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 Bay City during CMS and state inspections, most recent first.
Multiple medication carts contained opened medications without documented open dates, including inhalers, oral solutions, creams, ointments, eye drops, nasal spray, patches, and tablets. The DON, RN, LVNs, and MA confirmed that medications were required to be dated when opened, but staff could not identify who opened the undated items. Facility policy required medication labeling to follow applicable requirements and accepted pharmaceutical practices, including expiration dates when applicable.
Failure to Document Flu and Pneumococcal Immunizations: The facility did not document evidence of offering or refusal of influenza and pneumococcal vaccines for multiple residents. Records for some residents showed MDS entries indicating they declined vaccines, but the EMR did not contain the corresponding refusal documentation. The ADON and DON stated immunization records were incomplete in PCC after a software change, and that influenza and pneumococcal vaccination documentation needed attention.
A facility failed to document COVID-19 vaccination status for three residents reviewed for immunization compliance. The residents had significant medical histories including AFib, DM2, HF, COPD, HTN, paraplegia, and cognitive impairment, but their EMRs did not show whether they received the vaccine, refused it, or had a contraindication. The ADON and DON stated the move from Matrix to PCC caused documentation gaps, and the facility could not locate the prior vaccine/refusal records.
A resident with Parkinson’s disease, dysphagia, and dementia had an NPO order and G-tube feeding, but the comprehensive care plan was not revised to reflect the change in status. The care plan still addressed oral intake and nutritional supplements, and the MDS nurse acknowledged it did not accurately reflect the resident’s current needs after hospitalization.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, on five days in November 2024. Interviews revealed reliance on agency nurses and the DON's assistance when needed, but no specific RN staffing policy was in place.
The facility failed to reorder and administer medications properly for two residents, leading to missed doses and inadequate monitoring of vital signs before medication administration. Staff interviews revealed lapses in following protocols, risking adverse effects for the residents.
The facility failed to follow professional standards for food service safety, as observed during a survey. A container of bacon grease, chicken noodle soup, and French toast were not labeled and dated, a bag of tortillas was unsealed, and the label on ground beef was illegible. The Dietary Manager acknowledged the oversight, attributing it to an employee's distraction. These lapses had the potential to place residents at risk of foodborne illness.
A facility failed to coordinate assessments with the PASRR program for a resident with multiple diagnoses, including depression and psychosis. The resident was not correctly identified as having a mental illness in the PASRR Level 1 Screening, despite being prescribed antidepressants. The MDS Coordinator copied the PASRR form from the hospital without a thorough assessment, risking the resident missing necessary services.
A resident in an LTC facility experienced medication administration errors, resulting in a seven percent error rate. The errors involved incorrect dosing of Clonazepam and improper timing of Methimazole administration. The resident, with multiple diagnoses including Alzheimer's and anxiety disorder, received a full Clonazepam tablet instead of half, and Methimazole was given after meals contrary to physician orders. Staff acknowledged the errors and the facility's policy requires adherence to prescribed medication orders.
A facility failed to maintain proper infection control when a CNA did not use appropriate PPE during urinary catheter care for a resident on Enhanced Barrier Precautions. The CNA, despite being trained, only wore gloves and not a gown, contrary to the facility's policy. Interviews with the CNA, DON, and Infection Preventionist confirmed the lapse in protocol, highlighting the need for adherence to transmission-based precautions.
A resident with severe cognitive impairment and chronic heart failure did not have a comprehensive care plan addressing all care areas, as required by facility policy. The MDS Coordinator failed to complete the care plan, which was only focused on nutritional status, leaving other needs unaddressed. The oversight was not identified until later, despite procedures for review during readmission and quality meetings.
A facility failed to develop a comprehensive person-centered care plan for a resident within the required timeframe after completing the Admission MDS assessment. The MDS Coordinator, responsible for care plans, admitted to an oversight, and the Administrator acknowledged the error should have been caught during clinical review. The RNC, interim DON at the time, also recognized the oversight and stated that auditing should have been conducted. This failure could risk residents not receiving necessary person-centered care.
