Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Burleson during CMS and state inspections, most recent first.
Undated Opened Medications and Expired Supplies Found in Medication Storage: An observation of a nurse medication cart found two opened Albuterol inhalers, a partial bottle of Acetic Acid 0.25% that was leaking, and a partial bottle of Hydrogen Peroxide Solution that were opened but not dated. The medication storage room also contained six expired central line dressing kits. Staff interviews and facility policy confirmed that opened medications should be dated and expired items removed from active supply.
Undated and Uncovered Food Items in Kitchen Storage: Surveyors found a sheet cake in the cooler uncovered and not dated, along with an open bag of shredded lettuce that was also undated. The DM said the items had been recently prepared or opened, but staff forgot to date them, and stated food placed in the refrigerator or freezer should be covered and dated. The ADM said dietary aides, cooks, and the DM were responsible for covering, dating, and monitoring food items in storage.
A resident with documented anxiety, bipolar disorder, and depression was admitted with a PASARR Level I marked “No” for MI. The chart showed intact cognition, mood symptoms, and antidepressant use, while the resident reported a long history of mental illness, current psych meds, and ongoing therapy. Staff stated they reviewed records to verify PASARR accuracy, but the resident was not listed as PASARR positive.
A facility failed to complete a comprehensive MDS assessment for a newly admitted resident within the required 14 days. The resident, with multiple health conditions, had an incomplete MDS assessment due to the Care Coordinator Manager's recent promotion and illness. The Resident Records Manager and Administrator were aware of the delay, but the assessment remained unfinished.
A resident with an indwelling urinary catheter in an LTC facility was found with the catheter drainage bag and tubing resting on the floor, contrary to infection control protocols. Staff interviews revealed inconsistencies in catheter care practices, with the DON acknowledging the risk of contamination and the ADON noting frequent monitoring and replacement of the catheter bag. The facility's policy requires catheter care every shift and privacy bags at all times, but these were not consistently followed.
A resident with severe cognitive impairment and dependency on assistance for daily activities was found with their call light out of reach, contrary to the care plan and facility policy. Staff interviews confirmed the expectation that call lights should always be within reach to ensure residents can request assistance.
The facility failed to maintain a sanitary environment, with surveyors observing dried bowel movement on a shower chair and soiled wipes on the floor in shower rooms. Interviews with staff, including CNAs and an RN, revealed confusion over cleaning responsibilities, despite policies requiring disinfection after each use. The ADM acknowledged the risk of infection transmission due to these oversights.
A facility failed to monitor soup temperatures adequately, resulting in soup being served at 180 degrees, posing a burn risk to residents. A resident with quadriplegia noted a chemical taste in the food, but no burns were reported. The kitchen staff did not follow protocols for checking food temperatures, contributing to the deficiency.
A CNA failed to sanitize her hands before delivering meal trays to three residents, despite being trained to do so, potentially risking infection spread. The facility's policy requires hand hygiene, but the ADM could not provide a specific policy for meal tray delivery.
The facility failed to maintain a sanitary environment by not covering stored linens, exposing them to contamination. Additionally, a resident requiring Enhanced Barrier Precautions (EBP) due to a bacterial infection did not receive proper care, as an LVN provided assistance without wearing gloves or PPE. Staff interviews confirmed that policies were in place but not followed due to oversight and human error.
The facility failed to accommodate residents' needs by allowing metal handrails to obstruct bathroom call light systems, making it difficult for residents with cognitive impairments and mobility issues to call for assistance. This issue affected multiple residents, including those with dementia and amputations, who struggled to use the call light system due to the handrail's positioning.
A resident with dementia experienced discomfort due to a broken toilet seat in her bathroom, which was not promptly repaired by the facility. Despite informing staff, no work order was submitted through the maintenance reporting system, and the issue was not identified during Angel Rounds. The facility's maintenance policy was not followed, leading to a deficiency in providing a safe and comfortable environment.
The facility failed to maintain food safety and cleanliness standards in the kitchen, with cucumbers improperly stored, dented cans not separated, and dusty air vents. Staff interviews revealed unclear responsibilities and lack of cleaning schedules, potentially risking cross-contamination and air-borne illnesses.
A resident in an LTC facility, who was cognitively intact and dependent on staff for transfers and bathing, did not receive scheduled and requested bed baths and was not assisted to attend a Resident Council meeting. Despite expressing her needs, staff failed to provide the necessary assistance, and management was aware of previous complaints but did not adequately address the issues.
