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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Burkburnett during CMS and state inspections, most recent first.
Kitchen sanitation and food handling deficiencies: A kitchen aide prepared resident drinks without covering his facial hair, and the cart used for preparation was soiled with food crumbs. Surveyors also found dirty shelves, a mixer bowl with food crumbs, a grease fryer with leftover food and grease buildup, a stove missing knobs and soiled with food and dried debris, a dusty vent hood, standing food in the disposal, and food thickener stored in an improperly sealed container.
Call lights were not kept within reach for two residents with care plans requiring accessible call systems. One resident with stroke-related deficits and moderate cognitive impairment was repeatedly observed with the call light hanging between the bed and wall, out of reach, even after multiple staff entered the room. Another resident with dementia, Alzheimer’s disease, and severe cognitive impairment was observed sleeping in a recliner while her call light was left on the bed and not accessible. Staff and the DON stated it was everyone’s responsibility to ensure call lights were in reach.
Controlled pain meds were not consistently documented on the MAR for three residents, even though the controlled med logs showed the doses were given and counts were correct. One resident had chronic pain syndrome, another had bipolar disorder, chronic pain, and anxiety, and a third was receiving rehab and hospice services. Staff also failed to document follow-up for pain med effectiveness or symptoms after administration, despite care plans and facility policy requiring MAR documentation, pain scale entry, and monitoring of results.
Failure to Follow Hand Hygiene and Perineal Care Practices: A CNA and an MA provided incontinent care to a dependent, cognitively impaired resident with bowel and bladder incontinence without following required hand hygiene and perineal care steps. The CNA donned gloves without washing hands, changed gloves without using hand sanitizer, and cleansed from the rectal area toward the penis using only one wipe; the MA also used improper hand hygiene practices during the care. The DON stated staff had been trained on hand hygiene and were competency checked annually, and facility policy required hand hygiene before resident contact, after glove removal, and clean-to-dirty perineal care.
A licensed 3-bed ward room used by the therapy department did not provide the required floor space per resident. The Administrator stated the room was still considered under licensure as a 3-bed ward and wanted to continue the existing room size waiver. Surveyors observed therapy equipment and a desk in the room, and measurement showed 221.8 square feet total, or 73.9 square feet per person.
A resident with spastic quadriplegic cerebral palsy, spina bifida, recurrent depressive disorders, and protein-calorie malnutrition did not have a comprehensive, person-centered care plan in place, despite a completed MDS showing positive PASARR conditions and moderate cognitive impairment. Staff, including a CNA, reported relying on the resident’s verbal directions and shift-to-shift verbal reports rather than a documented care plan. Leadership and the MDS nurse acknowledged that only a baseline care plan existed and that the comprehensive care plan—required to include measurable objectives, timeframes, PASARR-related services, admission goals, desired outcomes, and discharge preferences—had not been completed due to a software transition and workload issues, even though services were being provided.
A resident with spastic quadriplegic cerebral palsy, spina bifida, recurrent depressive disorders, and protein-calorie malnutrition did not have a comprehensive care plan completed within 7 days of a comprehensive MDS assessment. The MDS nurse, who was responsible for both the assessment and care planning, reported being delayed due to a change in company ownership and healthcare software that required manual entry of each care plan. The ADM and ADON confirmed that the MDS nurse was solely responsible for completing the care plan and that, during this period, staff relied on verbal reports to guide care instead of a completed written care plan, contrary to the facility’s policy.
A facility exceeded the acceptable medication error rate with an 8% error rate due to two incidents involving a resident. An LVN administered a Heparin flush without a physician's order and delayed the administration of Meropenem. The resident, with a PICC line for IV medication, did not have a physician order for the Heparin flush, and the facility's protocol did not include the SASH method. The delay in Meropenem administration was attributed to the LVN being busy and waiting for the resident to finish lunch.
A resident with osteomyelitis was administered a Heparin flush via PICC line without a physician's order, following the SASH method, which was not a facility protocol. LVN A did not verify the order, and the Medical Director confirmed no such order was given. The facility's policy requires verifying orders before medication administration, which was not followed in this case.
