Onion Creek Nursing and Rehabilitation Center
1700 Onion Creek Pkwy · Austin, TX · 78748 · 5122914900
125 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
$51,337 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
RN staffing in the bottom 10% nationally
0.27 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
61% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.12 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.27 | 0.55–0.75 |
| Weekend hours / resident-day | 2.74 | ≈ weekday level |
| Nursing turnover / year | 61% | median 45% |
| Fines (3-yr window) | 2 · $51,337 |
Inspection citations (26 in the current record)
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Potential for harm · D January 28, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected March 3, 2026 · Resident Rights
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Potential for harm · E November 5, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected December 12, 2025 · Pharmacy Service
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Potential for harm · D July 3, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 3, 2025 · found via complaint
Assist a resident in gaining access to vision and hearing services.
Corrected July 18, 2025 · Quality of Life and Care
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Immediate jeopardy · K April 5, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 21, 2025 · Quality of Life and Care
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Immediate jeopardy · J February 19, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 5, 2025 · Quality of Life and Care
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Potential for harm · D February 19, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 5, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · H October 2, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 3, 2024 · Quality of Life and Care
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Potential for harm · E July 1, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected July 9, 2024 · Pharmacy Service
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Potential for harm · E July 1, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected July 2, 2024 · Pharmacy Service
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Potential for harm · E February 29, 2024
Keep residents' personal and medical records private and confidential.
Corrected March 1, 2024 · Resident Rights
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Potential for harm · D February 29, 2024
Ensure each resident receives an accurate assessment.
Corrected March 15, 2024 · Resident Assessment and Care Planning
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Potential for harm · E February 29, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 15, 2024 · Quality of Life and Care
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Potential for harm · D February 29, 2024
Provide activities to meet all resident's needs.
Corrected March 29, 2024 · Quality of Life and Care
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Potential for harm · D February 29, 2024
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected March 8, 2024 · Nutrition and Dietary
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Potential for harm · F February 29, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 8, 2024 · Nutrition and Dietary
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Potential for harm · D December 2, 2022
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected December 9, 2022 · Resident Rights
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Potential for harm · E December 2, 2022
Ensure medication error rates are not 5 percent or greater.
Corrected December 9, 2022 · Pharmacy Service
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Potential for harm · F December 2, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 9, 2022 · Nutrition and Dietary
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Potential for harm · D December 2, 2022
Provide and implement an infection prevention and control program.
Corrected December 9, 2022 · Infection Control
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Potential for harm · E September 10, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 28, 2021 · Resident Assessment and Care Planning
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Potential for harm · D September 10, 2021
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected September 28, 2021 · Quality of Life and Care
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Potential for harm · E September 10, 2021
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected September 28, 2021 · Pharmacy Service
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Potential for harm · E September 10, 2021
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected September 28, 2021 · Pharmacy Service
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Potential for harm · E September 10, 2021
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected September 28, 2021 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 5, 2025 | Fine | $42,224 |
| February 19, 2025 | Fine | $9,113 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676271 · certified since February 16, 2011. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.