Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Baird during CMS and state inspections, most recent first.
RN Coverage Not Maintained on Weekends: The facility failed to have an RN onsite for at least 8 consecutive hours a day, 7 days a week on multiple days reviewed. Records showed an RN was absent for the required coverage on two days and present for only 4.3 hours on another day. Staff reported that weekends were often covered without an RN in the building, with corporate approval for RN availability by phone, and the DON stated the weekend RN had quit without notice and had not been replaced.
Incorrect PASRR Screening for Resident with Mental Illness: A resident with generalized anxiety disorder and unspecified psychosis had a PASRR Level I marked negative for MI, DD, and IDD despite record evidence of psychosis, antipsychotic monitoring, and antipsychotic medication use. The DON said she and the ADON were responsible for PASRR accuracy, stated she was new to the process, and reported there was no process in place to ensure PASRRs were completed accurately.
Failure to Develop Baseline Care Plan Within 48 Hours: A resident admitted with COPD, dementia, and depression did not have a documented baseline care plan in the EHR within the required timeframe. Record review showed no evidence of a completed MDS assessment or initiated care plan in the chart, and the DON stated the baseline care plan was completed on paper at admission but could not provide it; she later entered it into the computer after the admission period.
A resident with multiple diagnoses, including dementia, COPD, PTSD, and heart failure, had an implanted venous access port in the upper right chest with a physician order for monthly flushing and use for access, lab draws, or IV infusion. The resident stated only one RN was trained to flush the port and that staff should avoid the right arm for BP checks, but the care plan did not address the port. Staff interviews confirmed the DON was responsible for care plans and that medical devices should be included, yet the DON could not explain why the port was omitted.
The facility failed to maintain required RN coverage for at least 8 consecutive hours daily on multiple days, as confirmed by PBJ staffing data and timecard reports showing no RN or insufficient RN hours on several dates. The DON acknowledged understanding that policy required an RN on staff 8 hours a day but reported ongoing difficulty recruiting RNs and confirmed the uncovered days. Facility policy specified that an RN must provide services at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified days.
The facility allowed two nurse aides to provide direct resident care for longer than four months without obtaining CNA certification or documentation of listing on the Nurse Aide Registry. Both aides had completed a state-approved nurse aide training program and skills checkoffs and were working regular hours providing resident care, but their personnel files lacked proof of CNA status. The DON reported being unaware of the 120-day certification requirement, while the facility’s own policy limited non-certified aides to four months of employment while pursuing certification and required that they be on the path to registry listing.
A resident with hemiplegia, prior sepsis, kidney failure, and severe cognitive impairment who required max assistance for ADLs received perineal care during which the NA did not perform hand hygiene or change gloves between cleaning soiled areas and handling a clean brief or redressing the resident. In a later interview, the NA acknowledged that gloves should have been changed and hand hygiene performed at multiple points during the incontinent care. The DON stated staff were expected to follow infection control policies, and the facility’s perineal care policy required handwashing and appropriate glove use as part of the procedure.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, seven days a week for 75 of 183 days reviewed. This deficiency was confirmed through a review of staffing data and interviews with staff, revealing multiple dates with no RN coverage and highlighting the potential negative impact on resident care.
The facility failed to develop and implement person-centered, comprehensive care plans with measurable objectives for five residents, affecting areas such as pain management, weight control, infection control, and dementia care. Interviews revealed that care plans were created by the ADON and monitored by the DON, but lacked specificity and measurability.
The facility failed to properly store, prepare, distribute, and serve food according to professional standards. Observations revealed improper thawing of meats and unsealed, unlabeled food items in storage. Interviews indicated a lack of knowledge and adherence to facility policies, potentially risking foodborne illnesses among residents.
The facility failed to complete and submit a discharge MDS assessment for a resident within the required 14-day period. The ADON and corporate regional MDS consultant were unsure why the assessment was not performed, despite facility policy outlining the necessary timelines and responsibilities.
The facility failed to ensure comprehensive care plans were accurately reviewed and revised for two residents. One resident's care plan incorrectly included intravenous antibiotic therapy without a physician's order, while another resident's care plan did not address her smoking status despite an assessment indicating she was a smoker. These deficiencies were identified through interviews and record reviews.
The facility failed to complete discharge summaries for residents, specifically for one resident with severe cognitive impairment and multiple medical conditions. The discharge occurred on a weekend and was unplanned, leading to the omission of essential documentation. This failure could potentially place other residents at risk by not providing necessary follow-up information and medication details.