The facility failed to secure the East Hall Medication Cart, which was found unlocked and unattended in the hallway. LVN A admitted to forgetting to lock the cart while administering medications in a resident's room, leaving it out of sight and accessible to nearby residents. The cart contained various medications, including narcotics, and the facility's policy requires all medication storage areas to be locked unless in use.
The facility did not meet the required floor space per resident in East Hall room, which was licensed as a 3-bed ward but only provided 73.9 square feet per person. The room was used by the therapy department and contained therapy equipment. The Administrator acknowledged the room's licensure status and sought to continue a previous room size waiver.
A resident with severe cognitive impairment developed a pressure ulcer that was not reported to the physician, family, or hospice services, leading to delayed treatment. The facility's policy on notifying changes in a resident's condition was not followed, resulting in a significant lapse in care.
A resident with severe cognitive impairment and high risk for pressure injuries developed a pressure injury on her right heel. The facility failed to notify the physician, resident representative, or hospice services, did not obtain wound care orders, and did not perform routine wound care. Weekly skin assessments were also not completed, leading to the worsening of the resident's condition.
A resident with dementia, bipolar disorder, PTSD, and anxiety experienced a fall with a major injury, a pressure ulcer, and aggressive behaviors. The facility failed to complete a comprehensive reassessment within 14 days, leading to gaps in the resident's care plan and necessary interventions.
The facility failed to develop a comprehensive care plan within 7 days after a significant change assessment for a resident with severe cognitive impairment and behavioral issues. The required IDT care conference was not held, and the resident's representative was not invited to participate. Staff acknowledged the oversight but maintained that care was still provided.
The facility failed to maintain accurate wound care records for a resident with dementia, bipolar disorder, PTSD, and anxiety. Despite a care plan indicating a risk for skin breakdown and weekly assessments showing a pressure injury, no documented wound care orders or treatments were provided until a hospice nurse's assessment. The resident reported self-cleaning the wound, and the ADON confirmed the absence of wound care orders. The LVN admitted to providing care without orders, contrary to the facility's documentation policy.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen observation, Kitchen Aide F was preparing drinks for residents without a hair restraint covering his mustache and goatee/beard, and the cart used to prepare the drinks was soiled with food crumbs on top. The shelves throughout the kitchen, including those holding dishes, pots, and pans, were soiled with food crumbs and dust, and the bowl attached to the mixer had food crumbs in the bottom. Additional observations showed the grease fryer contained pieces of fried okra from the day before and had grease buildup on top, the stove was missing 3 knobs and was soiled with food crumbs and dried food, and the oven was also soiled. The vent hood was covered with a layer of dust, the food disposal had standing food in it, and the container holding food thickener near the blender was not sealed properly because foil was covering the top instead of a lid. The Dietary Manager and Administrator were both informed of the findings and acknowledged the kitchen cleanliness and equipment issues, and the Dietary Manager stated staff were new and in training.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach and accessible for two residents who had care plans directing staff to keep the call light visible and in reach. Resident #33 was a male with diagnoses including cerebral infarction, left hand contracture, muscle wasting, and left-sided hemiparesis, and his quarterly MDS reflected a BIMS score of 11 with assistance needed for toileting, dressing, personal hygiene, and transferring. His care plan identified him as a fall risk and included a reachable call light and prompt response to calls for assistance. On 02/17/2026, Resident #33 was observed lying in bed with the call light hanging at the foot of the bed between the wall and the bed, out of his reach. He stated that staff sometimes left the call light where he could not reach it, that he could pull it with his right arm if it were reachable, and that if he could not reach it he would holler for help. After CNA D answered his call light and left the room, the call light remained out of reach. MA C later entered the room and adjusted the resident’s arm and pillow, but the call light still remained between the bed and wall. LVN A later entered to cut his fingernails and found the call light still out of reach, then moved the bed and placed the call light within reach before leaving. On 02/19/2026, Resident #33 was again observed with the call light hanging between the bed and wall and not in reach. Resident #23 was a female with diagnoses including dementia, Alzheimer’s disease, and muscle weakness. Her significant change MDS reflected a BIMS score of 3, indicating severe cognitive impairment, and she needed supervision or touch assistance with transferring and toileting. Her care plan identified her as a fall risk and directed staff to instruct her to call for help before getting out of bed and to always keep the call light visible and in reach. On 02/17/2026, she was observed sleeping in a recliner with the room dark, while her call light was lying on a freshly made bed and was not within reach. Later that day, she remained sleepy during lunch and staff were attempting to feed her, but she did not respond to interview attempts.