A resident in a LTC facility, who was cognitively intact and required assistance for daily activities, did not receive scheduled bed baths and missed a Resident Council meeting due to staff inaction. Despite her requests, staff failed to provide necessary assistance, citing reasons such as being busy or understaffed. Interviews with staff revealed a lack of communication and follow-up, leading to a deficiency in maintaining the resident's quality of life and dignity.
Undated Opened Medications and Expired Supplies Found in Medication Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles and that medications and related supplies were properly stored. On observation of the E Hall nurse medication cart, two opened Albuterol 90 MCG inhalers were not dated, a partial bottle of Acetic Acid 0.25% was opened and not dated and was leaking, and a partial bottle of Hydrogen Peroxide Solution 32 oz was opened and not dated. The report also noted that the medication storage room contained expired medication administration supplies, including six central line medication catheter dressing kits that had expired on 8/31/25 and 6/30/25. During interviews, MA B, LVN A, the ADON, and the ADM stated that expired supplies and undated medications should be discarded and that using expired items or undated opened medications could cause problems such as infections, skin problems, allergic reactions, or reduced effectiveness. Facility policy titled, Medication Storage in The Facility, dated June 9, 2025, stated that outdated, contaminated, or deteriorated medications and those without secure closures are to be immediately removed and disposed of, that containers are to be dated when the original seal is broken, and that all expired medications are to be removed from active supply and destroyed.
Undated and Uncovered Food Items in Kitchen Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food storage, food safety, and nutrition services in 1 of 1 kitchen. During observation on 9/21/2025 at 9:13 AM, surveyors found 1 sheet cake prepared in a pan sitting uncovered on top of boxes in the cooler and not dated. They also found 1 bag of shredded lettuce sitting on a shelf open and undated. In interview at that time, the DM stated the sheet cake had been cooked that morning and placed in the freezer to cool down, and the lettuce had just been opened, but staff forgot to place a date on it. The DM stated that normally anything placed in the refrigerator or freezer would be covered and dated, and that it was her responsibility to ensure items were dated and to check the refrigerator and freezer daily. In a later interview, the ADM stated dietary aides and cooks were responsible for covering and dating items placed in the freezer and refrigerator, and that the DM was responsible for daily monitoring of the refrigerator and freezer for expired, undated, and uncovered items. The ADM also stated he performed weekly kitchen walk-throughs and was responsible for monitoring the kitchen for dated and covered items. The facility's food storage policy dated October 01, 2018, stated to date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers approved for food storage, and to store frozen foods in moisture-proof wrap or containers that are labeled and dated.
Incorrect PASARR Mental Illness Screening
Penalty
Summary
The facility admitted a resident with diagnoses of anxiety, bipolar disorder, and depression, but the resident’s PASARR Level I screening was marked “No” for mental illness. The resident’s admission record showed she was admitted to the facility on [DATE], and her quarterly MDS documented a BIMS score of 14, indicating intact cognitive response, along with mood indicators such as little interest or pleasure in doing things and feeling down, depressed, or hopeless. The MDS also listed bipolar disorder and depression as active diagnoses. The resident’s care plan noted use of an antidepressant medication and included interventions to assess and document mood, monitor for medication side effects, and try non-pharmacological interventions before initiating drug therapy. The PASARR Level I dated 08/02/2024 indicated that the question asking whether there was evidence or an indicator of mental illness was answered “No,” despite the resident’s documented psychiatric diagnoses and mood symptoms in the record. During interview, the resident stated she had been diagnosed with a mental disorder a long time ago, had mental illnesses before coming to the facility, took medication for her mental illness, and saw a psychologist and therapist. She also stated she did not receive other mental health services and would like specialized services if she qualified. Facility staff stated they reviewed diagnoses and records to verify PASARR accuracy, and they acknowledged that if the PASARR was not marked correctly, a resident could miss services for which they were potentially eligible. The resident was not included on the facility’s PASARR positive resident list.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment for a resident within the required 14 calendar days after admission. The resident, an elderly male, was admitted with multiple health conditions including surgical aftercare, bladder cancer, altered mental status, diabetes, chronic kidney disease, muscle weakness, high blood pressure, chronic pain, heart disease, and heart failure. Upon review, it was found that the resident's Minimum Data Set (MDS) assessment was still in progress and had not been completed on time. Interviews revealed that the Care Coordinator Manager (CCM), who was responsible for completing the MDS assessments, had recently been promoted and was still reacquainting herself with the MDS process. The Resident Records Manager (RRM) acknowledged the delay and was aware of the timelines for assessments. The Administrator (ADM) confirmed the expectation for timely completion of MDS assessments but was unsure of the potential negative outcomes of late assessments. The CCM had prior MDS experience but had not worked in that capacity for several years, and the delay was attributed to her leaving early due to illness.
