Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Avir At Athens during CMS and state inspections, most recent first.
A resident with dementia, CKD, HF, and severe cognitive impairment was involved in a physical abuse allegation when a CNA struck or batted his arm/hand during care after he grabbed at staff. A witness reported that the CNA hit the resident hard and yelled at him, while the CNA said she only tapped his hand away and did not consider it abusive. The resident could not answer questions about the event, and the facility’s records showed the allegation was not promptly escalated through the abuse reporting chain.
Failure to Immediately Report Alleged Staff-to-Resident Abuse: A CNA was observed striking a resident’s arm during care, but the allegation was not promptly reported to the DON/abuse coordinator. The resident had severe cognitive impairment, dementia, CKD, HF, and required extensive ADL assistance. Staff communication broke down when the CNA told an LPN, who did not ensure direct reporting to administration, and the DON later learned of the allegation only after a delay.
A resident with multiple chronic conditions and impaired cognitive status experienced a significant change in condition the morning after admission, including abnormal respirations, hyperventilation, altered responsiveness, elevated blood glucose, and low oxygen saturation. A CNA first found the resident leaning backward on the commode and unable to explain how she got there, and later a therapist alerted an LVN to the resident’s minimal responsiveness and abnormal breathing. The LVN assessed the resident, notified the provider, and obtained an order to transfer the resident to the ER, with EMS transporting the resident shortly thereafter. Record review showed no documentation that the resident’s representative was notified of the change in condition or the transfer, and the representative reported learning of the hospitalization only when another family member arrived and found the resident’s bed empty, despite facility policy requiring prompt notification and documentation of such changes.
A resident with encephalopathy, depression, Parkinsonism, and acute kidney failure missed ordered doses of clonazepam and hydrocodone-acetaminophen because the meds were not available for several days after admission. An LVN said the meds required a triplicate Rx form from the physician and that she did not learn they were unavailable until after leaving for the day.
Incomplete physician orders were found for three residents. One resident with a trach was observed on continuous O2, but no O2 order was in the chart; another resident with a foley catheter had the device in place, but no catheter order was documented; and a third resident on a renal diet and receiving dialysis had no diet or dialysis orders recorded. Staff acknowledged the missing orders and stated the chart did not accurately reflect the residents' care and treatment needs.
Incomplete Baseline Care Plan After Admission: A resident admitted with encephalopathy, hypothyroidism, hyperlipidemia, depression, Parkinsonism, and acute kidney failure did not have a completed baseline care plan within 48 hours. The plan was undated, incomplete, and unsigned, and it lacked initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations. Interviews showed confusion among the ADON, MDS coordinator, ADM, and admitting nurse about who was responsible for completing and signing the plan.
The facility failed to ensure accurate MDS assessments for six residents, leading to discrepancies in PASRR coding. The Regional Reimbursement Consultant, while training a new MDS Coordinator, identified incorrect coding and was unaware of the connection between Section I Active Diagnoses and Section A PASRR documentation. The facility lacked a specific policy for MDS accuracy, relying on the RAI manual, contributing to these deficiencies.
A resident with diabetes and severe cognitive impairment did not receive scheduled insulin doses due to low blood sugar levels, without physician notification. The LVN withheld insulin based on blood sugar readings, despite the absence of such instructions in the physician's orders. The facility's policy required notifying the physician of significant changes, but this was not done, and the facility lacked a specific insulin administration policy.
A resident with chronic hepatic failure was incorrectly administered 20 ml of lactulose solution instead of the prescribed 30 ml due to a medication aide's misunderstanding of the dosage instructions. The aide misinterpreted the concentration and dosage on the medication label and MAR, leading to the error.
A resident with Alzheimer's disease was abused by a CNA, who was witnessed hitting the resident in the stomach. The incident was not reported immediately by the witnessing staff, allowing the CNA to remain in the facility for over three hours. The resident was assessed with no visible injuries, but the delay in reporting highlights deficiencies in the facility's handling of abuse allegations.
