Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Cisco during CMS and state inspections, most recent first.
The facility failed to follow its abuse, neglect, exploitation, and misappropriation prevention policy by allowing a nurse aide to begin working with residents without documented completion of required pre-employment background checks, including EMR, NAR, and criminal history screenings. Review of the aide’s personnel file showed no evidence that these checks were completed before the aide’s hire or before the aide began working on the floor. In interviews, the ADMN and DON confirmed that such checks were required prior to resident access, acknowledged they were not documented for this aide, and indicated there was no clear process or monitoring in place to ensure these mandatory screenings were completed.
A resident with a colostomy, brain bleed, and kidney disease had physician orders for routine stoma and pouch care, but the comprehensive care plan contained no evidence of the colostomy or related care needs. The resident stated that facility staff provided the colostomy care, and the DON acknowledged that the colostomy and how to care for it should have been care planned.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, seven days a week, over a period of more than a year. The DON, responsible for scheduling, cited RNs' reluctance to work full shifts and a regional shortage of RNs as reasons for the deficiency. Despite these issues, the ADMN believed there was no negative impact on residents, as staff had access to an RN and the DON through sister facilities.
The facility failed to provide meals that were palatable, attractive, and at a safe temperature. Observations showed improper lid use and low food temperatures, with residents expressing dissatisfaction. Staff interviews revealed a lack of plate warmers and untimely service as contributing factors.
The facility failed to develop comprehensive care plans for three residents, neglecting to include pressure ulcers and psychotropic medications in their care plans. A resident with pressure ulcers had no related interventions in her care plan, while two residents on psychotropic medications had no corresponding care plan goals. Interviews revealed that care plans were not regularly updated, with staff relying on physician orders instead.
The facility failed to maintain an effective infection prevention and control program, as two CNAs were observed transporting unbagged soiled linens and briefs, contrary to established protocols. Despite having received training, the CNAs admitted to not following proper procedures, risking cross-contamination. The DON and ADON confirmed the expectation for all staff to bag soiled items before leaving resident rooms, as per facility policy.
A resident with cognitive impairment and muscle disorders was involved in a transfer incident where CNAs failed to lock the wheelchair during a Hoyer lift transfer. This oversight was against the facility's policy and the manufacturer's manual, which require wheelchair locks to be engaged to prevent accidents. Interviews indicated inadequate training and confusion about the policy, acknowledged by the DON.
A medication cart was found unlocked and unattended, containing various medications including narcotics, posing a risk of unauthorized access. The LVN responsible admitted the cart should have been locked, and the DON confirmed the potential for harm. Facility policy mandates carts be locked when not in use.
A facility failed to maintain complete medical records by not ensuring weekly skin assessments for a resident with multiple health issues. The admitting nurse did not follow the Admission Checklist, leading to a lack of documented assessments until July. The DON noted that while skin checks were done during daily care, they were not documented, attributing the oversight to using previous facility orders.
Failure to Complete and Document Required Pre-Employment Background Checks
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property by not ensuring required pre-employment screening was completed and documented for one nurse aide (NA-A). Record review of NA-A’s employee file showed a hire date of 01/01/2026 with no evidence that an Employee Misconduct Registry (EMR), Nurse Aide Registry (NAR), or criminal history check had been completed prior to hire or before NA-A began working on the floor on 01/02/2026. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, required the facility to conduct employee background checks and not knowingly employ individuals with findings or disciplinary actions related to abuse, neglect, exploitation, mistreatment, or misappropriation. During interviews, the Administrator (ADMN) confirmed that NA-A was hired and began working with residents without documented EMR/NAR and criminal history checks in the file and stated he could not locate these records, although he believed they had been done. The Director of Nursing (DON) stated that employees should be screened for criminal history and EMR/NAR checks before being allowed access to residents and acknowledged she did not know why these checks were not completed for NA-A before she started working. The DON also stated she did not know who monitored to ensure the mandatory checks were done. The ADMN further stated that Corporate HR was responsible for monitoring that pre-employment checks were performed but he did not know how often this monitoring occurred, and he acknowledged that the absence of these checks could allow an unemployable person to work with residents.
