Onion Creek Nursing and Rehabilitation Center
1700 Onion Creek Pkwy, Austin, TX 78748 · Travis County · 125 certified beds · avg 110 residents/day · certified since Feb 16, 2011
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
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)
▲ Immediate jeopardy, repeated · Apr 5, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Apr 21, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 5, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Oct 2, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 3, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (27)
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 |
|---|---|---|
| Jun 5, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 5, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 3, 2025 | 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. · from a complaint |
| Jul 3, 2025 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · from a complaint |
| Apr 5, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 19, 2025 | ▲ J · Immediate jeopardy, 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 |
| Feb 19, 2025 | 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 2, 2024 | ▲ H · Actual harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 1, 2024 | 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 |
| Jul 1, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 29, 2024 | 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. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Dec 2, 2022 | 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. |
| Dec 2, 2022 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Dec 2, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Dec 2, 2022 | 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. |
| Sep 10, 2021 | E · Potential for harm, repeated | 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. |
| Sep 10, 2021 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 10, 2021 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 10, 2021 | E · Potential for harm, repeated | 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. |
| Sep 10, 2021 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Sep 10, 2021 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 6 | 0 | E |
| 2022 | 4 | 0 | F |
| 2024 | 9 | 1 | H ▲ |
| 2025 | 6 | 2 | K ▲ |
| 2026 | 2 | 0 | D |
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)
2 fines totaling $51,337.
| Date | Type | Amount / length |
|---|---|---|
| Apr 5, 2025 | Fine | $42,224 |
| Feb 19, 2025 | Fine | $9,113 |
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 | 0.24 | 0.44 | 0.69 | bottom 15% in Texas; bottom 5% in the U.S. |
| Weekend total nurse staffing | 3.08 | 3.04 | 3.50 | top 36% in Texas; bottom 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.08 | 0.34 | 0.48 | bottom 1% in Texas; bottom 1% in the U.S. |
| Total nursing staff turnover (%) | 50.5 | 55.3 | 45.8 | top 46% in Texas; bottom 36% in the U.S. |
| RN turnover (%) | 55.6 | 54.6 | 42.9 | bottom 48% in Texas; bottom 28% in the U.S. |
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 3.09, RN 0.22, weekend 2.76. 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: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 01/18/2022 |
| Cooper, Brian | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2022 |
| Cooper, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2022 |
| Cooper, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/18/2022 |
| Hooper, Grady | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2015 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Roadrunner Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2022 |
| Roadrunner Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 10/23/2025 |
| Talley, Causha | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2022 |
| Talley, Causha | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2022 |
| Talley, Causha | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you arrange eye and hearing care for residents, including appointments and equipment like glasses or hearing aids?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "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 |
|---|---|---|---|---|---|
| Southpark Meadows Nursing and Rehabilitation Cente | 1.8 mi | Austin, TX | ★★☆☆☆ | 3/5 | |
| Brodie Ranch Nursing and Rehabilitation Center | 2.8 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Marbridge Villa | 3.6 mi | Manchaca, TX | ★★★★☆ | 4/5 | |
| West Oaks Nursing and Rehabilitation Center | 4.1 mi | Austin, TX | ★★☆☆☆ | 2/5 | |
| Brush Country Nursing and Rehabilitation | 6.6 mi | Austin, TX | ★☆☆☆☆ | 1/5 | |
| Barton Valley Rehabilitation and Healthcare Center | 6.8 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Riverside Nursing and Rehabilitation Center | 8.4 mi | Austin, TX | ★☆☆☆☆ | 2/5 | abuse |
| Brookdale Westlake Hills | 8.9 mi | Austin, TX | ★★☆☆☆ | 2/5 | |
| Legend Oaks Healthcare and Rehabilitation-Kyle | 9.7 mi | Kyle, TX | ★★★☆☆ | 3/5 | |
| Stonebridge Health Rehab | 11.1 mi | Austin, TX | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676271.