A resident with Alzheimer's was abused by a CNA, who was witnessed hitting the resident but was not reported immediately by the observing staff. The incident was not reported until the next shift, allowing the CNA to remain in the facility for hours. The resident was severely cognitively impaired and required substantial assistance with daily activities.
A resident fell during a Hoyer lift transfer when a CNA, without a second staff member, allowed a family member to assist. The sling strap was improperly attached, causing the fall. The resident, with a history of muscle weakness and obesity, experienced severe pain but refused hospital evaluation. The facility's policy requires two staff for such transfers.
Physical abuse allegation involving a resident during care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA slapped the resident’s arm during care. The resident was a male with dementia without behavioral disturbance, chronic kidney disease, and heart failure. His care plan identified that he could be physically aggressive due to poor impulse control and resistive to care because of impaired cognition, and his quarterly MDS showed severely impaired cognition with a BIMS score of 2, extensive assistance needs for most ADLs, and bowel and bladder incontinence. According to the incident documentation, the event occurred in the resident’s room during care when one CNA reported that another CNA hit the resident’s hand after the resident grabbed her. A written statement from the witnessing CNA said the CNA hit the resident hard on the arm and then yelled at him. The resident was unable to answer questions about the event because of his stroke and cognitive impairment, and the incident report noted that he had a history of hitting staff. The CNA involved stated that the resident struck her arm and that she tapped his hand gently, comparing her action to what one would do with a child. The facility’s investigation summary described the contact as the CNA batting the resident’s hand away, while the witness described it as striking the resident on the arm. The report also showed that the allegation was not immediately escalated through the facility’s abuse reporting process, as the witness said she reported it to an LVN and was told the DON had been notified, but the abuse coordinator did not receive the information until later. The facility’s records also reflected that the incident was ultimately treated as an unsubstantiated allegation of abuse.
Failure to Immediately Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was immediately reported to the Administrator/abuse coordinator, but not later than 2 hours after the allegation was made. The allegation involved a CNA striking a resident on the arm during care on 5/10/26 at approximately 6:00 p.m., but the Administrator stated he was not notified until the morning of 5/12/26. The facility’s investigation summary and provider report both reflected that the allegation was not reported to the abuse coordinator until 5/12/26, well after the incident occurred. Resident #1 was a male resident with diagnoses including dementia without behavioral disturbance, chronic kidney disease, and heart failure. His quarterly MDS indicated severely impaired cognition with a BIMS score of 2, limited ability to respond to simple direct communication, extensive assistance needs for most ADLs, and bowel and bladder incontinence. His care plan identified potential physical aggression due to poor impulse control and resistive behavior during care, with interventions to calm and redirect him when agitated or resistive. According to the incident documentation, CNA C reported that during shift change rounds CNA B hit Resident #1’s hand when he grabbed CNA B, and CNA B then yelled at the resident. CNA C stated she told LVN D about the incident, and LVN D told her the DON would be contacted. The DON later stated she never received a text from LVN D and first learned of the allegation on 5/12/26 after a group text from another nurse. The Administrator stated staff were expected to immediately report allegations of abuse to the abuse coordinator, and the facility’s policy required employees to report allegations to the administrator, who would then report to HHSC. The report also states CNA C was counseled for not following the proper abuse reporting procedure.
