Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakcrest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple neurocognitive and psychiatric diagnoses, who required assistance with personal hygiene, was found non-interviewable in his room with a urinal on the bedside table containing dark yellow urine and surrounded by numerous small bugs, while the urinal itself appeared stained and corroded. A CNA reported last entering the room earlier that morning, acknowledged the presence of many bugs around the urinal, and noted the room’s toilet was not working, requiring the urinal to be emptied elsewhere. The resident’s privacy curtains were visibly soiled with a brown substance and described by staff as “nasty,” and the Maintenance Director, responsible for monitoring pests and environmental issues, had not been in the room that day but later identified the bugs as gnats and stated the curtains looked dirty and should have been changed. Separately, surveyors observed peeled and raised laminate flooring in an east hallway, which another resident said had been peeled by a resident, while the Maintenance Director stated the flooring would be repaired later and that no trips had been reported, despite facility policies requiring a clean, well-maintained environment and safe, decent, clean conditions for residents.
A resident with intact cognition and documented diagnoses of dementia, bipolar disorder, and schizoaffective disorder, as well as a known history of rape and head injuries, did not have her trauma history, delusional behavior, or major psychiatric diagnoses fully incorporated into her comprehensive care plan. Initial care plan review showed no mention of sexual trauma, delusions, schizophrenia, or bipolar disorder, and a later revision added only that she was a victim of physical abuse with general safety-related interventions, still omitting specific interventions for delusions and psychiatric conditions. The SW had long been aware of the resident’s assault history and persistent schizophrenia and delusions, and the psychologist’s documentation and progress notes described trauma-related experiences and increased manic behavior, but the DON, who was responsible for clinical care plan updates and did not perform a clinical background check, did not ensure these needs were reflected in the care plan, contrary to facility policy requiring a comprehensive, person-centered care plan including social services.
A facility failed to update care plans for residents, leading to significant deficiencies. A resident with dysphagia was not identified as a choking risk in their care plan, resulting in a fatal choking incident. Another resident's refusal of ADL care was not addressed in their care plan, and a third resident's challenging behaviors were not documented, leaving staff without guidance. Additionally, two residents' smoking habits were not reflected in their care plans, potentially impacting their care.
A resident with multiple diagnoses, including dementia and Alzheimer's, choked and died during a meal due to inadequate supervision and failure to update care plans with necessary interventions. Despite being diagnosed with oropharyngeal dysphagia, the resident's care plan did not reflect the need for assistance with feeding. Staff were unaware of the resident's swallowing difficulties, and there was no clear communication or documentation of dietary requirements and risk factors.
A resident with a history of swallowing difficulties choked and died, but the incident was not reported to the State agency as required. The facility staff, including the DON and ADM, were uncertain about the need to report the incident, and no investigation was conducted. Interviews revealed inconsistencies in the understanding of the resident's condition and lack of communication regarding the resident's care plan.
A facility failed to properly administer medication to a resident with multiple diagnoses, including Alzheimer's and schizophrenia. A pill was found on the floor of the resident's room, identified as Depakote, which should have been administered by the night MA. The DON and ADM emphasized the importance of ensuring medications are swallowed and not left unsupervised, as per the facility's policy.
A resident with a history of mental illness and other medical conditions walked out of the facility unattended due to inadequate supervision. The night nurse did not physically check on the resident, leading to an unnoticed elopement. The facility's policy required physical checks every two hours, but this was not followed.