RN Coverage Not Maintained on Weekends
Penalty
Summary
The facility failed to use the services of an RN for at least 8 consecutive hours a day, 7 days a week on 3 of 39 days reviewed for RN coverage. Record review showed that an RN was not onsite for the required 8 consecutive hours on 06/20/2026 and 07/05/2026, and an RN was onsite for only 4.3 hours on 06/21/2026. The facility policy titled Staffing, Sufficient and Competent Nursing stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week. During interviews, staff stated the facility had worked several weekends without an RN in the building and that corporate had approved no RN onsite as long as an RN was available by phone. Interviewees stated RN response time by phone had been up to 2 hours, and that staff were concerned about retaliation after raising the issue. The DON stated she was responsible for the nursing schedule and that she and another RN had been alternating weekends, but the weekend RN quit without notice in May 2026 and the facility had not found a replacement. The DON and RNC both acknowledged that weekend RN coverage by phone was being used, and the RNC stated the facility had the ability to share staff with other facilities.
Incorrect PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to accurately complete a PASRR Level I screening for one resident who had diagnoses of generalized anxiety disorder and unspecified psychosis not due to substance or known physiological condition. Record review showed the resident was admitted with these diagnoses, had physician orders for antipsychotic behavior monitoring every shift and medications including Citalopram, Lorazepam, and Seroquel, and had a care plan noting use of antipsychotic medications for psychosis. Despite this information, the PASRR Level I completed for the resident was marked negative for MI, DD, and IDD. During interview, the DON stated she and the ADON were responsible for ensuring PASRR information was completed and accurate, and she said the failure occurred because she was new to the PASRR process. The DON stated she did not feel the failure affected the resident and said the resident care would not be changed by the PASRR evaluation. She also stated she was responsible for ensuring PASRRs were completed and accurate and did not have a process to accomplish this. The ADM stated his expectation was that PASRR information would be completed in a timely manner. The facility policy stated the purpose of PASRR is to identify residents with MI, ID, or DD/related conditions and ensure they receive needed services.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #38 within 48 hours of admission. Resident #38 was an [AGE] year-old female admitted with diagnoses including chronic obstructive pulmonary disease, dementia, and depression. Record review of the resident’s electronic face sheet, MDS tab, Care Plan tab, Assessments tab, and MISC tab on 07/06/2026 showed no evidence that a comprehensive MDS assessment had been completed and no evidence that a baseline care plan had been initiated or documented in the record. During interview, the DON stated her expectation was for baseline care plans to be completed within 24 to 48 hours after admission and stated she was responsible for completing the baseline care plan. She stated Resident #38’s baseline care plan was completed on the day of admission on paper and that a meeting was held, but she was unable to provide the handwritten care plan from admission. She also stated she entered the baseline care plan into the computer on 07/07/2026. Facility policy titled Care Plans-Baseline, dated March 2022, stated that a baseline plan of care to meet the resident’s immediate health and safety needs is developed for each resident within 48 hours of admission.
Care Plan Missing Implanted Venous Access Port
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for Resident #11 that included measurable objectives and time frames to meet, attain, and/or maintain his highest practicable physical, mental, and psychosocial well-being. Resident #11 was a [AGE]-year-old male admitted with diagnoses including major depressive disorder, COPD, hallucinations, pain, anxiety, long-term anticoagulant use, dementia, PTSD, peripheral vascular disease, heart failure, chronic embolism, and weakness. His annual MDS showed a BIMS score of 15, indicating intact cognition. The care plan reviewed and revised on 05/03/2026 did not address his implanted venous access port located in the upper right chest. A physician order dated 02/18/2026 directed access to the implanted port with a 22Gx3/4 Huber needle and monthly flushing with 10 cc NS followed by 5 cc heparin on the first of every month, as well as use as needed for port access, lab draws, or IV infusion. During interview, Resident #11 stated he had the access port in his upper right chest, that the nurse was supposed to flush it monthly, and that only one RN was trained to flush the port. He also stated he was not supposed to have blood pressure taken on his right arm because of the port. Staff interviews confirmed the DON was responsible for care plans and that any medical device should have been included so staff would know the care expectations, but the DON stated she was unable to explain why the venous access port was not included on the care plan.
Failure to Maintain Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week for multiple days within a 12‑month review period. Review of CMS PBJ staffing data for fiscal quarters 1 and 2 showed no RN coverage on five specific dates. Timecard reports for the same months, provided by the DON, confirmed there was either no RN coverage or not a full 8 hours of RN coverage on those dates. The DON verbally confirmed the lack of RN coverage or full 8 hours of RN coverage on each of the identified days. During an interview, the DON stated her understanding that facility policy required an RN to be on staff 8 hours a day and acknowledged that the facility had difficulty finding RNs, stating they tried their best but were not always successful. She reported that she started working at the facility in November 2025 and indicated she would respond by phone and come in if called when an RN‑level assessment was needed. The facility’s written policy stated that a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified dates.