Failure to Notify Resident Representative of Significant Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition and transfer to the hospital, as required by facility policy. The resident was an older adult female with multiple diagnoses including cerebral infarction with aphasia, type 2 diabetes mellitus, primary hypertension, congestive heart failure, and stage 3 chronic kidney disease. Her MDS showed a BIMs score of 00, indicating she could not complete the mental status interview. She had been admitted to the facility the prior evening, and her representative and another family member visited her shortly after admission. On the morning following admission, at approximately 6:00 a.m., a CNA arriving on the unit observed the resident’s bathroom light on and found the resident seated on the commode, leaning backward. The CNA reported the resident was able to communicate but could not state how she got to the bathroom. When the CNA attempted to assist her to stand with one-person assistance, the resident staggered backward, so the CNA returned her to a seated position on the commode and called for help. Staff obtained a wheelchair and assisted the resident back to bed. Later that morning, at approximately 7:45 a.m., a therapist reported to an LVN that the resident was minimally responsive and breathing abnormally. The LVN assessed the resident and found her hyperventilating, not verbally responsive but making eye contact, with vital signs including pulse 100, respirations 24, temperature 97.7°F, blood glucose 371, oxygen saturation 91% on room air, and an unmeasurable manual blood pressure; the resident was diaphoretic and cold to the touch. The LVN notified the provider of the change in condition and received an order to send the resident to the emergency room, and the resident left the facility with EMS at approximately 8:00 a.m. in stable condition. Review of the medical record showed no documentation that the resident’s representative or family was notified of the change in condition or the transfer. The resident’s representative later stated he was not notified by the facility and only learned of the transfer when another family member arrived at the facility and discovered the resident was not in her bed, at which time staff informed that family member of the transfer. The ADON and RNC both stated that facility policy requires notification of the resident’s representative for significant changes in condition and documentation of that notification in the medical record, and they could not confirm that notification occurred because there was no documentation. The facility’s written policy on change in a resident’s condition or status states that the facility promptly notifies the resident, attending physician, and resident representative of changes in the resident’s medical or mental condition and/or status.
Medications Not Available for Resident After Admission
Penalty
Summary
The facility failed to ensure that Resident #87’s ordered medications were available and administered for 6 consecutive days after admission. Resident #87 was a [AGE]-year-old female admitted on [DATE] with diagnoses including encephalopathy, hypothyroidism, hyperlipidemia, depression, Parkinsonism, and acute kidney failure. Her active medication list included Clonazepam 0.5 mg twice daily and Hydrocodone-Acetaminophen 10-325 mg four times daily, along with Acetaminophen as needed and Meloxicam daily. The medication administration record showed that Resident #87 did not receive Clonazepam from 02/13/2026 through 02/17/2026, totaling 9 missed doses, and did not receive Hydrocodone-Acetaminophen from 02/13/2026 through 02/18/2026, totaling 19 missed doses. During observation, the resident was seen listening to music in the living room and later sitting in a wheelchair in her room, appearing comfortable and without facial grimacing. She stated that she felt some anxiety and pain, but that it did not prevent her from participating in activities of daily living. An LVN stated that the medications had not been received because they required a triplicate prescription form from the physician and that she did not learn they were unavailable until after leaving for the day on 02/16/2026.
Incomplete Physician Orders for Oxygen, Foley Catheter, Diet, and Dialysis
Penalty
Summary
Medical records were not complete and accurately documented for three residents because physician orders did not match the care and treatments being provided. Resident #53, a male with diagnoses including tracheostomy status, traumatic hemorrhage of the cerebrum, heart failure, post cardiac arrest, and gastrostomy status, had a BIMS score of 3 and was documented in the MDS as receiving continuous oxygen. He was observed on multiple occasions receiving oxygen at 3.5 LPM via a mask over his tracheostomy, but his physician orders did not include an oxygen order. An RN stated the resident had an order for oxygen via tracheostomy at 2-4 LPM to maintain oxygen saturation above 90%, but the order could not be located in the chart. Resident #59, a female with diagnoses including bullous pemphigoid, chronic kidney disease, and Parkinson's disease, had a BIMS score of 9 and was documented in the MDS as having a foley catheter. She was observed with a foley catheter in place and draining urine to a closed collection bag suspended from her wheelchair, but her physician orders did not include an order for the foley catheter. An RN stated the catheter was being used due to skin issues on the resident's buttocks and said the order should have been in the chart. Resident #73, a male with diabetes and end-stage kidney disease requiring renal dialysis, had a BIMS score of 15 and his baseline care plan indicated he was on a renal diet and required dialysis treatments. He stated he went to dialysis three times a week and received meals in his room, but his physician orders did not include dialysis or a diet order. An RN and the ADON stated they could not find the dialysis or diet orders in the chart, and the ADON said the DON had usually reviewed admission orders before leaving the facility. The Administrator stated he expected physician orders to accurately reflect residents' care and treatment needs, and the facility policy required current orders to be maintained in each resident's electronic record.