Undated Open Medications Found on Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the required open date on medications after they were opened. During a medication storage observation, multiple medications on Medication Cart #1 on the 400 Hall were found without a documented date indicating when they were opened, including valproic acid solution, Dayquil Severe Cold and Flu, nystatin powder, zinc oxide paste with menthol, triple antibiotic ointment, and Prevent Silicone cream. Additional medication storage observations identified the same issue on other carts. On Medication Cart #2 on the 300 Hall, medications without an open date included two albuterol sulfate inhalers, valproic acid solution, cetirizine, promethazine/codeine solution, and ConvaTec Stomahesive Paste. On Medication Cart #3 on the 500 Hall, medications without an open date included collagenase Santyl ointment, silver sulfadiazine cream, albuterol sulfate inhalation solution, ammonium lactate cream, zinc oxide cream, fluticasone propionate nasal spray, Miebo drops, nitroglycerin patches, pantoprazole sodium oral suspension, famotidine tablets, alendronate sodium packets, guaifenesin, brimonidine tartrate/timolol maleate ophthalmic solution, Linzess packets, bisacodyl tablets, and cyclosporine ophthalmic emulsion. On Medication Cart #4 on the 500 Hall, additional opened medications were also found without a documented date, including collagenase Santyl ointment, albuterol sulfate inhalation solution, antimicrobial skin and wound gel, triple antibiotic ointment, Triad Hydrophilic wound dressing, Dakin's solution, Therahoney gel, and loperamide tablets. Interviews with RN I, LVN J, MA L, LVN K, and the DON confirmed that staff were expected to date medications when opened, but none of the staff knew which person had opened the undated medications. The DON stated that all licensed nursing staff and medication aides were expected to know this requirement, and the facility policy titled Medication Labeling and Storage stated that medication labeling must be consistent with applicable federal and state requirements and accepted pharmaceutical practices, including expiration dates when applicable.
Failure to Document Influenza and Pneumococcal Immunization Status
Penalty
Summary
The facility failed to document evidence of offering or refusal of influenza and pneumococcal immunizations for 5 of 5 residents reviewed. Record review showed no documented evidence in the electronic medical record for Resident #12 or Resident #2 regarding the offering or refusal of either influenza or pneumococcal vaccines. For Resident #7, Resident #39, and Resident #5, the electronic medical record did not show documented evidence of refusal of the pneumococcal vaccine. Resident #12 was a female admitted on 2/12/2026 with diagnoses including unspecified atrial fibrillation, type 2 diabetes mellitus, and hypertensive heart disease with heart failure. Resident #2 was a male with COPD, essential hypertension, and type 2 diabetes mellitus; his Comprehensive MDS showed a BIMS score of 3 and indicated severe cognitive impairment, and Section O stated he was not up to date with influenza and pneumococcal vaccines and had declined both, but the electronic record did not contain that refusal. Resident #7 had paraplegia, heart failure, type 2 diabetes mellitus, and essential hypertension; his quarterly MDS showed a BIMS score of 12 and indicated he was not up to date with pneumococcal vaccination and had declined it, but the refusal was not documented in the electronic record. Resident #39 had polyneuropathy, dementia, and heart failure; her quarterly MDS showed a BIMS score of 7 and indicated she was not up to date on pneumococcal vaccination and had declined it, but the refusal was not documented in the electronic medical record. Resident #5 had non-traumatic intracerebral hemorrhage, end stage renal disease, type 2 diabetes mellitus, and epilepsy; her Comprehensive MDS showed a BIMS score of 11 and indicated she was not up to date with pneumococcal vaccination and had declined it, but the refusal was not documented in the electronic record. The ADON stated she was the infection preventionist and responsible for immunization compliance with the DON, that residents were offered influenza, pneumococcal, and COVID vaccines on admission, and that the facility had an influenza vaccination event in October and November 2025 while a pneumococcal vaccination event was being planned. The DON stated not all influenza immunization records had been uploaded into PCC and that immunization documentation was an area needing attention.
Missing COVID-19 Immunization Documentation for Multiple Residents
Penalty
Summary
The facility failed to implement its policy to ensure residents were offered, received, or refused COVID-19 immunization, and failed to document the vaccination status of 3 of 5 residents reviewed for immunization compliance: Resident #12, Resident #7, and Resident #2. Record review showed no documented evidence in the electronic medical record for any of these residents indicating that they had received the COVID-19 vaccine, refused it, or had a medical contraindication. Resident #12 was a [AGE]-year-old female admitted with diagnoses including unspecified atrial fibrillation, type 2 diabetes mellitus, and hypertensive heart disease with heart failure. Resident #7 was a [AGE]-year-old male with paraplegia, heart failure, type 2 diabetes mellitus, and essential hypertension, and his quarterly MDS showed a BIMS score of 12 indicating moderate cognitive impairment. Resident #2 was a [AGE]-year-old male with COPD, essential hypertension, and type 2 diabetes mellitus, and his comprehensive MDS showed a BIMS score of 3 indicating severe cognitive impairment. During interview, the ADON stated she was the infection preventionist and responsible for immunization compliance along with the DON. She stated residents are offered influenza, pneumococcal, and COVID immunizations on admission, but the facility changed from the Matrix system to Point Click Care (PCC), and immunizations administered or refused were not transferred into PCC. She could not locate documentation for COVID vaccine administration or refusal for the three residents reviewed and stated the process was still a work in progress. The DON also stated immunization documentation was an area needing attention and that the system change was causing problems with documenting COVID vaccine administrations and refusals. Facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents stated the resident's medical record includes documentation that indicates at a minimum signed consent and prior vaccination or refusal.
