Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Center during CMS and state inspections, most recent first.
The facility restricted visitation hours for all residents, posting signs and sending letters to families indicating visits were only allowed between 6:00 AM and 10:00 PM, with exceptions requiring administrative approval. This policy was enacted after complaints about late-night disturbances from visitors, including incidents involving intoxicated individuals. Residents were not aware of the new limitations, and the facility's own documents stated residents have the right to receive visitors.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
Essential kitchen equipment was not maintained in safe operating condition, as the gas stove’s pilot light for one burner repeatedly went out, requiring staff to manually ignite the burner with a striker. The issue was attributed to airflow from a ceiling vent extinguishing the pilot light, and both dietary and maintenance staff were aware of the ongoing problem. There was no facility policy for equipment maintenance, and the deficiency persisted over an extended period.
A resident with dementia, mobility impairment, and a history of falls was found to have an emergency call light in the bathroom that was positioned three feet above the floor, making it inaccessible in the event of a fall. Staff interviews and observation confirmed the deficiency, and facility policy required call lights to be within reach and accessible to all residents.
Three resident rooms on a secured unit were found to be below the required 80 square feet per resident, as determined by direct measurement and record review. The administrator confirmed no structural changes had occurred and acknowledged a prior waiver for these rooms.
A resident with severe cognitive impairment and a history of elopement risk managed to exit a secured unit and leave the facility, crossing a highway before being found in a shopping center parking lot. Despite functioning security systems, the facility failed to provide adequate supervision, leading to the resident's unsupervised departure.
A resident with severe cognitive impairment eloped from a secured unit and was found unharmed across a highway. The facility failed to report the incident to the state agency within 24 hours, as required by policy. Interviews revealed a lack of documentation and adherence to reporting protocols, potentially placing residents at risk.
The facility's kitchen operations were found deficient in food safety and sanitation practices. Observations revealed that a dietary aide did not fully cover her hair with a hairnet, and food items in the refrigerator and freezer were not properly labeled or dated, with some being expired. Additionally, the cook and dietary manager failed to perform proper hand hygiene between tasks. These lapses were acknowledged by the staff, who were aware of the importance of these practices in preventing contamination and illness.
The facility failed to maintain proper infection control practices, as observed in the care of two residents. A hospice aide did not follow enhanced barrier precautions for a resident with chronic wounds, and a CNA did not perform hand hygiene between glove changes and improperly wiped a resident during incontinent care. Despite training efforts, these lapses highlight deficiencies in the facility's infection prevention program.
A resident with dementia and a urinary tract infection did not receive proper respiratory care as the facility failed to change her oxygen tubing weekly as ordered by the physician. Observations showed outdated tubing, and interviews with staff revealed a lack of monitoring and specific training for this task, despite the facility's policy requiring weekly changes.
The facility failed to provide the required 80 square feet per resident in five rooms on the secured unit. The Administrator acknowledged the issue, citing a previous waiver for these rooms. Observations and records confirmed the deficiency, although the rooms were unoccupied at the time.
Failure to Ensure Resident Visitation Rights Maintained
Penalty
Summary
The facility failed to ensure that residents maintained the right to receive visitors of their choosing at any time, as required. Observations revealed a sign at the main entrance restricting visitation hours to 6:00 AM to 10:00 PM. Record review confirmed that a letter was sent to families and visitors outlining these restricted hours, and that any visits outside of these times required arrangement with administrative staff. During a resident council meeting, residents were not aware of the limitation on visiting hours. The facility's admission packet indicated that residents have the right to receive visitors, but this right was not upheld due to the imposed restrictions. Interviews with the interim Administrator and the social worker revealed that the decision to limit visitation hours was made in response to complaints from residents about late-night disturbances caused by family members visiting after midnight, including incidents involving intoxicated visitors. Despite these complaints, the facility implemented a blanket restriction on all residents and visitors, rather than addressing the specific individuals involved. Both the Administrator and social worker stated that all resident representatives were notified of the new visitation policy and that no complaints were received regarding the change. There were no reports of residents voicing concerns or experiencing negative effects related to the restricted visitation hours at the time of the survey.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events involving individual residents or staff, nor does it detail specific observations or incidents that led to the deficiency.
