Inspection Reports for West Oaks Nursing and Rehabilitation Center
3200 W Slaughter Ln, Austin, TX 78748, TX, 78748
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safety regulations, specifically to ensure the nursing home environment is free from accident hazards and that residents receive adequate supervision and assistance devices to prevent accidents.
Findings
The facility failed to ensure that Resident #1's wheelchair brakes were functional, posing a risk for injury and decreased quality of life. Despite Resident #1 alerting staff multiple times, the left brake remained non-functional for over a month, increasing the risk of falls during self-transfers.
Deficiencies (1)
Failure to ensure the resident environment remained free from accident hazards and provide adequate supervision to prevent accidents, specifically the non-functional wheelchair brakes for Resident #1.
Report Facts
Residents reviewed for accidents and hazards: 8
Residents affected: 1
BIMS score: 12
Falls history: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Nurse for Resident #1, unaware of non-functional wheelchair brakes |
| DOR | Director of Rehabilitation | Spoke with Resident #1 about wheelchair brake issue and planned to notify OT |
| OT C | Occupational Therapist | Alerted to wheelchair brake issue, scheduled to assess Resident #1's wheelchair |
| ADON | Assistant Director of Nursing | Stated therapy department responsibility for equipment safety and functionality |
| ADM | Administrator | Discussed facility expectations for fall risk management and equipment checks |
| CNA A | Certified Nursing Assistant | Unaware of wheelchair brake issue, assists Resident #1 with transfers |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Feb 11, 2025
Visit Reason
The inspection was initiated due to an abbreviated survey triggered by concerns about pharmaceutical services and medication errors, specifically related to Resident #1's hospital discharge orders not being followed, which led to rehospitalization due to hypoglycemia.
Findings
The facility failed to ensure accurate pharmaceutical services including acquiring, receiving, dispensing, and administering medications. Resident #1 was given discontinued diabetes medications (metformin and glyburide), blood sugar monitoring was not implemented timely, and an appetite stimulant was not started as ordered. These failures resulted in immediate jeopardy to resident health and safety, with Resident #1 experiencing multiple hospitalizations due to hypoglycemia and related complications.
Deficiencies (3)
Failure to discontinue Resident #1's metformin and glyburide medications after hospital discharge.
Failure to implement blood sugar monitoring for Resident #1 as ordered.
Failure to start Resident #1 on the appetite stimulant (Mirtazapine) as ordered.
Report Facts
Blood sugar level: 27
Blood sugar level: 24
Blood sugar level: 42
Medication administration dates: 3
Medication administration counts: 5
Number of nurses trained: 25
Admissions audited: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Interviewed regarding Resident #1's blood sugar monitoring and medication order verification |
| RN D | Registered Nurse | Interviewed regarding Resident #1's emergency care and hospital transfers |
| LVN A | Licensed Vocational Nurse | Interviewed about Resident #1's readmission and medication paperwork handling |
| NP | Nurse Practitioner | Interviewed about medication reconciliation and Resident #1's care |
| RN E | Registered Nurse | Interviewed about Resident #1's dialysis and low blood sugar event |
| DON | Director of Nursing | Interviewed about facility policies, in-service training, and corrective actions |
| ED | Executive Director | Notified about Immediate Jeopardy and involved in corrective action plan |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, privacy, supervision, medication storage, food safety, and infection control at West Oaks Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide timely meals affecting resident dignity, failure to respect resident privacy by not knocking before entering rooms, inadequate supervision during feeding placing residents at risk, unsecured medication carts, improper food storage and sanitation practices in the kitchen and nourishment areas, and lapses in infection prevention and control practices including improper catheter care.
Deficiencies (6)
Failure to ensure Resident #93 received lunch meal in an adequate timeframe affecting dignity.
Failure to ensure resident rights for personal privacy by not knocking before entering rooms for 4 residents.
Failure to provide adequate supervision to prevent accidents for Resident #69 during ice chip feeding.