Failure to Maintain Clean Resident Room and Safe Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a safe, clean, comfortable, and homelike environment for a male resident with dementia, bipolar disorder, schizophrenia, stroke history, type 2 diabetes, major depressive disorder, Alzheimer's disease, and dysphagia. His MDS showed he required setup or clean-up assistance with personal hygiene and his care plan noted risk for increased confusion and decline in ADLs as his disease progressed. On observation, the resident was non-interviewable and seated in his wheelchair in his room with a urinal on the table in front of him that was about one third full of dark yellow urine. There were approximately 25 small bugs visible on and around the urinal and an upside-down foam cup, and the urinal appeared stained and the plastic corroded. A CNA reported that the last time he had been in the resident’s room was around 9:00 AM that day and that the resident liked to empty his own urinal and sometimes refused to have it emptied, but that morning he did not refuse. The CNA stated the toilet in the resident’s room was not working, so he had to empty the urinal elsewhere. During this same observation, the resident’s curtains were noted to be stained with a brown substance, and the CNA described the curtains as “nasty” and acknowledged there were a lot of bugs around the urinal. The Maintenance Director, who stated it was his responsibility to monitor for pests and to be notified of pest issues, had not entered the resident’s room that day. After viewing a photo of the urinal, he identified the bugs as gnats and estimated, based on their number, that the urine had likely been sitting for two days. He also stated that staff were supposed to notify him or housekeeping when curtains needed to be removed for cleaning and agreed the curtains looked dirty and should have been changed. In addition to the conditions in the resident’s room, surveyors observed environmental deficiencies in the facility’s east hallway, where laminate floor paneling was peeled off and raised. Another resident reported that a resident had peeled off the floor. The Maintenance Director stated the damaged flooring would be repaired the following week and that, to his knowledge, no residents had tripped over it. The DON stated that pest control services occurred every two weeks and that it was everyone’s responsibility to monitor resident rooms for pests, but he had not been in this resident’s room that morning and stated he did not know how residents could be affected by pests. The Administrator reported that the facility had policies for maintenance, housekeeping, and resident rights for a homelike environment, that everyone was responsible for monitoring and reporting environmental concerns, and that he assumed urinals were emptied once a day. Facility policies reviewed stated that the residence would be kept clean and well-maintained through regular cleaning and preventive maintenance, and that residents had the right to safe, decent, and clean conditions.
Failure to Incorporate Trauma History and Psychiatric Diagnoses Into Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that incorporated a resident’s known psychiatric diagnoses and trauma history. Record review showed that the resident, an adult female with intact cognition (BIMS score of 15), had documented diagnoses including cognitive communication deficit, restlessness and agitation, unspecified dementia, bipolar disorder, and schizoaffective disorder. A psychologist’s clinical treatment plan documented that she had experienced rape and head injuries while living with others and on the street. Progress notes reflected increased manic behavior and a claim of an alleged rape occurrence. Despite this, review of the resident’s care plan on consecutive days showed that it initially contained no mention of her history of sexual trauma, delusional behavior, or diagnoses of schizophrenia and bipolar disorder. When the care plan was revised, it was updated only to reflect that the resident was a victim of physical abuse, with interventions focused on providing a safe environment, establishing safety and trust, discussing safe and healthy relationship skills, and providing referrals and resources. There continued to be no care plan interventions addressing her delusional behavior or her schizophrenia and bipolar disorder. Interviews with the DON, Administrator, and SW revealed that the DON and nursing staff were responsible for revising care plans, that the DON did not conduct a clinical background check when updating care plans, and that the SW had long been aware of the resident’s sexual assault history and persistent schizophrenia and delusions but did not revise care plans. The facility’s own care planning policy required development of a comprehensive, person-centered care plan based on individual assessed needs, including social services, yet the resident’s documented trauma history and psychiatric conditions were not fully incorporated into her comprehensive care plan. The Administrator acknowledged that nursing should know about the resident’s history and that not having an updated care plan created potential for a negative outcome if important information was missed.
Failure to Update Care Plans Leads to Resident Harm
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to significant deficiencies in care. Resident #47, who had a history of dysphagia and was identified as a choking risk, did not have an updated care plan reflecting these needs. Despite a swallow study indicating severe dysphagia and a high risk for aspiration and choking, the care plan lacked necessary interventions and dietary information. This oversight contributed to a fatal choking incident during a meal, where staff attempted the Heimlich maneuver and CPR, but the resident ultimately passed away. Resident #52's care plan was not updated to address his refusal of activities of daily living (ADL) care, including bathing. Despite multiple attempts by staff to encourage hygiene practices, the resident consistently refused, citing past trauma related to water. The care plan did not reflect these refusals or include strategies to manage his hygiene needs, leaving staff without guidance on how to address his non-compliance effectively. Resident #57 exhibited challenging behaviors, such as urinating in inappropriate places and becoming combative with staff. However, these behaviors were not documented in his care plan, leaving staff without a structured approach to manage his actions. Additionally, the care plans for Residents #43 and #67 did not reflect their status as smokers, omitting necessary interventions and timelines for managing their smoking habits. These omissions in care planning could lead to unmet needs and decreased quality of life for the residents.