Deficient Catheter Care Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency in infection control practices. The resident, an elderly male with multiple health issues including bladder cancer and chronic kidney disease, was observed with his catheter drainage bag and tubing resting directly on the floor. This was noted during two separate observations on the same day, indicating a lapse in maintaining the catheter system off the ground, which is crucial to prevent contamination and potential infections. Interviews with facility staff revealed inconsistencies in catheter care practices. The Director of Nursing (DON) acknowledged that the catheter drainage bag and tubing should not touch the floor due to the risk of contamination and infection. The Assistant Director of Nursing (ADON) confirmed that the resident was admitted with a catheter and urostomy, and there were ongoing issues with the urostomy not adhering properly to the skin. The ADON also mentioned that the facility had to frequently monitor the catheter bag and replace it if found on the floor, as per infection control procedures. The facility's policy on catheter care, dated December 2023, mandates that catheter care be performed every shift, with privacy bags covering the drainage bags at all times. However, the observations and staff interviews indicate that these procedures were not consistently followed, as the resident's catheter bag was found on the floor and not always covered with a privacy bag. This deficiency in adhering to established protocols could potentially lead to increased risk of urinary tract infections for residents with indwelling catheters.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents who require assistance with activities of daily living. On the date of observation, the resident, who had severe cognitive impairment and was dependent on assistance for various daily activities, was found lying in bed with the call light placed on a chair out of reach. This was observed twice on the same day, indicating a failure to adhere to the care plan that required the call light to be within reach at all times. Interviews with staff, including a CNA and the DON, confirmed that it is the responsibility of all staff members to ensure call lights are within reach to allow residents to request assistance. The facility's policy on answering call lights emphasizes the importance of timely responses to residents' needs, and specifically states that call lights should be within easy reach when residents are in bed or confined to a chair. Despite these guidelines, the resident's call light was not accessible, which could prevent the resident from receiving timely assistance.
Inadequate Cleaning and Disinfection in Shower Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by the presence of dried bowel movement on a shower chair in a combined shower room and soiled wipes left on the floor in another shower room. These observations were made during a survey, and interviews with staff members, including CNAs and an RN, revealed a lack of clarity and accountability regarding the cleaning and disinfecting responsibilities after each use of the shower rooms. The staff members interviewed acknowledged the expectation to clean and disinfect the shower areas after each use, but there was no clear indication of who was responsible for the oversight. The facility's Infection Prevention and Control Policy, as well as the Bathrooms Policy, emphasize the importance of maintaining a clean and disinfected environment to prevent the transmission of communicable diseases. However, the interviews with various staff members, including the ADM and ADON, highlighted a recurring issue of shower chairs being left uncleaned with feces and soiled wipes not being discarded properly. This lack of adherence to established cleaning protocols could potentially place residents at risk of infection transmission, as noted by the ADM during the interview.
Failure to Monitor Food Temperature Poses Burn Risk
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically in the kitchen area, where soup was served at an excessively high temperature of 180 degrees. This oversight was identified during a state surveyor's evaluation of a lunch test tray, where the soup was found to be dangerously hot, posing a risk of burns to residents. The kitchen staff did not adequately monitor the temperature of the soup during meal service, relying on dial thermometers that were not instant-read and failing to wait for an accurate temperature reading. Resident #11, a man with quadriplegia and no cognitive impairment, expressed concerns about the taste of the food, noting a chemical taste, although this was not corroborated by the state surveyor's taste test. The facility's kitchen manager admitted to not checking the soup's temperature more than once during meal service and acknowledged that the steam table's high setting might have contributed to the soup's excessive temperature. The facility's food temperature chart indicated that temperatures should be recorded at multiple points during service, but this protocol was not followed. Interviews with facility staff, including the kitchen manager and assistant director of nursing, revealed a lack of adherence to established policies regarding food temperature monitoring. The facility's policies required that hot foods be served at safe temperatures and that temperatures be checked at the beginning, middle, and end of tray service. However, these procedures were not implemented, leading to the potential risk of burns from the hot soup. Despite the oversight, no residents reported being burned, and the facility's incident and accident records did not show any injuries related to hot food or beverages during the review period.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, which could have placed residents at risk of infection. Observations revealed that a Certified Nursing Assistant (CNA) did not sanitize her hands before delivering meal trays to three residents. This was observed during meal service delivery to residents who were independent with eating and had specific dietary orders due to their medical conditions, such as major depression and schizophrenia. The CNA was observed delivering food trays to three residents without sanitizing her hands before entering their rooms and after exiting. This was confirmed through interviews with the CNA, who admitted to not sanitizing her hands despite being trained to do so. The facility's Assistant Director of Nursing (ADON) and Administrator (ADM) acknowledged that hand sanitizing was part of the facility's policy, and staff were trained accordingly. However, the ADM was unable to present a specific policy addressing hand sanitizing prior to each meal tray delivery. The facility's hand hygiene policy and the 2022 Food Code require staff to maintain clean hands to prevent the spread of infections. Despite these guidelines, the failure to sanitize hands before meal service was attributed to human error and oversight. This deficiency highlights a lapse in adherence to infection control protocols, which are critical in maintaining resident safety and preventing the spread of infections.