Care Plan Not Updated for NPO Status
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plan for Resident #22 to reflect the resident’s NPO status. Resident #22 was a male with diagnoses including Parkinson’s Disease, oropharyngeal dysphagia, and unspecified dementia. His order summary showed an NPO diet with a start date of 2/18/2026, and he also had an order for Jevity 1.5 ml at 69 ml per hour via gastrostomy tube using a stationary pump. However, the most recent comprehensive care plan obtained 2/25/2026 still identified the resident as being at risk for aspiration and included interventions related to monitoring oral intake and encouraging nutritional supplements between meals. A nursing progress note dated 2/17/2026 documented that Resident #22 was readmitted to the facility and was NPO. During interview, the MDS nurse stated she was responsible for all resident care plans and acknowledged that Resident #22’s care plan did not accurately reflect the resident’s current needs, including the recent change to NPO status after hospitalization. The ADON stated she was not responsible for care plans, and the DON stated the MDS nurse was responsible for updating care plans to reflect significant changes in residents’ care. The facility policy on Comprehensive Assessments stated that assessments are used to develop, review, and revise the resident’s comprehensive care plan, but the policy did not specifically address revision of comprehensive care plans.
Deficiency in RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulations. This deficiency was observed on five specific days in November 2024, where there were no RN hours recorded on November 9, 10, 23, and 24, and only 2.25 hours on November 30. The Director of Nursing (DON) also did not work any hours on these days. The absence of RN coverage could potentially place residents at risk due to a lack of nursing oversight and a higher level of care. Interviews with facility staff revealed that in the event of a last-minute call-in, the facility would first attempt to contact their own staff and, if unsuccessful, would reach out to an agency for nurses. The DON mentioned that the facility had one full-time RN and a PRN RN working nights, and she would assist if no RN was on duty. Despite the lack of RN coverage, the DON did not perceive a risk to residents, citing that some LVNs were better workers than RNs. The facility did not have a specific policy for RN staffing, relying instead on state rules and regulations.
Medication Administration and Monitoring Failures
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration issues. For one resident, the facility did not reorder Hydrocodone-acetaminophen in a timely manner, resulting in missed doses. The medication was not available for administration at the scheduled times, and the resident did not receive two doses as prescribed. The process for reordering controlled substances involved notifying the nurse practitioner, but there was a delay in communication and follow-up, which contributed to the medication not being available when needed. Additionally, the facility did not properly monitor vital signs before administering certain medications to two residents. One resident was given Diltiazem and Amiodarone without checking blood pressure and pulse as required by the physician's orders. Similarly, another resident received Metoprolol and Losartan without the necessary vital sign checks. The medication administration records showed repeated instances where the same blood pressure and pulse readings were used for multiple doses, indicating a lack of proper monitoring. Interviews with staff revealed a lack of adherence to protocols for medication reordering and administration. The charge nurse, medication aides, and director of nursing acknowledged the failures in following physician orders and the potential risks to residents. The facility's policy required checking vital signs before administering medications with specific parameters, but this was not consistently followed, leading to potential adverse effects for the residents involved.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On a specific date, a container of bacon grease, chicken noodle soup, and French toast in the refrigerator were not labeled and dated with their preparation and expiration dates. Additionally, a bag of open tortillas was found unsealed, and the label on the ground beef in the freezer was illegible. These lapses in food storage and labeling practices were identified during interviews and observations with the Dietary Manager. The Dietary Manager acknowledged that the facility's policy required all prepared foods to be labeled and dated with preparation and expiration dates and to be sealed properly. The manager attributed the oversight to an employee's distraction or forgetfulness. The facility's policy, as reviewed, mandates that foods be stored in compliance with safe food handling practices, including being covered, labeled, and dated. The failure to follow these protocols had the potential to place residents at risk of serious complications from foodborne illness due to their compromised health status.