Inadequate Supervision Leads to Resident Choking Incident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a resident choking and ultimately passing away. The resident, a male with multiple diagnoses including dementia and Alzheimer's, was on a mechanically altered diet and was considered independent in feeding according to his MDS. However, a professional evaluation had diagnosed him with oropharyngeal dysphagia, indicating a risk for choking, and recommended assistance with feeding. Despite this, the resident's care plan did not reflect these needs, and there were no documented dietary orders for a mechanical soft diet. On the day of the incident, the resident began choking during supper. Staff attempted to perform the Heimlich maneuver and clear the airway, but the resident passed out and subsequently died despite CPR efforts. Interviews with staff revealed a lack of awareness regarding the resident's swallowing difficulties and dietary needs. The DON and other staff members were unaware of the resident's diagnosis of swallowing difficulty, and there was no clear communication or documentation of the resident's dietary requirements and risk factors. The facility's failure to monitor the resident during meal intake and to update care plans with necessary interventions for residents at risk of choking contributed to the incident. The lack of a clear policy for following up on swallow study results and notifying the doctor, as well as inadequate supervision during meals, were significant factors in the deficiency. The report highlights the need for improved communication and documentation to ensure resident safety and prevent similar incidents in the future.
Failure to Report Choking Incident Leading to Resident's Death
Penalty
Summary
The facility failed to report an incident involving a resident who choked and subsequently died, which was a violation of the requirement to report alleged violations involving neglect immediately or within two hours if they result in bodily injury. The resident, a male with multiple diagnoses including dementia and Alzheimer's, was on a mechanical soft diet and had a history of swallowing difficulties as indicated by a swallow study. Despite these known issues, the incident was not reported to the State agency, and no investigation was conducted because the incident was witnessed by staff. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed uncertainty about whether the incident needed to be reported. The DON and ADM both stated that they were unsure if the incident should be reported, despite the fact that the resident's death was due to choking, which is considered an unusual circumstance. The DON also mentioned that the resident had missing teeth and no dentures, but claimed the resident did not have swallowing issues, contradicting the swallow study results. Further interviews with nursing staff and a speech pathologist highlighted inconsistencies in the understanding of the resident's condition. The RN who responded to the choking incident was unaware of the resident's swallowing difficulties or dietary restrictions. The speech pathologist confirmed the resident's diagnosis of Oropharyngeal Dysphagia and stated that recommendations were made based on the swallow study. However, the resident's primary doctor and nurse practitioner were either unaware of the swallow study results or did not follow its recommendations, indicating a lack of communication and coordination in the resident's care plan.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the proper administration of medication to a resident, identified as Resident #1, who was diagnosed with Alzheimer's disease, Parkinson's disease, unspecified psychosis, schizophrenia, COPD, and primary hypertension. During an observation, a white pill was found on the floor of Resident #1's room, which was identified as Depakote, a medication prescribed for schizoaffective disorder. The Director of Nursing (DON) confirmed the medication should have been administered by the night medication aide (MA) and expressed uncertainty about how it ended up on the floor. The DON emphasized the expectation that staff should ensure oral medications are swallowed by residents to prevent potential negative outcomes. Interviews with the night MA and the Administrator (ADM) revealed that the MA claimed to have administered the medication and ensured residents took their medications before leaving. However, the MA was uncertain how the medication was left behind. The ADM reiterated the expectation that medication should not be left unsupervised, as it could lead to another resident taking it or the intended resident not receiving their full dose. The facility's Medication Administration policy mandates that medications be administered within a one-hour window and that the seven rights of medication administration be followed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who walked out of the facility unattended. The resident, who had a history of mental illness and other medical conditions, was found to be missing on a routine check. The staff member responsible for monitoring the resident every two hours did not physically check on the resident but instead assumed the resident was present, leading to the resident's unnoticed elopement. The resident's care plan indicated that he should be placed in an area where frequent observation was possible due to his habit of intruding into other residents' privacy. Despite this, the resident managed to exit the facility through a secured gate by forcefully opening it. The monitoring sheet falsely indicated that the resident was present throughout the night, even though CCTV footage showed the resident leaving the facility. Interviews with staff revealed that the night nurse did not physically check on the residents but used a flashlight from the door for observation. The facility's policy required physical checks every two hours, but this was not followed. The Director of Nursing acknowledged that there was no system in place to verify the accuracy of these observations, contributing to the resident's elopement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sedona Trace Health And Wellness Center | 3.8 mi | — | 1 | 0 |
| Legend Oaks Healthcare And Rehabilitation - North | 4 mi | — | 5 | 2 |
| Heritage Park Rehabilitation And Skilled Nursing C | 6.4 mi | — | 8 | 1 |
| Gracy Woods Ii Living Center | 6.9 mi | — | 0 | 0 |
| Gracy Woods Nursing Center | 7 mi | — | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.