Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Burnet during CMS and state inspections, most recent first.
Improper Food Labeling and Storage in Kitchen: Surveyors found unlabeled and undated diced green onions in the walk-in refrigerator, along with two bags of shredded lettuce that had already expired. The DM stated the garnish items should have been labeled and the expired lettuce should have been removed. Interviews with the DM, FA, CK, RVP, and DON confirmed that food items should be labeled with contents and use-by dates, and the facility policy required refrigerated foods to be covered, labeled, and dated.
Hand hygiene and glove-use failures occurred during peri care, wound care, and blood glucose monitoring. A CNA used contaminated gloves during perineal care for a resident with severe cognitive impairment and did not wash hands after glove removal; an ADON performing wound care on a resident with multiple pressure ulcers did not wash hands before exiting and handled treatment scissors without sanitizing them; and an LVN performing a blood sugar check on a resident with diabetes touched the med cart with a contaminated glove and did not sanitize hands before documenting. Staff acknowledged the lapses and stated they had been trained on infection control.
Inaccurate PASARR Level I screenings were found for two residents. One resident had major depressive disorder, and another had bipolar II disorder, depression, and anxiety disorder, yet both PASARR Level I forms stated there was no evidence of mental illness. The MDS nurse, RVP, and DON acknowledged that diagnoses such as bipolar disorder should affect PASARR status and that an updated 1012 form or regenerated PASARR was needed when diagnoses changed.
Incorrect Vitamin D Dose Administered: A resident with hypothyroidism, severe protein-calorie malnutrition, COPD, and CKD had an order for Cholecalciferol 10 MCG daily, but a CMA administered quartered 50 MCG tablets because the correct dose was not available. The CMA stated the tablet was not scored and the dose was approximated, and the wrong dose was given for a week without proper documentation of the medication error.
The facility failed to ensure dietary aides wore proper hair restraints, as observed with Dietary Aide B having uncovered hair while preparing food and Dietary Aide A passing by food without a hair net. Despite training and policy requirements, these lapses in food service safety standards were noted by surveyors.
A facility failed to develop an accurate care plan for a resident with renal disease and smoking habits. The care plan incorrectly included dialysis interventions, despite the resident not undergoing dialysis or having shunts. Additionally, the smoking care plan was inaccurate, as the resident had cigarettes and a lighter in her possession, contrary to the care plan's instructions. The MDS nurse and DON acknowledged the errors and the potential risk of improper care due to these inaccuracies.
A resident was found with cigarettes and a lighter in her possession, violating the facility's smoking policy. The facility did not provide supervised smoking times and relied on the family to manage smoking materials, posing a potential risk for accidents. The resident was cognitively intact and required supervision for some ADLs.
A resident developed a pressure ulcer at the coccyx area, but the family was not informed until the resident was transferred to a hospital. The resident, who had cognitive issues and was at risk for pressure ulcers, was seen by a wound care doctor without family consent. Staff interviews revealed assumptions and lack of documentation regarding family notification, contrary to the facility's policy on resident rights and notification procedures.
A resident with an indwelling urinary catheter did not receive appropriate care and monitoring due to the absence of physician orders and documentation. Despite having a care plan that included catheter care interventions, there were no corresponding orders or records in the MARs and TARs. Facility staff confirmed the presence of the catheter, but the DON acknowledged the lack of necessary orders and monitoring. The resident was transferred to a hospital with fever and low blood pressure, underscoring the potential risks of inadequate catheter management.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation. During an initial kitchen observation, surveyors found five small single-serve condiment containers holding diced green onions in the walk-in refrigerator that were not labeled or dated, along with two bags of shredded lettuce that had expired on 04/22/2026. The DM removed and disposed of the items and stated the green onions had been used as garnish the previous evening, but should have been labeled, and that the lettuce should have been removed. During interviews, the DM, FA, CK, RVP, and DON each stated that food items should be labeled with their contents and use-by date, and that expired items should be removed because they could be used to prepare meals and cause residents to become sick. Record review of the facility policy, Food Receiving and Storage, revised November 2022, stated that food shall be received and stored in a manner that complies with safe food handling practices and that all foods in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date. The policy also stated refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.