Controlled Medication Administration Not Properly Documented
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for 3 residents reviewed for treatment administration. For Residents #2, #7, and #38, staff did not accurately document the administration of controlled substance pain medications on the Medication Administration Record (MAR), even though the controlled medication logs showed the medications were given and the counts were correct. The report also found that staff did not document follow-up for effectiveness or symptoms after narcotic pain medication administration for these residents, as required by facility policy. Resident #2 had diagnoses including Type 2 Diabetes, a non-pressure chronic ulcer of the right foot, and chronic pain syndrome. Her physician ordered Acetaminophen-Codeine 300-60 mg every 4 hours as needed for pain. Review of the MAR and controlled medication log showed multiple doses documented on the controlled medication log between 2/11/2026 and 2/19/2026, but those administrations were not documented on the MAR. Review of progress notes showed no nursing note or documentation of follow-up for effectiveness of the pain medication. During observation, she was in bed watching television and stated she received medications on time and nurses were good about getting pain medication when needed. Resident #7 had diagnoses including bipolar disorder, chronic pain, and anxiety, and her care plan directed staff to administer analgesics and anti-anxiety medications as ordered and monitor/document side effects and effectiveness each shift. Resident #38 was receiving rehab and hospice services and stated his pain was sometimes more than the medication would help, though hospice was trying to adjust medications. For both residents, the report states that controlled medication administration was documented on the controlled medication logs but not on the MAR, and there was no nursing documentation showing follow-up for effectiveness after pain medication administration. Staff interviews confirmed that controlled medications were expected to be documented on both the controlled medication log and the MAR, along with pain scale and effectiveness, and the DON stated the logs were to be completed when medications were administered and documented in the residents' MAR.
Failure to Follow Hand Hygiene and Perineal Care Practices
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident reviewed for infection control. Resident #22 was a male with diagnoses including urinary retention, abnormal gait and mobility, a pressure area of the sacrum, and diarrhea. His quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment, and he was dependent on staff for all ADLs, including toileting hygiene. He was also incontinent of bowel and bladder, and his care plan addressed the potential for skin breakdown related to incontinence, impaired mobility, and disease process. During an observation of incontinent care, CNA B and MA C entered the resident’s room and began care without following required hand hygiene practices. CNA B ran his hand through his hair and then put on gloves without washing his hands. MA C used hand sanitizer from her pocket before donning gloves. CNA B left the soiled brief under the resident while providing care and cleansed the penis and perineal area by wiping from the rectal area up the shaft of the penis to the penis head using only one wipe. MA C also cleansed the shaft of the resident’s penis, changed her gloves, and used alcohol-based hand sanitizer before putting on new gloves. CNA B changed gloves without using hand sanitizer before turning the resident to clean the buttocks and rectal area, then changed gloves again to apply a clean brief and disposed of the soiled brief afterward. In interview, MA C stated CNA B did not perform incontinent care correctly, did not use hand sanitizer between glove changes, and wiped from a dirty to a clean area. CNA B stated he should have washed his hands before patient contact and used hand sanitizer between glove changes, and said he did not have hand sanitizer available during the care. The DON stated staff had been trained on hand hygiene, including washing hands before and after glove use, and that staff were competency checked annually. Facility policies stated hand hygiene is the primary means to prevent the spread of healthcare associated infections and that perineal care should be performed using clean-to-dirty technique with handwashing and sanitizing after glove removal.
Insufficient Floor Space in Licensed 3-Bed Room
Penalty
Summary
The facility failed to ensure that East Hall room [ROOM NUMBER], which was included in the licensed capacity as a three-bed resident room, provided the minimum floor space required per resident. Review of the Bed Classifications Form 3740, signed by the Administrator on 2/17/2026, showed the room was licensed for three beds and categorized as Title 18 (Medicare). During an interview on 2/17/2026, the Administrator stated the room was considered under licensure as a 3-bed ward but was being used for therapy, and she wanted to continue the room size waiver that had been in effect for the room. On 2/18/2026, observation with the Life Safety Code surveyor and the Maintenance Director found Room #E15 being used by the therapy department and containing therapy equipment and a desk. The room floor space was measured at 221.8 square feet, which equaled 73.9 square feet per person.
