooper, Grady
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Roadrunner Healthcare, Inc.
Operational/Managerial Control · Organization
Talley, Causha
Operational/Managerial Control · Individual
Nearby options
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1-star overall rating with 2-star inspections with $16,920 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Brodie Ranch Nursing And Rehabilitation Center
Austin, TX
3-star overall rating with 3-star inspections with $235,557 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Marbridge Villa
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5-star overall rating with 4-star inspections with $45,778 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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