Medication cart left unattended and unlocked with keys in lock.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled and expired foods, poor sanitation, improper hand hygiene, and improper thawing.
Failure to establish and maintain an infection prevention and control program including improper hand hygiene and glove use during catheter care for Resident #46.
Report Facts
Residents reviewed for dignity: 6
Residents reviewed for personal privacy: 15
Residents reviewed for accidents and supervision: 4
Medication carts reviewed: 4
Residents reviewed for infection control: 2
BIMS score Resident #93: 14
BIMS score Resident #23: 14
BIMS score Resident #52: 12
BIMS score Resident #78: 15
BIMS score Resident #69: 7
Dishwasher temperature: 110
Margarine temperature: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Named in findings related to meal service delay, medication cart left unlocked, and infection control lapses. | |
| RN B | Named in findings related to meal service delay and improper hand hygiene while serving meals. | |
| CNA E | Named in findings related to failure to knock before entering resident room. | |
| DM | Dietary Manager | Named in findings related to food safety and sanitation deficiencies. |
| ADM | Administrator | Named in findings related to meal service, medication cart security, food safety, and infection control oversight. |
| DON | Director of Nursing | Named in findings related to resident privacy, medication cart security, and infection control oversight. |
| CNA G | Named in infection control deficiency related to catheter care. | |
| Cook J | Named in food safety deficiencies related to hand hygiene, jewelry, and food temperature. | |
| Dietitian | Named in food safety and sanitation oversight. | |
| MDSN | Named in supervision deficiency related to Resident #69. | |
| ADT | Named in supervision deficiency related to Resident #69. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 13, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan implementation and fall prevention measures, specifically focusing on Resident #1's care plan and fall risk interventions.
Findings
The facility failed to implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #1 and failed to ensure a fall mat was consistently placed at Resident #1's bedside, placing residents at risk of harm. Multiple staff interviews and observations confirmed lapses in fall mat placement and care plan adherence.
Deficiencies (2)
Failed to implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #1.
Failed to have a fall mat at Resident #1's bedside while he was lying in bed, increasing fall risk.
Report Facts
Residents reviewed for comprehensive care plans: 6
Falls recorded for Resident #1: 5
Date of Resident #1's admission record: May 9, 2024
Date of Resident #1's MDS Assessment: Mar 22, 2024
Date of Resident #1's Fall Risk Evaluation: May 7, 2024
Date of staff in-service training on falls: May 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Answered Resident #1's call light and repositioned fall mat to bedside; trained on falls by ADONs |
| CNA B | Certified Nursing Assistant | Responsible for second half of hallway; trained and in-serviced on falls |
| RN C | Registered Nurse | Checked on residents and fall risk residents every hour; responsible for ensuring fall mats were next to beds |
| PT D | Physical Therapist | Provided therapy to Resident #1 and ensured fall mat was next to bed after therapy |
| ADON E | Assistant Director of Nursing | In-serviced staff weekly on falls; responsible for two halls; expected staff to ensure fall mats were next to beds |
| ADON F | Assistant Director of Nursing | Trained and in-serviced staff on falls; expected staff to check residents every two hours and ensure fall mats placement |
| DON | Director of Nursing | Trained and in-serviced staff on falls; expected nursing staff to check residents every two hours and ensure fall mats placement |
| MDS G | MDS Coordinator | Trained and in-serviced on falls; noted failure to follow care plan regarding fall mats |
| LVN H | Licensed Vocational Nurse | Checked on residents every hour; stated fall mats should be next to beds |
| ADM | Administrator | Expected residents at risk for falls to have floor mats next to beds |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 10, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights to dignity and appropriate pain management, including medication administration timeliness.
Findings
The facility failed to ensure residents' dignity was maintained for 2 of 11 residents, including inappropriate public communication and exposure of a resident's incontinence brief. Additionally, the facility failed to provide timely pain management and medication administration for 1 of 4 residents, resulting in late delivery of scheduled medications over multiple days.
