Mesa Springs Healthcare Center

Name: Mesa Springs Healthcare Center
Address: 7171 Buffalo Gap Rd, Abilene, TX, 79606, US
Telephone: 3256928080

7171 Buffalo Gap Rd, Abilene, TX 79606 · Taylor County · 89 certified beds · avg 68 residents/day · certified since Dec 4, 1996

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

$8,190

Fines, last 3 years

3.44

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Oct 12, 2023 · F-0656 · triggered by a complaint

The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.

Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 13, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (33)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 15, 2026	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Mar 19, 2026	F · Potential for harm, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Mar 19, 2026	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 19, 2026	E · Potential for harm, repeated	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Mar 19, 2026	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Mar 19, 2026	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 19, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 19, 2026	B · Minimal risk, repeated	The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Mar 19, 2026	B · Minimal risk, repeated	The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Mar 19, 2026	B · Minimal risk, repeated	The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated.
Jun 6, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Jun 6, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Jan 16, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jan 16, 2025	E · Potential for harm, repeated	The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint
Jan 16, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Jan 16, 2025	E · Potential for harm, repeated	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · from a complaint
Jan 16, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jan 16, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Jan 16, 2025	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint
Jan 16, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 16, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Jan 16, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Nov 21, 2024	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential. · from a complaint
Jun 25, 2024	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jun 25, 2024	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Nov 30, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Nov 30, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Oct 12, 2023	▲ G · Actual harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Oct 12, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Oct 12, 2023	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Oct 12, 2023	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Oct 12, 2023	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Oct 12, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 9).

Year	Citations	Serious (G–L)	Worst severity that year
2023	8	1	G ▲
2024	3	0	D
2025	12	0	E
2026	10	0	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $8,190.

Date	Type	Amount / length
Oct 12, 2023	Fine	$8,190

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.44	3.46	3.95	top 40% in Texas; bottom 34% in the U.S.
Registered Nurse hours	0.48	0.44	0.69	top 29% in Texas; bottom 35% in the U.S.
Weekend total nurse staffing	3.00	3.04	3.50	top 42% in Texas; bottom 31% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.41	0.34	0.48	top 25% in Texas; top 47% in the U.S.
Total nursing staff turnover (%)	0.0	55.3	45.8	—
RN turnover (%)	0.0	54.6	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.45, RN 0.48, weekend 3.00. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Eastland Memorial Hospital District	Organization	5% or Greater Direct Ownership Interest	100%	04/01/2017
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	02/01/2015
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	12/01/2015
Forrest Hill Healthcare, INC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2017
Forrest Hill Healthcare, INC	Organization	ADP of the SNF	NOT APPLICABLE	08/13/2025
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
McGrew, Pamela	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/01/2015
McGrew, Pamela	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2015
McGrew, Pamela	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2015
McKnight, Maxey	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/01/2016
McKnight, Maxey	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2016
McKnight, Maxey	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2016
Rio Mesa Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	02/01/2015
Standard Bearer Healthcare Op, LP	Organization	ADP of the SNF	NOT APPLICABLE	02/01/2015
Taylor, Stephen	Individual	Corporate Officer	NOT APPLICABLE	07/01/2025
The Ensign Group INC	Organization	ADP of the SNF	NOT APPLICABLE	02/01/2015

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you show me an example care plan, and how are families included when it's created and updated?"
"What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
"How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"What alternatives do you try before using bed rails, and how do you involve families in that decision?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What training do all staff get on dementia care and on spotting and reporting abuse?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Wesley Court Health Center	1.7 mi	Abilene, TX	★★★★★	4/5
Windcrest Health & Rehabilitation	2.3 mi	Abilene, TX	★★★☆☆	3/5
Wisteria Place	3.4 mi	Abilene, TX	★★★☆☆	3/5
Willowcreek Rehab and Nursing	5.5 mi	Abilene, TX	★★☆☆☆	2/5
Brightpointe at Lytle Lake	6.8 mi	Abilene, TX	★☆☆☆☆	1/5	abuse
The Oaks at Radford Hills Healthcare Center	7.2 mi	Abilene, TX	★★☆☆☆	1/5
Avir at Coronado	7.5 mi	Abilene, TX	★★☆☆☆	2/5
Hendrick Skilled Nursing Facility	8.0 mi	Abilene, TX	★★★★★	5/5
Northern Oaks Living & Rehabilitation Center	8.4 mi	Abilene, TX	★★★☆☆	4/5
Silver Spring	9.2 mi	Abilene, TX	★☆☆☆☆	1/5
Merkel Nursing Center	15.8 mi	Merkel, TX	★☆☆☆☆	1/5	abuseSFF
Clyde Nursing Center	17.1 mi	Clyde, TX	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Abilene →

Facility data as of CMS processing date 2026-08-01. CCN 675645.

The Care File

Visit checklist — Mesa Springs Healthcare Center

7171 Buffalo Gap Rd, Abilene, TX 79606 · 3256928080

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $8,190

Most serious findings on record:

▲ Oct 12, 2023 (F-0656, Actual harm, one-off): The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.

Questions for the administrator:

☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
☐ "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What training do all staff get on dementia care and on spotting and reporting abuse?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 675645 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)