Use of Non-Certified Nurse Aides Beyond 4-Month Limit
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than four months were certified and competent, and that nurse aides who had worked less than four months were appropriately enrolled in training. One nurse aide (NA A) was hired as a nurse aide trainee on 03/01/25, completed the Texas Performance Nurse Aide Program training and skills checkoffs on 03/30/25, and began working regular hours on her hire date. As of 02/08/26, she remained employed and was observed providing resident care, but there was no documentation that she was a Certified Nurse Assistant or listed on the Nurse Aide Registry, despite having worked well beyond four months. Another nurse aide (NA B) was hired as a nurse aide trainee on 08/06/25, completed the Texas Performance Nurse Aide Program training and skills checkoffs on 01/30/26, and her timesheets showed she started working regular hours on 07/13/24. She was also observed providing resident care on 02/08/26, with no proof of CNA certification in her employee record. During an interview, the DON stated that NA A and NA B had completed their classes and competencies but were not yet certified and acknowledged not knowing that nurse aides needed to be certified within 120 days of hire. The facility’s undated policy stated that trained but non-certified nurse aides may work for up to four months while pursuing certification and must be on the path to being listed on the Nurse Aide Registry, but the records did not show that these requirements were met for NA A and NA B.
Failure to Perform Hand Hygiene and Glove Changes During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinent care for one resident. The resident was an elderly female with hemiplegia/hemiparesis, a history of sepsis, and kidney failure, who was severely cognitively impaired per a BIMS score of 00 and required maximal assistance with transfers, toileting, and bathing. Her comprehensive care plan included interventions for risk of pressure ulcers and other skin issues, including checking for incontinence during rounds and providing care as needed. During an observation of perineal care, the nursing assistant providing care did not perform hand washing, hand hygiene, or change gloves between cleaning soiled areas and handling a clean brief or redressing the resident. In a subsequent interview, the nursing assistant acknowledged that she should have changed gloves after cleaning the perineal area and before opening the new brief, and again after cleaning the resident’s bottom and before touching the new brief, and admitted she did not perform any hand hygiene throughout the incontinent care. The DON stated that staff were expected to follow the facility’s infection control policies and procedures and noted that cross contamination could contribute to infection. The facility’s Perineal Care Policy specified that staff were to wash hands and wear gloves, following Standard Precautions if contact with blood or body fluids was likely, as part of the beginning steps of the procedure. The observed care did not comply with these established policy requirements for hand hygiene and glove use.
Failure to Ensure RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week for 75 of 183 days reviewed. Specifically, there was no RN coverage for 65 days out of 92 days in Fiscal Year Quarter 1 2024 and 10 out of 91 days from January 1, 2024, to March 31, 2024. This deficiency was identified through a review of the facility's Payroll Based Journal Staffing Data Report and RN Time Sheets, which revealed multiple dates with no RN coverage. The facility was unable to provide documentation of RN coverage on the specified dates when requested by the surveyors. Interviews with staff, including an LVN and the Regional Nurse Consultant, confirmed the lack of RN coverage and highlighted the potential negative impact on resident care due to the absence of an RN for required assessments and decision-making. The facility's policy titled 'Hours of Work' did not address the requirement for an RN to be in the building for eight consecutive hours a day, seven days a week, and no specific policy was provided to meet this requirement.
Failure to Develop Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for five residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. The care plans for these residents lacked specific, measurable goals, making it difficult to determine if interventions were successful or needed to be revised. This deficiency was identified through interviews and record reviews conducted by surveyors. For Resident #8, the care plan did not include measurable objectives for pain management, weight fluctuations, urinary control, psychotropic medications, insomnia, pacemaker management, hypertension, anticoagulant therapy, and seasonal allergies. Similarly, Resident #9's care plan lacked measurable objectives for infection control, behavior management, compliance with physician's orders, pain management, risk for malnutrition, mobility, and functional abilities. Resident #19's care plan was deficient in areas such as meal choices, activities of daily living, laboratory testing, dementia care, post-traumatic stress disorder, chronic pain, and vision impairment. Resident #26's care plan did not have measurable objectives for infection control, weight management, dementia care, pain management, and participation in activities. Lastly, Resident #31's care plan was missing measurable objectives for weight management, pain management, therapy services, mobility, allergies, and participation in activities. Interviews with facility staff revealed that the care plans were created by the ADON and monitored by the DON, but the objectives were not specific or measurable, leading to inadequate care planning for the residents.