Incomplete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #87. Resident #87 was an [AGE] year-old female admitted on [DATE] with diagnoses including encephalopathy, hypothyroidism, hyperlipidemia, depression, Parkinsonism, and acute kidney failure. A record review on 02/17/2026 showed her baseline care plan was undated, incomplete, and unsigned. The completed portions included identification information, modes of communication, vision and hearing, daily preferences, and advance directive. The baseline care plan did not include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, or any PASARR recommendations. During interviews, the ADON stated baseline care plans were to be completed within 48 hours and that the DON or MDS coordinator usually initiated them, while the admitting nurse entered information. The MDS coordinator stated she initiated Resident #87's baseline care plan but denied that any one person was ultimately responsible for ensuring completion. The ADM stated there was no DON on staff at the time of admission and that the MDS coordinator should have signed off and ensured completion. LVN A, the admitting nurse, stated she was not sure whether she completed her section and was unaware of the required timeframe.
Inaccurate MDS Assessments Due to PASRR Coding Errors
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for six residents, which could potentially impact the care and services they receive. The inaccuracies were primarily related to the Preadmission Screening and Resident Review (PASRR) coding. For instance, Resident #1's PASRR Level 1 screening indicated a positive result for mental illness, but the MDS assessment inaccurately reflected a negative result for serious mental illness or intellectual disability. Similar discrepancies were noted for Residents #2, #17, #50, #60, and #65, where their PASRR evaluations indicated positive results for mental illness or intellectual disabilities, but the MDS assessments did not accurately reflect these conditions. The report highlights that the facility's Regional Reimbursement Consultant was in the process of training a new MDS Coordinator and had identified incorrect coding in some residents' MDS files. The consultant admitted to not realizing the connection between Section I Active Diagnoses and Section A PASRR screening documentation, leading to the incorrect coding. The consultant was in the process of submitting changes to the MDS to the Centers for Medicare & Medicaid Services (CMS) to correct these errors. During interviews, it was revealed that the facility did not have a specific policy for maintaining the accuracy of MDS assessments, relying instead on the Resident Assessment Instrument (RAI) manual. The administrator confirmed the absence of a specific policy and acknowledged the reliance on the RAI manual for ensuring accuracy. This lack of a specific policy and the incorrect understanding of the PASRR documentation requirements contributed to the deficiencies in the MDS assessments.
Failure to Notify Physician of Withheld Insulin Doses
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically regarding the administration of insulin. The resident, a female with multiple diagnoses including diabetes mellitus and severe cognitive impairment, was dependent on staff for all activities of daily living. The physician's orders required routine administration of insulin without prior blood sugar checks or parameters for withholding the medication. However, the Licensed Vocational Nurse (LVN) withheld insulin doses when the resident's blood sugar was below 100, despite the absence of such instructions in the physician's orders. The LVN did not notify the physician when insulin was withheld due to low blood sugar levels, nor did she request an order for glucometer checks or parameters for withholding insulin. The insulin administration record showed that insulin was withheld six times without physician notification, even when blood sugar levels were above 100 on two occasions. The Director of Nursing (DON) confirmed that the physician should have been notified of the withheld doses and consulted about the insulin administration orders, which resulted in multiple daily blood sugar checks. The facility's policy required informing the resident's physician of significant changes in the resident's status, such as clinical complications. However, the facility did not have a specific policy for insulin administration, contributing to the oversight. The DON acknowledged the risk of a lower-than-normal blood sugar level and a decline in the resident's status due to the failure to administer insulin as ordered and the lack of physician notification.
