West Oaks Nursing and Rehabilitation Center
3200 W. Slaughter Lane, Austin, TX 78748 · Travis County · 125 certified beds · avg 107 residents/day · certified since Mar 31, 2006
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: 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)
▲ Immediate jeopardy, repeated · Feb 11, 2025 · F-0760 · triggered by a complaint
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.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 12, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Mar 28, 2024 · 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 27, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Sep 3, 2023 · F-0689
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: Oct 3, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Apr 10, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 7, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Apr 10, 2024 · F-0755 · triggered by a complaint
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 7, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (31)
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 |
|---|---|---|
| Feb 25, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 25, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Feb 25, 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. |
| Feb 25, 2026 | 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. |
| Feb 25, 2026 | 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 25, 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. |
| Feb 25, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 11, 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 |
| Feb 11, 2025 | ▲ K · Immediate jeopardy, 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 |
| Nov 26, 2024 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Nov 26, 2024 | 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. |
| Nov 26, 2024 | 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. |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 26, 2024 | 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. |
| Nov 26, 2024 | 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. |
| May 13, 2024 | 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 |
| Apr 10, 2024 | ▲ H · Actual harm, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Apr 10, 2024 | ▲ H · Actual 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 |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 28, 2024 | ▲ 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 |
| Mar 28, 2024 | D · Potential for harm, one-off | 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. · from a complaint |
| Nov 13, 2023 | E · Potential for harm, repeated | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint |
| Sep 3, 2023 | ▲ 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. |
| Sep 3, 2023 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Sep 3, 2023 | E · Potential for harm, repeated | 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. |
| Sep 3, 2023 | E · Potential for harm, repeated | 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 3, 2023 | E · Potential for harm, repeated | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. |
| Sep 3, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Sep 3, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Sep 3, 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. |
| Aug 24, 2023 | 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. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 10 | 1 | J ▲ |
| 2024 | 12 | 3 | J ▲ |
| 2025 | 2 | 1 | K ▲ |
| 2026 | 7 | 0 | E |
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 $39,527.
| Date | Type | Amount / length |
|---|---|---|
| Feb 11, 2025 | Fine | $26,683 |
| Mar 28, 2024 | Fine | $12,844 |
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) | 3.13 | 3.46 | 3.95 | bottom 32% in Texas; bottom 18% in the U.S. |
| Registered Nurse hours | 0.44 | 0.44 | 0.69 | top 37% in Texas; bottom 28% in the U.S. |
| Weekend total nurse staffing | 2.64 | 3.04 | 3.50 | bottom 24% in Texas; bottom 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.34 | 0.48 | top 33% in Texas; bottom 44% in the U.S. |
| Total nursing staff turnover (%) | 34.1 | 55.3 | 45.8 | top 11% in Texas; top 22% in the U.S. |
| RN turnover (%) | 40.0 | 54.6 | 42.9 | top 30% in Texas; top 46% 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 3.20, RN 0.45, weekend 2.70. Staffing rating: 2/5.
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: 2/5 · short-stay residents: 5/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| American Robin Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2022 |
| American Robin Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 10/27/2025 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 01/18/2022 |
| 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 |
| Martin, Dieter | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/14/2023 |
| Martin, Dieter | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/14/2023 |
| Martin, Dieter | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2023 |
| Thompson, Amber | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2022 |
| Thompson, Amber | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2022 |
| Thompson, Amber | 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.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "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 |
|---|---|---|---|---|---|
| Brodie Ranch Nursing and Rehabilitation Center | 2.2 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Southpark Meadows Nursing and Rehabilitation Cente | 2.8 mi | Austin, TX | ★★☆☆☆ | 3/5 | |
| Brush Country Nursing and Rehabilitation | 3.1 mi | Austin, TX | ★☆☆☆☆ | 1/5 | |
| Marbridge Villa | 3.1 mi | Manchaca, TX | ★★★★☆ | 4/5 | |
| Onion Creek Nursing and Rehabilitation Center | 4.1 mi | Austin, TX | ★☆☆☆☆ | 2/5 | |
| Barton Valley Rehabilitation and Healthcare Center | 4.4 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Brookdale Westlake Hills | 6.8 mi | Austin, TX | ★★☆☆☆ | 2/5 | |
| Stonebridge Health Rehab | 7.2 mi | Austin, TX | ★★★☆☆ | 3/5 | |
| Querencia at Barton Creek | 7.6 mi | Austin, TX | ★★★★★ | 4/5 | |
| Riverside Nursing and Rehabilitation Center | 9.1 mi | Austin, TX | ★☆☆☆☆ | 2/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676095.