Deficiencies (3)
Failure to honor residents' right to a dignified existence, including inappropriate public communication and exposure of incontinence brief.
Failure to provide safe, appropriate pain management and timely medication administration for Resident #3.
Failure to provide pharmaceutical services ensuring accurate and timely medication administration for Resident #3.
Report Facts
Residents reviewed for dignity: 11
Residents reviewed for pain management: 4
Days medication late: 7
BIMS score Resident #1: 0
BIMS score Resident #2: 10
BIMS score Resident #3: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PTA A | Named in findings related to failure to maintain resident dignity and inappropriate communication | |
| MA B | Named in findings related to medication administration delays for Resident #3 | |
| DON | Director of Nursing | Interviewed regarding dignity and medication administration failures |
| ADM | Administrator | Interviewed regarding facility oversight of dignity and medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 28, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide necessary assistance with activities of daily living, specifically showering, and failure to ensure adequate supervision to prevent elopement of a high-risk resident.
Complaint Details
The complaint investigation was substantiated. Resident #1 was not showered according to schedule and had to beg staff for showers. Resident #2, a high-elopement risk, eloped from the facility when the receptionist unlocked the front door, and was found over 24 hours later 12 miles away. The facility implemented corrective actions including staff in-services, suspension of the receptionist, and enhanced monitoring.
Findings
The facility failed to provide showers to Resident #1 according to his schedule, placing him at risk of hygiene decline and skin breakdown. The facility also failed to prevent Resident #2, a high-elopement risk, from leaving the facility unsupervised, resulting in an immediate jeopardy situation. The facility took corrective actions including staff in-services, suspension of the receptionist responsible, and enhanced monitoring.
Deficiencies (2)
Failed to provide showers to Resident #1 in compliance with his shower schedules, resulting in minimal harm or potential for actual harm.
Failed to ensure the residents environment remained free from accident hazards and provide adequate supervision to prevent elopement of Resident #2, resulting in immediate jeopardy to resident health or safety.
Report Facts
Showers received by Resident #1: 3
Elopement incident date and time: 2024-03-26 12:50
Distance Resident #2 was found from facility: 12
Duration of elopement: 28
Number of staff involved in search: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Documented nursing progress notes related to Resident #2's elopement. |
| CNA A | Certified Nursing Assistant | Shower aide and provided statements about shower schedules and in-service training. |
| CNA D | Certified Nursing Assistant | Worked on Resident #2's hall on the day of elopement and provided interview about monitoring. |
| ADM | Administrator | Provided statements regarding the elopement incident and facility expectations. |
| DON | Director of Nursing | Provided statements about shower schedules, elopement policies, and staff in-services. |
| SC | Staff Coordinator | Responsible for collecting shower sheets and monitoring showers; provided statements about elopement training. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
The inspection was conducted as an annual survey of West Oaks Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were reported as unknown.
Inspection Report
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with discharge planning and transfer rights, specifically focusing on whether discharge summaries were completed for residents discharged from the facility.
Findings
The facility failed to complete discharge summaries for three of five residents reviewed, placing residents at risk of not receiving appropriate care and services upon discharge. The discharge summaries were incomplete or missing for Residents #1, #2, and #3, despite policies requiring interdisciplinary team involvement and timely completion.
Deficiencies (1)
Failure to complete discharge summaries for three residents, resulting in risk of inadequate post-discharge care.
Report Facts
Residents reviewed for transfer and discharge rights: 5
Residents with incomplete discharge summaries: 3
Discharge dates: Nov 1, 2023
Discharge dates: Nov 5, 2023
Discharge dates: Oct 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed about discharge summary responsibilities | |
| Director of Nursing | Interviewed about discharge summary process and responsibility |
Inspection Report
Routine
Capacity: 125
Deficiencies: 8
Date: Sep 3, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), incomplete PASRR screening and follow-up, failure to develop comprehensive care plans timely, inadequate supervision to prevent resident elopement, improper catheter care, incomplete medical records, lack of a full-time social worker, and failure to update the facility-wide assessment to include elopement risks.