Failure in PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure proper coordination of assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident, leading to a deficiency. The resident, a male with multiple diagnoses including Parkinson's disease, psychosis, dementia, and depression, was not correctly identified as having a mental illness in his PASRR Level 1 Screening. Despite having active diagnoses of depression and psychotic disorder and being prescribed antidepressant medications, the PASRR screenings conducted both at the hospital and later at the facility incorrectly indicated the resident was negative for mental illness. The MDS Coordinator admitted to copying the PASRR Level 1 form from the hospital without conducting a thorough assessment based on the resident's clinical information and face sheet. The Regional Reimbursement Consultant confirmed that the PASRR assessment should be conducted on the first day of admission, using the referral packet and supporting diagnoses. The failure to correctly assess the resident's mental health status could result in the resident missing out on necessary services provided by the state. A policy for Resident Assessments was requested but not provided by the Administrator.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a seven percent error rate. This was based on two errors out of 28 opportunities, involving one resident. The errors included administering the incorrect dose of Clonazepam and not following the physician's instructions for Methimazole administration. A resident with Alzheimer's disease, hypothyroidism, generalized anxiety disorder, and major depressive disorder was involved in the medication errors. The resident's care plan included monitoring for drug effectiveness and adverse consequences. The physician's orders specified Clonazepam 0.5 mg, to be administered as half a tablet twice a day, and Methimazole 5 mg, to be administered one hour before meals. During a medication pass observation, the medication aide administered a full Clonazepam tablet instead of half and gave Methimazole after the resident had eaten. The medication aide admitted to not being aware of the correct dosage and timing, and the LVN confirmed the errors. The facility's policy requires medications to be administered as ordered, and the staff acknowledged the potential side effects and risks of incorrect administration.
Inadequate PPE Use During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper use of personal protective equipment (PPE) by a certified nursing assistant (CNA) during urinary catheter care for a resident. The resident, who was on Enhanced Barrier Precautions due to a Foley catheter, required healthcare workers to wear a gown and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms. However, during an observation, the CNA only donned gloves and failed to wear a gown while providing urinary catheter care, which included cleaning the catheter and handling the drainage bag. Interviews with the CNA, the Director of Nursing (DON), and the Infection Preventionist confirmed that the CNA was aware of the Enhanced Barrier Precautions and the necessity of wearing both a gown and gloves. Despite having been trained on the facility's infection control policy, the CNA did not adhere to the required precautions. The DON and Infection Preventionist acknowledged the lapse in protocol and reiterated that all staff are responsible for implementing transmission-based precautions. The facility's policy on Enhanced Barrier Precautions was reviewed, which emphasized the importance of using targeted gown and glove use during high-contact resident care activities.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was identified during a review of the Care Area Assessment (CAA) of the Admission Minimum Data Set (MDS) assessment. The resident, an elderly male with severe cognitive impairment and a primary diagnosis of chronic diastolic congestive heart failure, was admitted to the facility and later readmitted after a hospital stay. Despite the resident's complex medical and psychosocial needs, the care plan only addressed nutritional status, leaving other critical areas such as cognitive loss, communication, and pain unaddressed. Interviews with facility staff revealed that the MDS Coordinator, responsible for completing all MDS assessments and comprehensive care plans, acknowledged the oversight in failing to complete the care plan for the resident. The MDS Coordinator stated that the comprehensive care plan should have been developed within 21 days of admission, based on the CAA summary. However, the care plan was not reviewed for accuracy, and the oversight was not identified until instructed by the facility's corporate nurse to update it. The facility's Administrator and the corporate nurse, who was the interim Director of Nursing (DON) at the time, confirmed the oversight and acknowledged the lack of a comprehensive care plan for the resident. They stated that the error should have been caught during the clinical review of the resident's records upon readmission and during the weekly quality of care meetings. The facility's policy requires that a comprehensive, person-centered care plan be developed and implemented for each resident, including measurable objectives and timetables to meet their needs, which was not adhered to in this case.
Failure to Develop Timely Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for one resident within seven days of completing the Admission MDS assessment and no more than 21 days after admission. The MDS Coordinator, who was responsible for completing all MDS assessments and comprehensive care plans, admitted to an oversight in not completing the care plan for the resident. The resident was admitted on a specific date, and the Admission MDS was completed on June 21, 2024, but the care plan was not finalized until September 11, 2024. This delay was attributed to a lack of review and oversight, as the MDS Coordinator's work was not checked for accuracy by anyone else. The Administrator, who started on August 26, 2024, acknowledged the oversight and noted that the error should have been identified during the clinical review of the resident's records upon readmission from the hospital. The RNC, who was the interim DON at the time, also recognized the oversight and stated that she should have been auditing the care plans. The facility's policy requires that a comprehensive, person-centered care plan be developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. The failure to adhere to this policy could place residents at risk of not receiving the required person-centered care.
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What surveyors actually found near you
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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 Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At Bay City | 0.7 mi | ★★★★★ | 0 | 0 |
| Matagorda Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 1 | 1 |
| Paradigm At Sweeny | 18.1 mi | ★★★★★ | 2 | 0 |
| Paradigm At The Prairies | 23.5 mi | ★★★★★ | 15 | 2 |
| Wharton Nursing And Rehabilitation Center | 23.7 mi | ★★★★★ | 8 | 4 |
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