Cycle 1
Health 2024-11-26 · Fire 2024-11-26
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Austin, TX
West Oaks Nursing And Rehabilitation Center
3-star overall rating with 2-star inspections with $39,527 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3200 W. Slaughter Lane, Austin, TX
(512) 282-0141
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
110
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2006-03-31
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
0.55
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.51
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.36
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
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,188
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.64
Baseline 19.49% · Performance 18.82% · Measure score 5.64 · Achievement 5.64 · Improvement 2.22
Healthcare-associated infections
6.50
Baseline 5.22% · Performance 5.89% · Measure score 6.50 · Achievement 6.50 · Improvement 0
Total nurse turnover
4.64
Performance 44.71% · Measure score 4.64 · Achievement 4.64 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.44
Baseline 2.64 hours · Performance 3.25 hours · Measure score 1.44 · Achievement 0.61 · Improvement 1.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 13.98% · Lower 95% interval 7.99% |
| Discharge to community | 46.61% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 39.68% · Lower 95% interval 35.47% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.73% |
95.27%
3.5 pts better
|
Numerator 78 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 68.97% |
53.69%
15.3 pts better
|
Numerator 40 · Denominator 58 |
| Discharge mobility score | 53.45% |
50.94%
2.5 pts better
|
Numerator 31 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.53% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 79 · Adjusted rate 2.12% |
| Healthcare-associated infections requiring hospitalization | 5.89% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 3.28% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 36.11% |
42%
5.9 pts worse
|
Numerator 78 · Denominator 216 |
| Discharge function score | 65.52% |
56.45%
9.1 pts better
|
Numerator 38 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.33% |
25.2%
22.9 pts worse
|
Numerator 1 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
97.9%
1.2 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.3%
0.1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 5.3% · Q4 4.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
2.7%
1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
3.3%
2.5 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.0% · Q3 7.3% · Q4 2.2% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
18.9%
6.8 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 10.9% · Q3 11.2% · Q4 14.1% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
10.8%
1.4 pts worse
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 10.8% · Q3 9.2% · Q4 11.9% · 4Q avg 12.2% · 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 | 37.7% |
15.4%
22.3 pts worse
|
16.3%
21.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 38.0% · Q3 39.4% · Q4 39.4% · 4Q avg 37.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.2% |
16.1%
21.1 pts worse
|
14.9%
22.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 29.6% · Q3 36.7% · Q4 40.7% · 4Q avg 37.2% · 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 | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
15.0%
6.1 pts worse
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 18.8% · Q3 13.4% · Q4 23.5% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.2%
0.3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.2% · Q3 2.9% · Q4 2.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
89.7%
2.5 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 94.4% · Q3 90.9% · Q4 87.6% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.6% |
12.0%
9.4 pts better
|
12.0%
9.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.6% · Observed 2.8% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
88.0%
0.9 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
25.9%
8.1 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 16.9% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-03 · Fire 2023-09-03
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-07-14 · Fire 2022-07-14
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
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
2024-11-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-22
E · Potential for more than minimal harm
2024-11-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-01
D · Potential for more than minimal harm
2024-11-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-11-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-01
F · Potential for more than minimal harm
2023-09-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-03
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 2023-10-10
E · Potential for more than minimal harm
2023-09-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
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 2025-12-15
K · Immediate jeopardy
2025-02-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-12
E · Potential for more than minimal harm
2024-11-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-21
E · Potential for more than minimal harm
2024-11-26
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 2024-12-21
E · Potential for more than minimal harm
2024-11-26
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 2024-12-23
D · Potential for more than minimal harm
2024-11-26
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 2024-12-21
D · Potential for more than minimal harm
2024-11-26
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 2024-12-21
D · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-05-13
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 2024-05-22
H · Actual harm
2024-04-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-07
H · Actual harm
2024-04-10
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 2024-05-07
D · Potential for more than minimal harm
2024-04-10
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 2024-05-07
J · Immediate jeopardy
2024-03-28
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 2024-03-27
D · Potential for more than minimal harm
2024-03-28
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 2024-05-01
E · Potential for more than minimal harm
2023-11-13
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-12-26
J · Immediate jeopardy
2023-09-03
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 2023-10-03
F · Potential for more than minimal harm
2023-09-03
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-03
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 2023-10-03
E · Potential for more than minimal harm
2023-09-03
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 2023-10-03
E · Potential for more than minimal harm
2023-09-03
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-03
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 2023-10-03
D · Potential for more than minimal harm
2023-08-24
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
D · Potential for more than minimal harm
2023-07-05
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-03-29
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 2023-04-14
F · Potential for more than minimal harm
2022-07-14
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 2022-08-05
E · Potential for more than minimal harm
2022-07-14
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 2022-08-05
E · Potential for more than minimal harm
2022-07-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-14
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 2022-08-05
Penalties and ownership
What sits behind the stars
$26,683
2025-02-11
Fine
Fine · fine $26,683
Fine
$12,844
2024-03-28
Fine
Fine · fine $12,844
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
American Robin Healthcare, Inc.
Operational/Managerial Control · Organization
Burnam, Soon
Corporate Officer · Individual
Hooper, Grady
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Martin, Dieter
Operational/Managerial Control · Individual
Thompson, Amber
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Southpark Meadows Nursing And Rehabilitation Cente
Austin, TX
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
#3
Brush Country Nursing and Rehabilitation
Austin, TX
1-star overall rating with 1-star inspections with $143,157 in total fines with 24 recent health deficiencies
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