Hand Hygiene and Glove Use Failures During Resident Care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for three residents reviewed for infection control. The deficiency involved hand hygiene and glove-use failures during direct resident care and wound care, including perineal care for a resident with severe cognitive impairment and urinary incontinence, wound care for a resident with multiple pressure ulcers, and blood glucose monitoring for a resident with diabetes. During observation of perineal care for a resident with Alzheimer’s disease, severe cognitive impairment, and extensive assistance needs for toileting and incontinence care, CNA B did not change contaminated gloves between cleaning the front and back perineal areas. While repositioning the resident, she touched the resident’s clothes, body, bedding, and clean incontinence brief with contaminated gloves. After removing the gloves, she did not wash her hands before lowering the bed, placing the call light within reach, and opening the resident’s door. In interview, CNA B stated she had been in-serviced on hand hygiene and infection control and acknowledged she was supposed to change gloves between the front and back perineal area and wash her hands after glove removal and before leaving the room. During wound care for a resident admitted with a stage 4 right ischium pressure ulcer and additional pressure injuries, the ADON washed her hands before starting, applied PPE, and completed the dressing application, but after removing gloves and discarding supplies she picked up treatment scissors from the resident’s table and exited the room without washing her hands. She used hand sanitizer outside the room and did not sanitize the scissors before placing them in the treatment cart. She also did not date the bordered foam dressing. During interview, the ADON stated she was responsible for the infection prevention and control program, knew hand hygiene should occur before entering a room, between glove changes, and before exiting, and stated she forgot to wash her hands before leaving the room. During blood glucose monitoring for a resident with diabetes, the LVN lanced the resident’s finger and, after receiving an error message, removed one glove and touched the medication cart with the contaminated glove before obtaining new supplies. She did not sanitize her hands between glove changes. After completing the blood sugar check and removing her gloves, she did not sanitize her hands before documenting the result on the computer. The LVN stated she had been trained on handwashing and infection control and acknowledged she did not sanitize her hands between changing gloves and after glove removal. The DON and RVP stated that staff were expected to follow infection control and hand hygiene protocols during peri care, wound care, medication administration, and other direct resident care.
Inaccurate PASARR Level I Screenings for Two Residents
Penalty
Summary
The facility failed to ensure that PASARR Level I screenings accurately reflected the status of 2 residents reviewed for PASARR screening. Resident #3’s record showed diagnoses of unspecified dementia, major depressive disorder, and hypertension, and the MDS and care plan also identified depression and major depressive disorder. However, the resident’s PASARR Level I screening dated 03/21/2026 indicated that he did not have evidence of a mental illness. Resident #6’s record showed diagnoses of bipolar II disorder, depression, anxiety disorder, and unspecified dementia, and the MDS and care plan identified anxiety, depression, and bipolar disorder. Despite those diagnoses, the resident’s PASARR Level I screening dated 07/21/2023 indicated that she did not have evidence of a mental illness. The record review also showed that no 1012 form had been completed to update either resident’s PASARR Level I screening with the diagnosis information. During interviews, the MDS nurse stated that diagnoses such as bipolar disorder would indicate a positive PASARR Level I and that Resident #3’s PASARR should have been positive because of major depressive disorder. She also stated that Resident #6’s PASARR should have been regenerated if the diagnosis was added later. The RVP and DON stated that PASARR should be completed upon admission and that an inaccurate PASARR could delay services or cause residents to miss benefits they may have been eligible for.
Incorrect Vitamin D Dose Administered
Penalty
Summary
The facility failed to provide pharmaceutical services that assured accurate dispensing and administration of drugs and biologicals for one resident. Resident #32, a [AGE]-year-old male admitted with diagnoses including hypothyroidism, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, and chronic kidney disease, had an order for Cholecalciferol Oral Tablet 10 MCG (400 Unit), 1 tablet by mouth daily for vitamin D supplementation starting 04/19/2026. The medication administration record showed the medication was documented as administered daily from 04/19/2026 through 04/27/2026. During observation of medication administration, CMA C removed an over-the-counter container of Cholecalciferol Oral Tablet 50 MCG (2000 UT) and attempted to split the tablet before placing it in a medication cup with the resident’s other medications. CMA C stated the dose was wrong, that the correct dose was not available on the cart or in medication storage, and that she split the tablet into quarters and administered a quarter tablet to the resident. She stated the tablet was not scored and that she approximated the split, and also stated that 50 MCG could not be split evenly to obtain the ordered 10 MCG dose. CMA C stated she had reported the discrepancy to a charge nurse, but the correct dose was not ordered and the wrong dose was administered for a week. She stated she should have documented the discrepancy and not administered the wrong dose. The ADON and DON stated that staff were responsible for following the 5 rights of medication administration, holding the medication if the correct dose was unavailable, and documenting medication errors, but the incorrect dose had not been documented or reported in the resident’s progress notes. The facility policy required medications to be administered according to prescriber order and for the administering individual to verify the right dosage and document the dosage given.
