Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burford Manor during CMS and state inspections, most recent first.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe cognitive impairment and Alzheimer's, who was dependent on staff for care, was subjected to physical and verbal abuse by an LPN who became aggravated, loudly demanded the resident sit down, and pushed the resident back into a wheelchair after repeated attempts to stand. The incident was witnessed by staff, who intervened and reported the event to the DON.
The facility failed to implement enhanced barrier precautions for two residents requiring such measures. One resident with a pressure wound and an indwelling catheter received wound care without appropriate signage or PPE, while another resident with multiple diagnoses received tube feeding under similar conditions. The DON was unaware of the need for EBP and lacked a policy, leading to inadequate infection control practices.
The facility failed to maintain a sanitary and safe environment for all 47 residents. Observations revealed holes in the wood flooring on the South Hall and black grime around the base of showers on the East/West and North Halls. Maintenance acknowledged these issues, attributing the flooring problem to the foundation and reporting regular caulking of the showers. The DON confirmed these issues and mentioned plans to fix them, but acknowledged that the showers were beyond the facility's repair capabilities.
A resident with Alzheimer's and dysphagia experienced a fall resulting in a head laceration and was sent to the ER. The facility failed to notify the resident's representative of the incident, despite policy requirements and attempts to contact them. The representative only became aware of the situation during a later visit, observing the resident with sutures and bruising.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Resident from Physical and Verbal Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of Alzheimer's disease, who was dependent on staff for all activities of daily living and had a history of repeated falls, was not protected from physical and verbal abuse by a staff member. The incident occurred when the resident repeatedly attempted to get up from their wheelchair during an evening meal service. An LPN became increasingly aggravated, raised their voice, and demanded the resident to sit down. The LPN was observed by staff to push the resident back into the wheelchair after the resident attempted to get up. The LPN's actions were loud enough to draw the attention of other staff, and the incident was witnessed by a dietary manager who intervened by removing the resident from the situation. The facility's policy stated a commitment to an abuse-free environment and outlined measures to prevent abuse, including supporting staff in managing frustration and stress. Despite these policies, the staff member's conduct constituted both physical and verbal abuse, as the resident was subjected to being pushed and spoken to in a demanding manner. The incident was reported to the DON, and an investigation was initiated. The resident's family was notified, but the deficiency centers on the failure to prevent the abusive behavior from occurring.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents identified as needing such precautions. Resident #13, diagnosed with Alzheimer's, depression, and high blood pressure, had a care plan indicating an alteration in skin integrity due to a pressure wound and an indwelling catheter. During an observation, LPN #1 performed wound care for this resident without any signage for EBP or a PPE kit available. The Director of Nursing (DON) was unable to provide an EBP policy and procedure, indicating a lack of awareness and implementation of necessary precautions. Similarly, Resident #25, with diagnoses including acute respiratory failure, dementia, chronic kidney disease, and chronic obstructive pulmonary disease, was observed receiving tube feeding without EBP signage or PPE kit availability. The DON confirmed the absence of an EBP policy and was unaware of the need for such precautions, confusing them with transmission-based precautions (TBP). This lack of policy and awareness led to the failure in implementing necessary infection control measures for residents requiring enhanced barrier precautions.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary and safe environment for all 47 residents. Observations revealed holes in the wood flooring on the South Hall, which maintenance acknowledged but attributed to the foundation. Additionally, black areas, identified as soap and grime, were observed around the base of showers on the East/West and North Halls. Maintenance reported caulking these areas every three months and were seeking contractors for tile replacement due to the persistent black scum. Further, chips were noted in the wood flooring between the common area and the main dining room. The Director of Nursing (DON) confirmed these issues and mentioned plans to fix them, but acknowledged that the showers were beyond the facility's repair capabilities.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, specifically for a resident with Alzheimer's disease and dysphagia. The resident sustained a laceration to the head and was sent to the emergency room for treatment. Despite attempts to contact the resident's representative, the facility did not successfully notify them of the incident. The representative was unaware of the fall and the emergency room visit until a later visit, where they observed the resident with sutures and bruising. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and representative. However, the facility did not adhere to this policy, as evidenced by the representative's report of not being informed of the fall or medication changes. The facility's staff, including an LPN and the DON, acknowledged the requirement to notify representatives of changes in condition and the need to document all attempts to contact them, but these procedures were not effectively followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Davis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Artesian Home | 7.3 mi | ★★★★★ | 9 | 0 |
| Callaway Nursing Home | 7.4 mi | ★★★★★ | 1 | 0 |
| Pauls Valley Care Center | 16.4 mi | ★★★★★ | 13 | 0 |
| Washita Valley Living Center | 17.5 mi | ★★★★★ | 0 | 0 |
| Elmbrook Home | 22 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.