Medication Administration Error Due to Misinterpretation of Dosage
Penalty
Summary
The facility failed to ensure the accurate administration of medication for a resident, specifically involving the drug lactulose solution. The resident, a male with a history of stroke, slow transit constipation, and chronic hepatic failure, was prescribed lactulose solution to be administered at 30 ml four times a day. However, during a medication administration observation, a medication aide (MA C) incorrectly administered only 20 ml of the solution. The error stemmed from a misunderstanding of the medication's concentration and dosage instructions, as the aide misinterpreted the order and the label on the medication bottle. The discrepancy between the physician's order and the medication administration record (MAR) was not identified by MA C, leading to the incorrect dosage being given. The Director of Nursing (DON) confirmed that MA C misunderstood the order, highlighting the importance of understanding liquid medication concentrations to ensure correct dosing. The facility's policy requires that medication labels and MARs be compared before administration, and any discrepancies should prompt a review of the physician's orders. This protocol was not followed, resulting in the administration error.
Resident Abuse Incident and Reporting Delay
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a CNA who was witnessed hitting a resident. The resident, who was severely cognitively impaired with Alzheimer's disease, was in her room when the abuse occurred. Two staff members, an LVN and another CNA, heard the resident screaming and upon entering the room, observed the CNA hitting the resident in the stomach area. The resident was yelling for the CNA to leave her alone, indicating distress and fear. The incident was not reported immediately by the witnessing staff members, who waited until the end of their shift to notify the administration. This delay in reporting allowed the abusive CNA to remain in the facility for over three hours, with access to the resident and others. The failure to promptly report the abuse is a significant lapse in protocol, as it potentially endangered the safety and well-being of the residents. The resident involved in the incident was assessed shortly after the event and again later in the morning, with no visible injuries noted. However, the failure to protect the resident from abuse and the delay in reporting the incident highlight serious deficiencies in the facility's handling of abuse allegations and the protection of its residents.
Failure to Report Abuse Immediately
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by regulations. Specifically, LVN E and CNA D did not report an incident of abuse they witnessed involving CNA C and a resident. CNA C was observed hitting the resident in the stomach area, yet was allowed to remain in the facility for over three hours with access to the resident and other residents before the incident was reported to the Administrator and other authorities. The resident involved was an elderly female with a diagnosis of Alzheimer's disease and unsteadiness on her feet. She was severely cognitively impaired and required substantial assistance with activities of daily living. During the incident, the resident was heard screaming and yelling, and upon investigation, it was found that CNA C had hit her. Despite the resident's distress, no immediate injuries were noted, and she did not complain of pain during the initial assessment. The incident occurred during the night shift, and the abuse was not reported until the morning when the day shift staff arrived. The delay in reporting the abuse was a significant failure in the facility's protocol, as the abuse should have been reported within two hours of the allegation. This failure could have led to continued abuse of the resident and potentially affected other residents in the facility.
Improper Hoyer Lift Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistive devices during a transfer, resulting in a fall for a resident. The incident involved a certified nursing assistant (CNA) who attempted to transfer a resident using a Hoyer lift without the assistance of another staff member, as required by the facility's policy. Instead, the CNA allowed the resident's family member to assist with the transfer. During the process, the Hoyer lift sling strap was not properly attached, causing the resident to fall out of the lift. The resident involved was a cognitively intact female with a history of muscle weakness, obesity, and lack of coordination. Her care plan specified that she required a mechanical lift with two staff members for all transfers due to her limited ability to transfer herself. On the day of the incident, the resident was being transferred from her bed to a shower chair when the improper attachment of the sling strap led to her fall. The resident experienced sharp pain in her neck and back, rated at 10 out of 10 on the pain scale, but refused to go to the hospital for further evaluation. The facility's investigation revealed that the CNA did not follow the policy requiring two staff members for Hoyer lift transfers and allowed the family member to assist, which contributed to the improper attachment of the sling strap. The resident was assessed for injuries, and x-rays were conducted, which showed no fractures. The CNA admitted to not securing the sling properly and acknowledged that the family member's assistance was a factor in the incident.
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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.
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Nursing homes near Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Highlands Nursing & Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Advanced Rehabilitation And Healthcare Of Athens | 1.7 mi | ★★★★★ | 15 | 3 |
| Cedar Lake Nursing Home | 8.9 mi | ★★★★★ | 6 | 0 |
| Mabank Nursing Center | 20.8 mi | ★★★★★ | 15 | 0 |
| Kerens Care Center | 22.4 mi | ★★★★★ | 1 | 1 |
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