Improper Hair Restraint Use in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that dietary aides wore proper hair restraints while handling food. During multiple observations, Dietary Aide B was seen with 3-4 inches of hair at the nape and wisps around her face not covered by a hair net while preparing drinks and handling plated food. Despite acknowledging her training to cover her entire head with a hair net, she continued to work without proper hair coverage. Similarly, Dietary Aide A was observed passing by food being plated without wearing a hair net, despite being trained to do so. The Dietary Manager confirmed that all staff were required to wear hair nets when entering the kitchen, with no exceptions. However, both aides were found non-compliant with this policy. The Administrator also stated that staff were expected to wear hair nets to prevent hair from contaminating food, although no complaints had been received. The facility's policy mandates that all dietary staff wear hair nets in any food preparation area, yet this was not consistently enforced, leading to the deficiency.
Inaccurate Care Plan for Resident with Renal Disease and Smoking
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #34, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan inaccurately included interventions for dialysis, despite the resident not having orders for dialysis or any shunts or grafts, as confirmed by the resident and observations. Additionally, the care plan for smoking was incorrect, as the resident was found to have cigarettes and a lighter in her possession, contrary to the care plan's instructions that these items be kept with the family and supervised by staff. The MDS nurse acknowledged that the interventions for dialysis might have been from a previous residency in 2019 and admitted the risk of incorrect interventions leading to improper care and services. The DON also expressed concern that incorrect care plans could result in residents not receiving needed services or causing confusion. The facility's policy requires the development of a comprehensive care plan that includes measurable objectives and timeframes, but this was not adhered to in the case of Resident #34.
Failure to Prevent Accident Hazards Due to Smoking Policy Lapse
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident. The resident, who was cognitively intact and required supervision for some activities of daily living, was found to have cigarettes and a lighter in her possession, contrary to the facility's smoking policy. The resident was able to smoke outside with her family, but the facility's policy required that all smoking paraphernalia be kept with the family or at the nursing station, which did not have a lock box. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not offer supervised smoking times and relied on the family to manage the resident's smoking materials. The Administrator was unaware that the resident had a lighter and cigarettes in her purse, which posed a potential risk for accidents. The facility's policy, included in the admission packet, prohibited residents from possessing smoking paraphernalia, and the family was responsible for ensuring compliance during visits.
Failure to Notify Family of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to inform a resident's family and responsible party about a significant change in the resident's condition, specifically the development of a pressure ulcer at the coccyx area. This deficiency involved a female resident who was admitted with a history of an unspecified fracture of the right femur, essential tremor, and the presence of an unspecified artificial knee. The resident was at risk for developing pressure ulcers, as indicated in her care plan, and had communication problems related to cognition. On August 5, 2024, a pressure ulcer was discovered on the resident's coccyx area, and she was subsequently seen by a wound care doctor on August 15 and August 21, 2024. However, there was no documentation in the resident's progress notes from August 5 to August 24, 2024, indicating that the family was notified of the pressure ulcer or that consent was obtained for the wound care treatment. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) who discovered the wound assumed the Director of Nursing (DON) would notify the family, but the DON did not document any such notification. The resident's family was not informed of the pressure ulcer until the resident was transferred to a local hospital on August 24, 2024. The family expressed that they were unaware of the wound's development or the involvement of a wound care doctor. The facility's policy on resident rights and notification procedures was not followed, leading to the family's lack of involvement in the resident's care decisions during this period.
Inadequate Catheter Management for Resident
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections. The resident, a female with a history of a right femur fracture and essential tremor, was admitted with an indwelling catheter. Despite the presence of the catheter, there were no physician orders for its care, monitoring, or output documentation from late July to late August. The resident's care plan included interventions for catheter care and monitoring, but these were not supported by corresponding physician orders or documented in the Medication Administration Records (MARs) and Treatment Administration Records (TARs). Interviews with facility staff, including an LVN, CNAs, and the DON, confirmed that the resident had a Foley catheter throughout her stay, yet there was no documentation of catheter care or output. The DON acknowledged the lack of physician orders and the necessity for monitoring due to the high risk of infection. The facility's policy on catheter care did not include procedures for implementing physician orders, contributing to the oversight. The resident was eventually transferred to a hospital due to fever and low blood pressure, highlighting the potential consequences of inadequate catheter management.
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 54 citations issued within 25 miles in the last 12 months — including the 1 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 Burnet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bertram Nursing And Rehabilitation | 10.3 mi | ★★★★★ | 5 | 0 |
| Granite Mesa Health Center | 12.2 mi | ★★★★★ | 9 | 0 |
| Avir At Kingsland | 14.5 mi | ★★★★★ | 18 | 0 |
| The Brixton At Horseshoe Bay | 16.2 mi | ★★★★★ | 0 | 0 |
| Lily Springs Rehabilitation And Healthcare Center | 21.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Burnet.
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.