Afton Oaks Nursing and Rehabilitation Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 72 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Abuse citation on record
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (26 vs median 8.0)
Bottom 25% in Texas · Critically understaffed (RN) · Worst in CREATIVE SOLUTIONS IN HEALTHCARE chain · $92,576 in fines · Special Focus Facility (CMS) · Abuse citation
What this means for your family
The facility appears to be undergoing a positive management and renovation turnaround, which is reflected in the high praise for the admissions and administrative teams. However, because there are serious, documented reports of medical neglect and hygiene issues, you should perform unannounced visits and specifically ask about their protocols for preventing bedsores and managing facility cleanliness.
Google Reviews
Google Reviews
72 reviews on Google“Families considering Afton Oaks will find a significant divide in experiences, with many recent reviews praising a recent management turnaround and a warm, welcoming admissions process. However, there are serious, recurring allegations of medical neglect, bedsores, and poor hygiene that must be addressed directly with the administration during your visit.”
Quality Themes
Tap a score for detailsStrengths
- Professional and helpful admissions team
- Warm and welcoming atmosphere
- Recent facility renovations
- Compassionate administrative staff
Concerns
- Allegations of medical neglect and bedsores (mentioned by 3 reviewers)
- Poor facility hygiene and unpleasant odors (mentioned by 3 reviewers)
- Slow staff response times (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 73 analyzed
How They Respond to Reviews
The owner provides personalized responses that frequently use the reviewer's name and acknowledge specific staff members mentioned in the text. For negative reviews, they maintain a professional tone, expressing a desire to improve and providing specific contact information for resolution.
Questions for Your Tour
- 1We were so impressed by how helpful and welcoming the admissions team was when we first walked in; how do you ensure that same level of care continues once a resident is settled in?
- 2With the recent renovations to the facility, what specific improvements have been made to the resident rooms and common areas?
- 3What specific protocols do you have in place to ensure high standards of cleanliness and hygiene throughout the building every day?
- 4How does the nursing team manage response times during the night shifts to ensure residents are attended to quickly if they need help?
- 5Can you tell us more about your skin care protocols and how the staff monitors residents to prevent issues like pressure sores?
- 6What does a typical day look like for residents in terms of social activities and group engagement?
Personalized based on this facility's data
Key Review Excerpts
“The facility staff have been so helpful and caring. The administrator and the interim DON went out of their way to ensure all my questions were answered. The treatment nurse and ADON ensured I was comfortable and checked on me regularly.”
“My dad was released from here and we had to have him rushed to the hospital. He had bed sores, declined in so many ways, and we thought we were going to lose him.”
“Te'lorr has been extremely kind and supportive. You can tell that she truly cares about the residents and their families which speaks volumes about her character.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
7
measures
3
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents whose bladder or bowel control got worse
Residents vaccinated for pneumonia
Residents on anti-anxiety or sleep medication
Residents whose walking got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families filed numerous complaints at this facility, triggering 30 of 45 total deficiencies across multiple surveys, with serious concerns about accident prevention recurring five times and remaining unresolved as of November 2025. The most problematic areas include resident safety and accident prevention, care planning and assessments, medication management, and protection from abuse and neglect, with issues persisting rather than being effectively corrected over time.
Jan 14, 2026Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nov 21, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Oct 27, 2025Complaint10
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
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.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Jul 11, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Apr 9, 2025Routine7
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
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
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.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Apr 9, 2025Complaint2
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Federal Penalties
Fine
Jan 14, 2026
$14,505
Fine
Oct 27, 2025
$70,400
Fine
Jul 11, 2025
$10,529
Fine
Sep 13, 2023
$19,861
Ownership & Operations
Who Operates This Facility
Winniestowell Hospital District
for profit
DIVERSICARE AFTON OAKS LLC
CHANDRA WILTZ-GARRETT
Chain Affiliation
Creative Solutions in Healthcare
149 facilities nationwide
Chain avg rating: 2.7/5 · Rank 118 of 148 (Worst)
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
72 reviews from families & visitors
Medicare data downloads
Original nursing home datasets
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