Deficiencies (8)
Failure to provide reasonable accommodation of resident needs for call light for 1 of 15 residents reviewed.
Failure to ensure accurate pre-admission PASRR Level I screening and follow-up for 1 of 5 residents reviewed.
Failure to develop a comprehensive care plan within 7 days of assessment for 1 of 8 residents reviewed.
Failure to ensure resident environment free from accident hazards and provide adequate supervision to prevent elopement for 1 of 4 residents reviewed.
Failure to provide appropriate catheter care for 2 of 15 residents reviewed, including unsecured catheter and improper urine bag positioning.
Failure to maintain complete and accurate medical records for 1 of 15 residents reviewed.
Failure to employ a qualified full-time social worker in a facility with more than 120 beds.
Failure to conduct and document a facility-wide assessment including elopement risk for residents.
Report Facts
Licensed capacity: 125
Residents reviewed for call light: 15
Residents reviewed for PASRR: 5
Residents reviewed for care plans: 8
Residents reviewed for accident hazards: 4
Residents reviewed for catheter care: 15
Residents reviewed for medical records: 15
Licensed nurses: 18
Certified nursing assistants: 44
Residents assessed for elopement risk: 97
Residents identified as high risk for elopement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in call light accommodation and catheter care findings |
| DON | Director of Nursing | Named in multiple findings including call light, PASRR, care plans, elopement, catheter care, and training oversight |
| LVN E | Licensed Vocational Nurse | Named in catheter care finding |
| Administrator | Facility Administrator | Named in elopement findings and social worker staffing |
| MDS Coordinator 7 | MDS Coordinator | Named in PASRR findings |
| CNA D | Certified Nursing Assistant | Named in elopement training |
| CNA E | Certified Nursing Assistant | Named in elopement training |
| LVN J | Licensed Vocational Nurse | Named in elopement training |
| LVN M | Licensed Vocational Nurse | Named in elopement training |
| LVN N | Licensed Vocational Nurse | Named in elopement training |
| CNA O | Certified Nursing Assistant | Named in elopement training |
| CNA K | Certified Nursing Assistant | Named in elopement training |
| CNA L | Certified Nursing Assistant | Named in elopement training |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with appropriate care standards for residents who are continent or incontinent of bowel/bladder, focusing on catheter care and prevention of urinary tract infections.
Findings
The facility failed to ensure that residents with indwelling catheters received routine catheter care as orders were not in place for such care for two residents reviewed. Documentation of catheter care was lacking, and the facility's staff did not consistently document or have orders for catheter care, potentially placing residents at risk of discomfort and urinary tract infections.
Deficiencies (1)
Failure to provide appropriate catheter care and prevent urinary tract infections for residents with indwelling catheters due to lack of routine catheter care orders and documentation.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Provided catheter care once a shift and documented urine output by checking off bladder task in electronic medical record |
| DON | Director of Nursing | Provided statements regarding catheter care orders, documentation practices, and staff training |
| Nurse Practitioner | Stated there should be orders in place for catheter care and described assessment responsibilities | |
| Administrator | Commented on catheter care practices and order transfers after company change |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to allow residents to manage their financial affairs, specifically concerning Resident #1's representative payee status.
Complaint Details
The complaint investigation found that Resident #1 was not informed or involved in the application process for the facility to become his representative payee despite owing money to the facility. The facility staff stated notification was not given because the decision was made by Social Security, and the facility lacked a policy on notification of representative payee changes.
Findings
The facility failed to notify Resident #1 when they applied and became his representative payee, which placed the resident at risk of loss of dignity and self-worth. Interviews revealed the facility did not have a policy for notifying residents or responsible parties about changes in representative payees.
Deficiencies (1)
Facility failed to notify Resident #1 when they applied and became his representative payee.