Infection Control Deficiencies in Linen Storage and EBP Adherence
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to deficiencies in infection prevention and control. Observations revealed that stored linens were not adequately covered, exposing them to potential contamination. A laundry cart in the hallway had its front opening uncovered, leaving linens, towels, and a box of open rubber gloves exposed to dust and other soiling agents. This lack of proper storage could contribute to the spread of infections within the facility. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident diagnosed with peripheral vascular disease and a bacterial infection. The resident required targeted gown and glove use during high-contact care activities due to the presence of intravenous antibiotics and wound care needs. However, an LVN was observed providing care without wearing gloves or other protective equipment, despite the presence of an EBP sign on the resident's door. This oversight in following EBP protocols could increase the risk of infection transmission. Interviews with facility staff, including the ADON and ADM, confirmed that there were policies in place for EBP and linen storage, but these were not followed due to staff oversight and human error. The facility's policies required that residents with EBP have a sign on their door indicating the necessary level of PPE, and that linens be protected from dirt and germs. The failure to adhere to these policies was attributed to honest mistakes and the need for continued staff education.
Inaccessible Call Light System Due to Obstructive Handrails
Penalty
Summary
The facility failed to ensure that residents had the right to receive services with reasonable accommodation of their needs and preferences. This deficiency was observed in four residents who were reviewed for accommodation of needs. The primary issue was the inaccessibility of the bathroom call light system (BCLB) due to metal handrails obstructing the call light boxes in several rooms. This obstruction made it difficult for residents to use the call light system effectively, potentially leaving them unable to call for assistance when needed. One resident, diagnosed with dementia and moderate cognitive impairment, had difficulty using the call light system due to the positioning of the metal handrail. The resident had tied the call light string in a knot around the handrail to create a loop, making it easier to use from a seated position. However, this adaptation rendered the call light inaccessible if the resident were to fall on the floor. The resident had not reported this issue to the staff, and it was only discovered during an interview and observation. Another resident, with moderate cognitive impairment and utilizing a walker, also faced challenges with the call light system due to the handrail's obstruction. The resident had to pinch and push the call light string downward, which was difficult from a seated position. Similar issues were noted with other residents, including one with a below-knee amputation who used a wheelchair. The facility's Angel Rounds checklist did not include instructions to check the accessibility of the call light system in bathrooms, and the facility's Call Light Policy did not adequately address the need for alternative accommodations for residents with disabilities.
Failure to Address Maintenance Issues in Resident's Bathroom
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically by not addressing maintenance issues in a timely manner. The resident, who was diagnosed with dementia and had moderate cognitive impairment, reported that the toilet seat in her bathroom had been broken since August and was only temporarily fixed. The seat became loose again and was completely detached by late September, causing discomfort to the resident when using the toilet. Despite the resident informing the nursing staff about the broken toilet seat, a work order was not submitted through the facility's maintenance reporting system, which utilized a QR code process. The Maintenance Director (MNTD) confirmed that no work order had been received for the broken toilet seat, and the facility's Angel Rounds, which were supposed to identify maintenance needs, failed to catch this issue. The Assistant Director of Nursing (ADON) and the Administrator (ADM) were unable to produce completed Angel Round checklists, indicating a lapse in the facility's maintenance oversight process. The facility's Maintenance Service Policy required the MNTD to maintain plumbing fixtures in a safe and operable manner, but this was not adhered to in this case. The ADM acknowledged the failure to identify the broken toilet seat and attributed it to a lack of follow-up on the Angel Rounds. The deficiency was noted as a failure to ensure the resident's environment was safe and comfortable, as required by regulatory standards.