Failure to Maintain Safe Operation of Kitchen Gas Stove
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove, where the pilot light for one of the burners repeatedly went out and allowed gas to leak. Observations showed that the back right burner’s pilot light was not staying lit, requiring staff to use a striker to ignite the burner directly. The Dietary Manager confirmed that the vent in the ceiling would blow air toward the pilot light, causing it to extinguish, and acknowledged that this had been a persistent issue over many years. The Dietary Manager was unable to recall when the issue was last reported to maintenance, though she stated maintenance had been made aware previously. The Maintenance Director confirmed awareness of the problem, noting that gas would continue to run if the pilot light was out, and recognized the potential fire hazard. The Administrator stated there was no facility policy for maintaining equipment and was not aware of previous attempts to resolve the issue. The deficiency was identified through observations, interviews, and record review, with staff acknowledging the ongoing nature of the problem and the lack of a clear maintenance protocol or resolution.
Inaccessible Bathroom Call Light for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible in the bathroom and bathing area for a resident with moderate cognitive impairment and mobility issues. Observation and interviews revealed that the emergency call light cord in the resident's bathroom was positioned three feet above the floor, making it unreachable for a resident who might fall. A housekeeper confirmed that if the resident were to fall, she would not be able to access the call light and would have to wait until staff made rounds or heard her. The maintenance director acknowledged that bathroom call lights needed to be accessible at floor level, and the assistant director of nursing stated that all staff were responsible for ensuring call lights were in place and accessible. Record review indicated that the resident was at risk for falls and required supervision or assistance for toileting and ambulation. The facility's policy required that call lights be within reach and accessible to residents, and that residents be instructed on their use. Despite this policy, the call light in the resident's bathroom was not accessible, as confirmed by multiple staff interviews and direct observation.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that bedrooms met the required minimum square footage per resident, as specified by regulations. Specifically, three out of eleven resident rooms reviewed (rooms 300, 309, and 310) did not provide at least 80 square feet per resident. Measurements taken during an observation showed that these rooms were below the required size, with dimensions recorded for each room. The deficiency was identified through observation, interview, and record review, including a bed classification worksheet completed by the facility administrator. During the investigation, it was noted that the rooms in question were located on a secured unit, and the administrator confirmed that there had been no structural changes to the building. The administrator also acknowledged awareness of a previously granted waiver for these rooms. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents, resulting in an elopement incident involving a resident with severe cognitive impairment. The resident, who had a history of dementia with behavioral disturbances, PTSD, psychosis, and Alzheimer's Disease, was admitted to the facility and was identified as being at risk for elopement. Despite these known risks, the resident was able to exit the secured unit and leave the facility through the main entrance. On the day of the incident, the resident was not accounted for, and staff initiated a search after realizing the resident was missing. The resident was found across a highway in a shopping center parking lot, unharmed but confused and agitated. Interviews with staff revealed that there was a lack of immediate recall of the incident, and no incident report was completed at the time. The facility's secured doors and keypad systems were reported to be functioning properly, yet the resident managed to elope, suggesting a lapse in supervision or protocol adherence. The incident highlighted a significant deficiency in the facility's ability to prevent elopement, particularly for residents with known risks. The lack of documentation and immediate staff awareness of the incident further underscored the deficiency in the facility's response to the elopement risk. The facility's failure to prevent the resident's elopement placed the resident at risk of serious injury, as evidenced by the resident's ability to cross a highway unaccompanied.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an alleged violation involving neglect to the state agency within the required 24-hour timeframe. This incident involved a resident with severe cognitive impairment and a history of dementia, PTSD, psychosis, and Alzheimer's Disease, who eloped from a secured unit. The resident was found across a highway in a shopping center parking lot without injury. Despite the incident, the administrator did not report it to the state agency, believing it was unnecessary due to the resident being found quickly and unharmed. Interviews with facility staff, including the Social Worker, ADON, and Administrator, revealed that the incident was not documented in the nurse's progress notes or facility incident reports. The facility's policy on elopement and reportable events requires such incidents to be reported to the state agency, but this protocol was not followed. The lack of documentation and failure to report the incident could place residents at risk for harm and injury.