Report Facts
Amount owed to facility: 1327.48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM | Business Office Manager | Interviewed regarding application to be resident's representative payee. |
| ADM | Administrator | Interviewed regarding notification policies for representative payee changes. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 29, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's pharmaceutical services, specifically regarding medication administration and supervision for residents.
Complaint Details
The investigation was complaint-related, focusing on medication administration practices. The complaint was substantiated by observations and interviews revealing improper medication supervision.
Findings
The facility failed to properly supervise medication administration, leaving medications unattended in residents' rooms, which placed residents at risk for drug diversion or ingestion leading to harm. Observations and interviews confirmed medications were left in rooms of two residents without proper supervision.
Deficiencies (2)
Failed to provide pharmaceutical services including accurate acquiring, receiving, dispensing, and administering of medications to meet residents' needs.
Left medications sitting out in Resident #1 and Resident #2's rooms without supervision.
Report Facts
Residents reviewed for medication administration: 5
BIMS score for Resident #1: 13
BIMS score for Resident #2: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Nurse | Resident #1 and Resident #2's nurse who admitted to leaving medications in rooms. |
| MA C | Medication Aide | Stated she did not administer muscle relaxer/pain medication and would never leave medications in rooms. |
| LVN B | Nurse | Stated she would never leave medications in rooms and always supervised ingestion. |
| ADM | Administrator | Stated expectations that no medications be left in resident rooms and no policy existed on this. |
| DON | Director of Nursing | Stated she had begun in-servicing nurses and medication aides on medication supervision. |
Inspection Report
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for West Oaks Nursing and Rehabilitation Center, summarizing the findings of a survey completed on 02/23/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 4
Date: Jul 14, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations related to resident care, activities, environment safety, and food service.
Findings
The facility failed to provide adequate personal hygiene care to residents, including nail care, and failed to provide an ongoing program of activities tailored to residents' needs. Additionally, the facility did not maintain a safe environment by leaving chemicals unsecured and failed to ensure proper food storage and hand hygiene in the kitchen.
Deficiencies (4)
Failed to provide necessary services to maintain good personal hygiene for 5 of 24 residents, including long, dirty, and jagged fingernails and facial hair not managed.
Failed to provide an ongoing program of activities meeting the interests and physical, mental, and psychosocial well-being of 11 of 24 residents reviewed for activities.
Failed to ensure the resident environment remained free of accident hazards as housekeeping cart containing chemicals was left unlocked and accessible to a resident.
Failed to store, prepare, distribute, and serve food under sanitary conditions, including improper food storage and labeling, and failure of staff to perform proper hand hygiene during food preparation.
Report Facts
Residents reviewed for ADL care: 24
Residents reviewed for activities: 24
Residents affected by hygiene deficiency: 5
Residents affected by activity deficiency: 11
Residents affected by environment hazard: 1
Housekeepers reviewed for hazards: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Interviewed regarding nail care practices and deficiencies |
| MA B | Medical Assistant | Interviewed regarding shower and nail care responsibilities |
| CNA H | Certified Nursing Assistant | Interviewed regarding nail care procedures and documentation |
| SA C | Shower Aide | Interviewed regarding shower and nail care duties |
| LVN A | Licensed Vocational Nurse | Interviewed regarding nail care expectations and monitoring |
| DON | Director of Nursing | Interviewed regarding nail care expectations and monitoring |
| ADM | Administrator | Interviewed regarding nail care expectations and monitoring |
| HK K | Housekeeper | Interviewed regarding leaving chemical cart unlocked |
| Housekeeper Supervisor | Supervisor | Interviewed regarding housekeeping cart chemical locking procedures and monitoring |
| CK I | Cook/Kitchen Staff | Observed and interviewed regarding improper hand hygiene during food preparation |
| DA J | Dietary Aide | Observed and interviewed regarding improper hand hygiene during food preparation |
| DS | Dietary Supervisor | Interviewed regarding food storage, labeling, and hand hygiene monitoring |
Viewing
Loading inspection reports...
