Northern Oaks Living & Rehabilitation Center

Inspection findings

1. Jul 2, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected Jul 3, 2026 · CMS health inspection

2. May 5, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected May 28, 2026 · CMS health inspection

3. Jan 22, 2026 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0577 Resident Rights Deficiencies

     Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     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 Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0761 Pharmacy Service Deficiencies

     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 Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 1, 2026 · CMS fire safety

4. Nov 7, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 8, 2025 · CMS health inspection

5. Mar 7, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 8, 2025 · CMS health inspection

6. Oct 29, 2024 Health · 11 findings
   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Nov 22, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 22, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Nov 22, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0131 Construction Deficiencies

     Meet requirements for sections of health care facilities separated by fire resistive construction.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0364 Smoke Deficiencies

     Install properly constructed windows in hallway walls or doors.

     Corrected Nov 22, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Nov 22, 2024 · CMS fire safety

7. Sep 20, 2023 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Oct 12, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Oct 12, 2023 · CMS health inspection

8. Aug 29, 2023 Health · 13 findings
   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     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 Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0690 Quality of Life and Care Deficiencies

     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 Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     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 Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0809 Nutrition and Dietary Deficiencies

     Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0840 Administration Deficiencies

     Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 22, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BURLESON, RHONDA — adp of the snf, NOT APPLICABLE, since 02/01/2015
• BURLESON, RHONDA — managing control - governing body, NOT APPLICABLE, since 02/01/2015
• BURLESON, RHONDA — operational/managerial control, NOT APPLICABLE, since 02/01/2015
• BURNAM, SOON — operational/managerial control, NOT APPLICABLE, since 01/01/2000
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 01/01/2000
• HUDMAN, EUGENE — adp of the snf, NOT APPLICABLE, since 05/15/2013
• HUDMAN, EUGENE — operational/managerial control, NOT APPLICABLE, since 05/15/2013
• HUDMAN, EUGENE — managing control - governing body, NOT APPLICABLE, since 05/15/2013
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• TAYLOR, STEPHEN — corporate officer, NOT APPLICABLE, since 07/01/2025
• ANSON HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 01/01/2000
• CARETRUST GP LLC — adp of the snf, NOT APPLICABLE, since 01/01/2000
• CARETRUST REIT INC — adp of the snf, NOT APPLICABLE, since 01/01/2000
• CTR PARTNERSHIP LP — adp of the snf, NOT APPLICABLE, since 01/01/2000
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/01/2015
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 08/01/2002
• NORTHERN OAKS HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 02/01/2015
• NORTHERN OAKS HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 08/12/2025