Failure to Develop Comprehensive Person-Centered Care Plan for PASARR-Positive Resident
Penalty
Summary
Surveyors identified a failure to develop a comprehensive, person-centered care plan with measurable objectives and timeframes for one resident. Record review showed that this resident, a male with spastic quadriplegic cerebral palsy, spina bifida, recurrent depressive disorders, and protein-calorie malnutrition, had been admitted on 11/26/2025. His electronic health record contained no evidence of a comprehensive care plan, despite a completed comprehensive MDS that identified positive PASARR conditions and a BIMS score of 11, indicating moderate cognitive impairment. Interviews with staff and the resident confirmed that care was being provided based on verbal communication and the resident’s own directions rather than a documented comprehensive care plan. CNA A reported she was familiar with the resident’s care needs and preferences and that staff communicated across shifts through verbal reports. The resident stated he felt safe, had not been hurt, and that staff cared for him as he requested. He also stated he was receiving PASARR services and that staff were following his plan of care, although no comprehensive written care plan was found in the record. Facility leadership and the MDS nurse acknowledged that no comprehensive care plan had been completed for this resident beyond a baseline care plan dated 11/26/2025. The ADM and DON confirmed that the baseline care plan was being used in place of a comprehensive care plan and that the comprehensive plan had not been developed. The MDS nurse stated she was responsible for completing care plans after MDS assessments, but due to a change in ownership, a software transition, and staffing issues, she had not yet entered this resident’s care plan into the new system. The ADM, DON, ADON, and MDS nurse all indicated that the resident was receiving services, including PASARR-related services and discharge planning discussions, but these were not reflected in a comprehensive care plan as required by the facility’s Comprehensive Care Planning policy, which calls for measurable objectives, timeframes, PASARR-related services, resident goals for admission, desired outcomes, and discharge preferences.
Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan within 7 days of completion of the comprehensive MDS assessment for one resident. Record review showed this resident was an adult male admitted with spastic quadriplegic cerebral palsy, spina bifida, recurrent depressive disorders, and protein-calorie malnutrition. His comprehensive MDS, identified as a nursing home comprehensive assessment with PASARR positive and a BIMS score of 11 (moderately cognitively impaired), had been completed, but the corresponding comprehensive care plan was not developed within the required 7-day timeframe as specified in the facility’s Comprehensive Care Planning policy dated March 2022. In interviews, the MDS nurse stated she was responsible for completing care plans after MDS assessments and acknowledged knowing the 7-day requirement. She explained that a new company had taken over the facility and the healthcare software had been changed, requiring her to manually enter each resident’s care plan into the new system, and she had not yet completed this resident’s care plan. The administrator confirmed that the MDS nurse was responsible for both the assessment and the comprehensive care plan and acknowledged awareness of the 7-day requirement, attributing the delay to the transition to the new company and software. The ADON also stated that the MDS nurse was solely responsible for completing care plans after assessments and reported that staff were relying on verbal reports to provide care when a care plan was not completed.
Medication Error Rate Exceeds 5% Due to Unordered Heparin Flush and Delayed Meropenem Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an 8 percent error rate due to two errors out of 25 opportunities. The errors involved a resident who was administered a Heparin flush without a physician's order and received a delayed dose of Meropenem. The resident, a [AGE] year-old female with diagnoses including osteomyelitis and atrial fibrillation, was admitted to the facility with a PICC line for intravenous medication administration. The first error occurred when LVN A administered a Heparin flush of 6 ml via the resident's PICC line, despite there being no physician order for this medication. The facility's protocol did not include the SASH method (saline, antibiotic, saline, and heparin flush) as a standard practice, and the Medical Director confirmed that he did not order the Heparin flush. The Heparin flush was found on the medication cart without a pharmacy label indicating a resident name or directions, and LVN A admitted to administering it without verifying the order. The second error involved the late administration of Meropenem, which was ordered to be given at 12:00 pm but was not administered until 1:31 pm. LVN A attributed the delay to being busy and waiting for the resident to finish lunch. The facility's policy requires medications to be administered within a specific time frame, and the delay in administering Meropenem could potentially affect the therapeutic effectiveness of the medication. The facility's failure to adhere to physician orders and medication administration protocols led to these medication errors.