Missing Care Plan for Colostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #21’s colostomy care. Resident #21 was a [AGE]-year-old male admitted on [DATE] with diagnoses including colostomy, brain bleed, and kidney disease. His MDS dated [DATE] showed a BIMS score of 13, indicating no cognitive impairment, and section H confirmed that he had a colostomy. However, the comprehensive care plan initiated on 04/21/2025 contained no evidence of the colostomy or related care needs. The resident’s physician orders directed staff to clean the area around the stoma with soap and water, pat dry, apply skin prep with wafer and bag, empty the colostomy bag every shift, and provide colostomy care every shift. During observation on 08/19/25, the resident was in bed with his colostomy bag in place and stated that he did not maintain the bag himself and that facility staff provided the care. The DON stated on 08/20/2025 that she was responsible for care plans, that care plans had been transferred from the old computer system to the new one, and that the resident’s colostomy and how to care for it should have been care planned.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week, over a period from June 8, 2023, to July 14, 2024. This deficiency was identified for 100 out of 403 days reviewed. The absence of RN coverage on specific dates was confirmed through record reviews and interviews. The Director of Nursing (DON), who was responsible for scheduling RN coverage, acknowledged the lack of full shifts by RNs and attributed it to RNs not wanting to work full shifts. The DON, hired in August 2023, stated that she monitored RN coverage through the schedule she created and was available by phone if needed. The Administrator (ADMN) also confirmed the expectation of having appropriate RN coverage as required by federal guidelines. However, the ADMN cited a shortage of RNs in the area and challenges in covering shifts when staff called in or when the DON was unavailable due to surgery. Despite these challenges, the ADMN believed there was no negative impact on residents, as staff had access to an RN and the DON through sister facilities. The facility did not have a specific policy for RN coverage, relying instead on federal guidelines.
Deficiency in Meal Temperature and Quality
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. During an observation, it was noted that the kitchen staff were using lids that did not fit properly and some were cracked, which contributed to the food cooling down. A test tray was monitored from the kitchen to the last meal served, and the food temperatures were found to be below the expected levels. The pork roast was 85 degrees, stuffing was 90 degrees, green beans were 80 degrees, and the roll was soggy. Additionally, the vanilla pudding had clumps and lacked a smooth texture. Interviews with staff and residents revealed dissatisfaction with the food quality and temperature. A resident on a mechanical soft diet expressed that the food was not hot or warm and lacked taste. The Director of Nursing (DON) acknowledged the issue, attributing it to the lack of plate warmers and improperly fitting lids. The Administrator (ADM) also noted that untimely service contributed to the food being cold when served. The facility's policy on food preparation and service was reviewed, highlighting the required internal cooking temperatures for various foods, which were not met in this instance.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could potentially impact their quality of life and care. Resident #29, a female with multiple diagnoses including dementia and diabetes, was found to have pressure ulcers that were not included in her care plan. Despite documentation of wound care in her Medication Administration Record (MAR), her care plan lacked goals or interventions for these pressure ulcers. Resident #30, a male with intact cognitive status and various medical conditions, was prescribed several psychotropic medications, including antidepressants and anticonvulsants. However, his care plan did not reflect these medications, lacking any goals or interventions related to their use. This oversight indicates a disconnect between the resident's medical needs and the care plan documentation. Resident #37, a male with hemiplegia and vascular dementia, was also affected by the facility's failure to update care plans. His care plan did not address his hemiplegia, hemiparesis, or the use of medications like Aricept and Clopidogrel. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that care plans were not consistently reviewed or updated, and there was a reliance on physician orders rather than care plans to guide staff actions.
