Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Burkburnett during CMS and state inspections, most recent first.
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.
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.
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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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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 | ★★★★★ | 0 | 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 July 2026) and official state health department websites.