Improper Food Storage and Thawing Procedures
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that frozen meats were not thawed properly, with chicken thighs and pork loin being defrosted in a sink with running water rather than being submerged in cold water or thawed in the refrigerator. Additionally, various food items in the freezer and dry storage were found unsealed and unlabeled, including meat patties, pastry, curly pasta, and alfredo sauce mix. These practices were not in line with the facility's policies on food preparation and storage, which require proper sealing, labeling, and specific thawing procedures to prevent bacterial growth and foodborne illnesses. Interviews with the Dietary Manager (DM) and the Administrator (ADMN) revealed a lack of knowledge and adherence to the facility's policies. The DM admitted to being unsure about the proper defrosting procedures and acknowledged that improper defrosting could lead to bacterial growth and illness. The ADMN also confirmed that meats should be defrosted in the refrigerator or with cold circulating water and that all foods should be stored in sealed containers. Both the DM and ADMN attributed the deficiencies to a lack of education and monitoring, acknowledging that these failures could result in foodborne illnesses among residents.
Failure to Complete and Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for one resident. Specifically, the facility did not encode, complete, and submit a discharge MDS for a resident who was admitted on 10/03/2023 and discharged on an unspecified date. The resident's care plan indicated the need for access to necessary services to promote adjustment to the new living environment or post-discharge from the facility. However, a review of the MDS assessment completion list revealed that a discharge MDS had not been completed for this resident. During interviews, the Assistant Director of Nursing (ADON) stated that she was responsible for performing MDS assessments and acknowledged that a discharge MDS should have been performed when the resident was discharged. She was unsure why the discharge MDS assessment was not performed. The corporate regional MDS consultant, who monitored assessments, also confirmed that discharge MDS assessments should be performed within 14 days of a census change but did not know why it had not been done in this case. The facility's policy on resident assessment, revised in September 2010, outlines the responsibilities and timelines for conducting and submitting MDS assessments, which were not adhered to in this instance.
Care Plan Inaccuracies for Two Residents
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, Resident #9's care plan inaccurately included intravenous antibiotic therapy without a corresponding physician's order, and Resident #185's care plan did not address her smoking status despite an assessment indicating she was a smoker. These deficiencies were identified through interviews and record reviews conducted by surveyors. Resident #9, a [AGE] year-old male with multiple medical diagnoses including Type 2 diabetes, dementia, and heart failure, had a care plan that incorrectly included intravenous antibiotic therapy. This error was attributed to a clerical data entry mistake. Resident #185, a [AGE] year-old female with moderate cognitive impairment and other medical conditions, had a smoking assessment indicating she was a safe smoker, but her care plan failed to address her smoking status. Interviews with facility staff, including the ADON, LVN, and DON, revealed a lack of clarity and oversight in updating and reviewing care plans, leading to these inaccuracies.
Failure to Complete Discharge Summaries
Penalty
Summary
The facility failed to complete discharge summaries for residents, specifically for one resident who was discharged without a summary. This resident, a male with a history of transient ischemic attack, cerebral infarction without residual deficits, hypertension, and chronic obstructive pulmonary disease, was discharged without the necessary documentation. The resident had severe cognitive impairment, as indicated by a BIMS score of 5, and was on multiple medications for his conditions. The deficiency was identified during a closed record review, which revealed that no discharge summary was completed for the resident. Interviews with the Regional Nurse Consultant and the Assistant Director of Nursing (ADON) confirmed that the discharge summary was not completed, possibly due to the discharge occurring on a weekend and being unplanned. The ADON mentioned that the charge nurse should have contacted her to complete the discharge summary, but this did not happen. The facility's policy requires a discharge summary to include a recapitulation of the resident's stay, medical history, current status, and a post-discharge plan. However, this was not followed in the case of the resident, leading to a lack of essential information being communicated to the resident and the receiving healthcare provider. The Regional Nurse Consultant acknowledged that this failure could potentially place other residents at risk by not providing necessary follow-up information and medication details, affecting the coordination of care after discharge.
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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 Baird
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clyde Nursing Center | 5.7 mi | ★★★★★ | 8 | 0 |
| Avir At Abilene | 18.6 mi | ★★★★★ | 12 | 0 |
| Silver Spring | 18.8 mi | ★★★★★ | 8 | 0 |
| The Oaks At Radford Hills Healthcare Center | 19.1 mi | ★★★★★ | 12 | 0 |
| Hendrick Skilled Nursing Facility | 20.4 mi | ★★★★★ | 1 | 0 |
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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 October 2026) and official state health department websites.