Medication Error: Unauthorized Heparin Flush Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was administered a Heparin flush without a physician's order. The resident, a female with a diagnosis of acute osteomyelitis in the right great toe, was not prescribed a Heparin flush via her PICC line. Despite this, LVN A administered a Heparin flush of 6 ml after disconnecting an IV antibiotic, following the SASH method, which was not a facility protocol nor ordered by the physician. Interviews with LVN A revealed that she followed what she believed to be the normal protocol but did not verify the physician's order for the Heparin flush. The Medical Director confirmed that he did not order the Heparin flush and emphasized the risk of bleeding associated with its administration without an order. The facility's RNC and ADM also stated that medications should only be administered with a physician's order, and the pharmacist confirmed that Heparin flushes are only sent if specifically ordered. The facility's policy on medication administration requires reviewing the MAR and verifying orders before administering medications. However, LVN A did not adhere to this policy, leading to the administration of a medication without a physician's order. The Heparin flush used was not labeled with a resident's name or directions, and the facility did not have a specific policy for PICC line administration, relying instead on a generalized IV medication administration policy.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured in locked compartments, as observed with the East Hall Medication Cart. On the specified date, the medication cart was found unlocked and unattended in the hallway outside a resident's room. The lock was in the unlock position, allowing the drawers to be easily opened by hand. At the time of observation, there was no nurse in the line of sight of the medication cart, and a resident was within six feet of the cart. The cart contained prescription medications, over-the-counter medications, and narcotics. In an interview, LVN A admitted to forgetting to lock the medication cart when entering a resident's room to administer medications. She acknowledged that the cart should be locked at all times when not in use and that she could not see the cart from inside the resident's room. The RNC confirmed that the expectation is for medication carts to be locked if not in use by the nurse, as unsecured carts could allow unauthorized access to medications. The facility's policy on medication administration procedures also mandates that all medication storage areas be locked unless in use and under direct observation.
Deficiency in Room Size Compliance
Penalty
Summary
The facility failed to ensure that East Hall room [ROOM NUMBER] provided the minimum required floor space of 80 square feet per resident. This room was included in the facility's licensed capacity as a three-bed resident room but only provided 73.9 square feet per person. The room was being used by the therapy department and contained therapy equipment and a desk. The Administrator acknowledged that the room was licensed as a 3-bed ward and expressed a desire to continue the room size waiver that was previously in effect. This deficiency could restrict residents' movement and limit the accommodation of resident use equipment and personal effects.
Failure to Notify Physician and Family of Pressure Ulcer
Penalty
Summary
The facility failed to consult with the resident's physician or the resident's representatives regarding a change in condition for one resident who developed a pressure ulcer. The resident, who had a history of dementia, bipolar disorder, PTSD, and anxiety, was identified as high risk for pressure injuries. Despite this, a pressure ulcer on the resident's right heel was first noted on 03/04/2024 and re-assessed on 04/07/2024 without any notification to the physician, family, or hospice services. The lack of communication and documentation led to a delay in appropriate care and interventions for the resident's pressure ulcer. The Assistant Director of Nursing (ADON) discovered the unreported pressure ulcer during a skin assessment on 04/08/2024. The ADON noted that the resident's chart did not reflect any ongoing skin integrity issues or treatment orders for the right foot. The ADON confirmed that the pressure ulcer should have been assessed weekly, and appropriate orders and treatments should have been implemented. The Medical Director and hospice nurse also confirmed that they were not informed about the pressure ulcer, which hindered timely medical intervention. Interviews with the involved staff revealed that the Licensed Vocational Nurse (LVN) who initially identified the wound did not notify the necessary parties due to being busy. This oversight resulted in the resident not receiving the required wound care and treatment, potentially worsening the pressure ulcer. The facility's policy on notifying changes in a resident's condition was not followed, leading to a significant lapse in care for the resident with severe cognitive impairment.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident. The resident, who had severe cognitive impairment and was at high risk for developing pressure injuries, developed a pressure injury on her right heel. The facility did not notify the resident's physician, resident representative, or hospice services after identifying the wound. Additionally, the facility did not obtain orders for wound care or perform routine wound care for the resident's right heel. Weekly skin assessments were also not completed as required. The resident's care plan indicated that she was at risk for skin breakdown due to incontinence and thin, fragile skin. Despite this, the facility did not follow its own skin care protocol or preventative measures. The resident's right heel wound was first documented as a stage 1 pressure injury, but it later worsened to an unstageable ulcer with moderate bloody exudate and granulated tissue. There were no documented weekly skin assessments for several weeks, and the resident reported that she had been cleaning and rewrapping the wound herself. Interviews with facility staff revealed that the ADON was responsible for skin care assessments but had not ensured that weekly observations were completed. The LVN who initially identified the wound did not notify the necessary parties or obtain wound care orders. The Medical Director was also not informed of the wound. The hospice nurse confirmed that there was no documentation of skin integrity issues in their records. The facility's failure to provide appropriate wound care and follow-up could result in the worsening of the resident's pressure injury.