Infection Control Lapses in Handling Soiled Linens and Briefs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs who did not follow proper procedures for handling soiled linens and briefs. CNA-D was observed carrying unbagged dirty briefs through the hallway to the dirty bins, and during an interview, she admitted to not using an extra trash bag to contain the briefs, acknowledging the risk of cross-contamination. Similarly, CNA-C was seen transporting unbagged dirty resident sheets through the hallway, and she admitted to placing them on the floor outside the laundry room to obtain a bag, which she knew was incorrect. Both CNAs had received training on infection control but failed to adhere to the protocols. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that all staff were expected to bag dirty linens and briefs before leaving resident rooms to prevent cross-contamination and the spread of infection. The DON attributed the failure to staff rushing through their duties, leading to lapses in following proper procedures. The facility's policy on infection prevention and control clearly outlines the requirement for all staff to handle, store, process, and transport linens in a manner that prevents the spread of infection, including bagging soiled linens at the bedside and securing them before transport.
Failure to Lock Wheelchair During Transfer
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision during a transfer involving a resident. The incident involved a female resident with a history of hypertension, muscle disorders, and cognitive impairment, who was dependent on assistance for transfers. During a Hoyer lift transfer from bed to wheelchair, the CNAs involved did not lock the wheelchair, contrary to the facility's policy and the manufacturer's manual, which mandates that wheelchair wheel locks must be engaged before lowering a patient into the wheelchair. Interviews revealed that the CNAs were not adequately trained on the importance of locking the wheelchair during transfers, and there was confusion regarding the facility's policy on when to lock the Hoyer lift and wheelchair. The Director of Nursing acknowledged the oversight and the potential risk of injury due to the failure to lock the wheelchair during the transfer. The facility's policy and the Hoyer lift manual both emphasize the necessity of locking the wheelchair to prevent accidents during transfers.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in permanently affixed compartments, as observed during a medication storage inspection. Specifically, medication cart #1 was found unlocked and unattended in the south hallway of the facility. This cart contained various prescription and over-the-counter medications, including eye medications, stool softeners, antipsychotics, insulins, blood pressure medications, and narcotics. The incident was observed at 8:38 PM, with the Licensed Vocational Nurse (LVN-B) responsible for the cart being out of the line of sight. During an interview, LVN-B acknowledged that the cart should have been locked at all times when out of sight and admitted that there were 19 resident medications stored in the cart. The Director of Nursing (DON) also confirmed that leaving the cart unlocked could allow residents to access medications that were unsafe for them, potentially leading to harm such as overdose or allergic reactions. The facility's policy, dated April 2007, clearly states that medication carts must be locked when not in use or out of the nurse's view, indicating a failure to adhere to established protocols.
Failure to Document Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically by not ensuring that weekly skin assessments were ordered and documented. The resident, a female with multiple diagnoses including unspecified dementia, repeated falls, depression, hypertension, heart failure, type II diabetes mellitus with diabetic nephropathy, and pain disorder, was admitted without the necessary orders for weekly skin assessments. This oversight was identified during a review of the resident's Medication Administration Records (MAR) for May, June, and July 2024, which showed no evidence of skin assessments being completed until July 3, 2024. Interviews with facility staff revealed that the admitting nurse failed to follow the facility's Admission Checklist, which should have included adding orders for weekly skin assessments. The Director of Nursing (DON) acknowledged that the expectation was for skin assessments to be completed weekly from the time of admission. However, the DON believed there was no negative effect on the resident because staff were performing daily foot soaks and showers, which involved observing the resident's skin, albeit without documentation. The failure to document these assessments was attributed to the use of orders from the previous facility rather than following the facility's established procedures.
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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 Cisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Woodlands | 8.5 mi | ★★★★★ | 15 | 0 |
| Premier Health Care Center | 19.1 mi | ★★★★★ | 3 | 1 |
| Rising Star Nursing Center | 19.7 mi | ★★★★★ | 4 | 0 |
| Homestead Nursing And Rehabilitation Of Baird | 23.4 mi | ★★★★★ | 3 | 0 |
| Villa Haven Health And Rehabilitation Center | 26.8 mi | ★★★★★ | 8 | 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.