Food Safety and Kitchen Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. The deficiencies included improper storage of cucumbers, which were found in an open box inside the refrigerator without being sealed, labeled, or dated. Additionally, dented cans of Vegan Salad Sliced Beets were discovered on the shelf with other canned goods in the dry storage area, contrary to guidelines that require such cans to be separated to prevent potential health risks. The kitchen also exhibited poor maintenance of air quality, with dust accumulation on air vents and filters, including those located above food preparation and dishwashing areas. This lack of cleanliness was noted during the survey, and interviews with staff revealed a lack of clarity regarding responsibilities for cleaning these areas. The Maintenance Director and Dietary Manager both acknowledged the absence of a cleaning log or schedule for the air vents, which contributed to the oversight. Interviews with various staff members, including the Dietary Manager and Maintenance Director, highlighted a lack of communication and accountability regarding food safety and kitchen cleanliness. The Dietary Manager admitted to not checking the dry storage area due to her absence from work, while the Maintenance Director confirmed that cleaning the air vents was his responsibility, yet no regular schedule was in place. These lapses in protocol and oversight could potentially lead to cross-contamination and air-borne illnesses among residents consuming food prepared in the facility's kitchen.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not providing scheduled and requested bed baths and assistance to attend a Resident Council meeting for Resident #18. Resident #18, a cognitively intact female with a BIMS score of 15, was dependent on staff for transfers and required maximal assistance for bathing. Despite her requests, she did not receive a bed bath on her scheduled days and was not assisted out of bed to attend a meeting she expressed interest in. Interviews with staff revealed inconsistencies in communication and follow-through regarding Resident #18's care needs. CNA A, who regularly worked with Resident #18, did not recall being asked to assist her to the meeting. CNA B acknowledged that Resident #18 missed her scheduled bath due to staffing shortages but admitted it should have been done. The Activity Director confirmed Resident #18's interest in attending the meeting and informed the staff, but Resident #18 was not assisted in time. The facility's management, including the ADON and DON, were aware of previous complaints about missed baths but did not follow up adequately to prevent recurrence. The Administrator was informed of the missed meeting but was unaware of the repeated issues with missed baths. The facility's policy emphasized respecting resident autonomy, but the failure to assist Resident #18 as requested demonstrated a lapse in adhering to this policy.
Failure to Assist Resident with ADLs and Meeting Attendance
Penalty
Summary
The facility failed to provide necessary assistance to Resident #18, who was unable to perform activities of daily living independently. Resident #18, a cognitively intact female with a BIMS score of 15, required extensive assistance for transfers and personal hygiene due to her medical conditions, including hypertension, diabetes, anxiety, and depression. Despite her care plan specifying the need for assistance with bathing and transfers, the facility did not ensure she received a bed bath as scheduled and failed to assist her in attending a Resident Council meeting, which she had expressed interest in attending. On multiple occasions, Resident #18 requested a bed bath and assistance to attend a meeting, but her requests were not fulfilled. She reported asking for a bed bath four times on a Saturday, but the staff did not provide it, citing various reasons such as being busy with other residents and not offering baths at night. Additionally, she missed a Resident Council meeting because staff did not assist her with the transfer from bed to chair, despite her request. The facility's staff, including CNAs and the Activity Director, acknowledged the resident's requests but failed to act on them, leading to her missing both the bath and the meeting. Interviews with facility staff revealed a lack of communication and follow-up regarding Resident #18's needs. The DON and ADON were aware of previous complaints about missed baths but did not ensure consistent follow-up or resolution. The Activity Director and CNAs involved did not recall specific details or actions taken to address the resident's requests, indicating a breakdown in the facility's processes to support resident autonomy and dignity. This failure to provide necessary care and assistance as per the resident's care plan and preferences resulted in a deficiency in maintaining the resident's quality of life and dignity.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 640 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — 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 Burleson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Rehabilitation & Healthcare Of Burleson | 1.4 mi | ★★★★★ | 13 | 1 |
| Crowley Nursing And Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Allegiant Wellness And Rehab | 3 mi | ★★★★★ | 0 | 0 |
| Park Bend Rehabilitation And Healthcare Center | 3.5 mi | ★★★★★ | 7 | 2 |
| Estates Healthcare And Rehabilitation Center | 7 mi | ★★★★★ | 29 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Burleson.
100% money-back within 48 hours.
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.