Failure to Reassess Resident After Significant Change in Condition
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition of a resident. The resident, who had a history of dementia with behavioral disturbances, bipolar disorder, PTSD, and anxiety, experienced multiple significant events including a fall with a major injury, the development of a pressure ulcer, and aggressive behaviors. Despite these changes, the facility did not conduct a timely reassessment to address the resident's evolving needs. This failure was identified through record reviews and interviews with staff, revealing that the resident's care plan was not updated to reflect the new conditions and required interventions. Specifically, the resident fell and sustained a head injury requiring staples, was involved in a physical altercation with another resident, and developed a pressure ulcer on the right heel. The MDS coordinator acknowledged that these events constituted a significant change in the resident's condition, necessitating a comprehensive reassessment. However, the reassessment was not completed, leading to gaps in the resident's care plan, including the lack of a wound care plan for the pressure ulcer. The facility's policy, guided by the RAI manual, was not followed, resulting in the resident not receiving appropriate care and interventions for their changed condition.
Failure to Develop Timely Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for a resident with significant cognitive and behavioral issues. The resident, who was admitted with diagnoses including dementia, bipolar disorder, PTSD, and anxiety, had a Significant Change MDS completed, but the required Intradisciplinary Team (IDT) care conference was not held. This lapse was confirmed through interviews with the resident's representative, the Director of Nursing (DON), the Social Worker (SW), and the MDS coordinator, all of whom acknowledged the oversight and its potential impact on the accuracy and timeliness of the resident's care plan. The resident's representative reported not being invited to a care plan meeting for an extended period, and the SW admitted to missing the scheduling of the care conference due to a lack of notification about the significant change. The MDS coordinator also expressed uncertainty about why the IDT meeting was missed, acknowledging that this failure could lead to inaccurate care plans and assessments. Despite these admissions, the staff maintained that the residents continued to receive care, although the care plans were not completed correctly as per the facility's policy.
Failure to Maintain Accurate Wound Care Records
Penalty
Summary
The facility failed to maintain accurate wound care records for a resident with a primary diagnosis of dementia, bipolar disorder, PTSD, and anxiety. The resident's care plan indicated a risk for skin breakdown, and weekly skin assessments showed a progression of a pressure injury on the right heel. However, there were no documented wound care orders or treatments provided until a hospice nurse assessed the resident. The resident reported self-cleaning and rewrapping the wound, and the ADON confirmed the absence of ongoing skin integrity issues and wound care orders in the resident's chart. Interviews with the medical director and LVN revealed that wound care should have been conducted since the injury was identified, but no orders were in place. The LVN admitted to providing wound care without orders and guessing the necessary treatment. The facility's policy on charting and documentation emphasized the need for complete and accurate records, which was not followed in this case, leading to inadequate care for the resident.
What surveyors are citing around you — mapped
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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 26 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 Burkburnett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sheridan Medical Lodge | 2 mi | ★★★★★ | 2 | 0 |
| Iowa Park Healthcare Center | 11.5 mi | — | 0 | 0 |
| Texhoma Christian Care Center Inc | 13.1 mi | ★★★★★ | 1 | 0 |
| Courtyard Gardens | 14 mi | — | 0 | 0 |
| Swan Health At Wichita Falls | 14.4 mi | ★★★★★ | 6 | 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 August 2026) and official state health department websites.