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. The dietary aide did not effectively wear a hairnet, leaving hair exposed on her forehead on multiple occasions. This was acknowledged by the dietary aide, who admitted to not fully covering her hair despite being trained on the importance of hair coverage to prevent contamination. Additionally, the facility did not ensure that foods stored in the refrigerator and freezer were properly labeled, dated, and not kept past their expiration dates. Observations revealed unlabeled and undated food items, including a bag of coleslaw and various frozen items, some of which were expired. The dietary manager confirmed these findings and acknowledged the importance of proper food labeling and storage to prevent spoilage and potential illness. The cook and dietary manager also failed to perform proper hand hygiene while performing kitchen duties. The cook did not wash her hands between tasks, such as handling food and using the dish machine, and the dietary manager entered the kitchen and began food preparation without washing her hands. Both staff members recognized the importance of hand hygiene and glove use in preventing the spread of germs and bacteria, yet these practices were not consistently followed.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper practices observed among staff and hospice aides. Specifically, a hospice aide did not adhere to enhanced barrier precautions while providing care to a resident with chronic wounds. Despite being aware of the requirement to wear a gown and gloves, the aide only wore gloves during the care session, which included shaving the resident. This oversight occurred despite the resident's care plan indicating the necessity for enhanced barrier precautions due to the presence of chronic wounds and a history of antibiotic-resistant bacteria. Another deficiency was observed during the provision of incontinent care to a resident by two CNAs. One CNA failed to perform hand hygiene between glove changes and improperly wiped the resident's rectal area from back to front, contrary to standard infection control practices. This CNA acknowledged the mistake during an interview, recognizing the potential risk of infection due to improper hand hygiene and wiping technique. The resident involved had severe cognitive impairment and was frequently incontinent, necessitating careful adherence to infection control protocols. Interviews with facility staff, including the ADON and DON, revealed that while in-service training on enhanced barrier precautions and incontinent care had been conducted, there were gaps in ensuring all staff, including hospice aides, were adequately trained. The facility had implemented visual reminders, such as yellow dot stickers, to identify residents requiring enhanced precautions, but these measures were not fully effective in preventing lapses in infection control practices.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as per physician orders. Resident #19, an elderly female with dementia and a urinary tract infection, was observed with oxygen tubing that had not been changed since 5/17, despite orders to change it every seven days. This oversight was noted during observations on 06/03/24 and 06/04/24, where the resident was receiving oxygen therapy at 3 liters per nasal cannula with outdated tubing. Interviews with facility staff, including an LVN and the DON, revealed that the responsibility for changing the oxygen tubing weekly fell on the night shift nurses. However, there was no monitoring system in place to ensure compliance with the physician's orders. The DON acknowledged the lack of specific training for oxygen tubing changes and emphasized the importance of following physician orders to prevent infections and ensure effective oxygen delivery. The facility's policy from 12/2017 also stated that oxygen therapy should be administered as ordered by a physician, with the entire setup replaced every seven days.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that bedrooms measured at least 80 square feet per resident in five of the 18 resident rooms reviewed for required square footage. Specifically, rooms numbered 300, 306, 308, 309, and 310 did not meet the required space per resident. This deficiency was identified through observation, interview, and record review. During an interview, the Administrator acknowledged that no structural changes had been made to the building and mentioned a previous waiver granted for these rooms. The facility's bed classification worksheet and census report confirmed that these rooms were part of the secured unit, which housed eight residents, although the specific rooms in question were not occupied at the time of the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Grove Nursing Center | 0 mi | ★★★★★ | 3 | 0 |
| Focused Care Of Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Stonecreek Nursing & Rehabilitation | 18.6 mi | ★★★★★ | 6 | 0 |
| Avir At San Augustine | 18.8 mi | ★★★★★ | 4 | 0 |
| Colonial Pines Healthcare Center | 19.1 mi | ★★★★★ | 9 | 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.