Above 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 Orem during CMS and state inspections, most recent first.
A resident with diagnoses including Major Depressive Disorder, ESRD, diabetes, and a stroke history had a positive PL1 indicating MI. The MDS nurse completed the PL1 but did not submit it to the Simple LTC Portal because the facility did not have an NPI number after a CHOW, so a PL2 was not completed. The DON stated she knew little about PASARR, and the facility policy required PL1 entry into the portal and notification to LIDDA for positive PL1s.
A resident with a history of atrial fibrillation, hypertension, and a pacemaker was given Metoprolol on multiple occasions despite blood pressure readings below the physician-ordered hold parameter. Medication aides and facility records confirmed the medication was administered outside of prescribed guidelines, contrary to facility policy and physician orders.
A resident who was dependent on staff for all care and incontinent of bowel and bladder received improper incontinent care when a CNA failed to change gloves, perform hand hygiene, and use clean wipes between cleaning different areas. The CNA used a single wipe for multiple areas and did not follow the correct order of care, contrary to facility policy and infection control standards. Staff interviews confirmed the lapse in protocol and the associated risk of infection.
A resident with multiple health conditions and on anticoagulant therapy developed a significant bruise of unknown origin. A CNA observed the bruise and reported it to a nurse, but the Administrator and DON were not notified as required, resulting in delayed investigation and family notification. Staff interviews revealed confusion about proper reporting protocols.
A resident who was dependent on staff for personal care and incontinence management did not receive timely incontinence care over a five-hour period. Staff interviews revealed confusion over assignment responsibilities, resulting in the resident not being checked or changed as required by facility policy and care plan. The deficiency was confirmed through observation, interviews, and record review.
A facility failed to implement a comprehensive care plan for a resident with an unstageable DTI on the right heel. The Wound Care Nurse documented treatment but did not provide it as ordered, leading to a deficiency. The DON emphasized the importance of following physician orders and using computer orders for accuracy.
A resident with a stage 4 pressure ulcer was at risk for infection due to lapses in infection control by the Wound Care Nurse and Wound Care Doctor. The nurse failed to perform hand hygiene between glove changes, and the doctor left the resident's wounds uncovered with soiled dressings improperly disposed of. The resident, with a history of pressure ulcers and impaired cognition, required substantial assistance for personal care. These actions were contrary to the facility's infection control policies, which emphasize hand hygiene as a primary means to prevent infection spread.
A facility failed to provide a resident's medical records to their legal representative despite a request made over a year prior. The resident, who had severe cognitive impairment and multiple health conditions, had their records requested by their family member in October 2023. Interviews revealed that the facility's process for handling such requests was not followed, as the records were not provided within the required timeframe.
A resident with severe cognitive impairment and multiple medical conditions was not provided with adequate incontinence care, leading to poor hygiene and potential skin breakdown. Despite being checked every two hours, the resident was found in a wet state, indicating a lapse in care. The facility's policy on providing appropriate care for residents unable to perform ADLs independently was not effectively implemented.
Failure to Complete PASARR Level II Review for Resident with Positive PL1
Penalty
Summary
The facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review after a significant change in status assessment for one resident. Resident #2 had diagnoses that included cerebral infarction, ESRD, Type 2 diabetes mellitus, and Major Depressive Disorder, and the quarterly MDS showed a BIMS score of 15, indicating intact cognition. The care plan also included a focus, initiated on 5/2/2026 and revised on 5/4/2026, stating the resident had a history of trauma related to PTSD from the Army and a potential for increased behaviors. Record review of the resident’s PASARR Level 1 Screening, dated 8/1/2025, showed a yes response in Section C 0100, indicating evidence or an indicator of mental illness. During interview, the MDS Nurse stated he completed the PL1 because the resident had Major Depressive Disorder, which he identified as a qualifying condition for mental illness. He stated he was not aware of a PTSD diagnosis in the record and was unclear why PTSD was listed in the care plan. He also stated he was unable to submit the PL1 to the Simple LTC Portal because the facility did not have an NPI number after the CHOW. The DON stated she was not responsible for PASARR screenings and knew very little about PASARR regulations. The Administrator stated the MDS Nurse was responsible for PASARR-related issues, and the facility ownership changed in August 2025 while the CHOW was still pending through the State. The facility policy stated the MDS Coordinator or designee would input all PL1s into the online portal on admission and, for a positive PL1 indicating possible ID/DD or MI, notify LIDDA within 2 calendar days and initiate the PE process.
Significant Medication Error: Blood Pressure Medication Administered Outside Physician Parameters
Penalty
Summary
A deficiency occurred when a male resident with a history of atrial fibrillation, hypertension, and a cardiac pacemaker did not receive his blood pressure medication, Metoprolol, as ordered by the physician. The physician's order specified that Metoprolol 12.5 mg should be administered twice daily by mouth, but to hold the medication if the resident's systolic blood pressure (SBP) was less than 100. Despite this, the medication was administered on six occasions in March when the resident's SBP was below the ordered threshold, with documented readings as low as 88/61. Medication administration records (MAR) and staff interviews confirmed that the medication was given outside of the prescribed parameters. Medication aides involved acknowledged that the medication should not have been administered when the SBP was below 100, and one aide stated it may have been a documentation error. The facility's policy required medications to be administered as prescribed, including adherence to any hold parameters, but this was not followed in these instances. Interviews with the facility's pharmacist, nurse practitioner, and nursing leadership confirmed that the physician's hold order was intended to prevent the resident's blood pressure from dropping too low. The staff involved were aware of the order and the associated risks, and the facility had processes in place for medication administration and monitoring, but these were not effectively implemented, resulting in the resident receiving medication outside of the physician's parameters.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident. During an observed episode of care, a CNA did not follow established protocols for glove changes, hand hygiene, and the use of clean wipes. Specifically, the CNA used a single wipe to clean multiple areas, including the resident's buttocks, anal area, groin, and penis, without changing gloves or performing hand hygiene between tasks. The care was also performed in the incorrect order, starting from the back rather than the front. The resident involved was a male with significant medical conditions, including hemiplegia, diabetes mellitus, nontraumatic intracerebral hemorrhage, epilepsy, and cerebrovascular disease. He was nonverbal, dependent on staff for all activities of daily living, and always incontinent of bowel and bladder. His care plan required cleaning the perineum with each incontinent episode to prevent skin breakdown, and he had an order for zinc oxide ointment to be applied to the scrotum twice daily. Interviews with the CNA, another staff member, and the DON confirmed that the correct procedures were not followed. The CNA acknowledged not changing wipes, gloves, or performing hand hygiene, attributing the lapse to nervousness and not thinking clearly. The DON and another CNA both recognized the risk of infection due to these lapses and confirmed that the facility's policies required discarding wipes after each use, changing gloves, and performing hand hygiene between tasks.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the Administrator and other required authorities as per regulatory requirements. Specifically, a certified nursing assistant (CNA) observed a bruise of unknown origin on a resident's right arm but did not immediately notify the Administrator. Instead, the CNA reported the finding to a charge nurse, but it is unclear if the charge nurse received the information, and the Administrator was not informed until several days later. The resident involved was an elderly woman with multiple medical conditions, including visual loss, osteoarthritis, anxiety disorder, muscle wasting, lack of coordination, hypertension, and was on long-term anticoagulant therapy. Her care plan included daily skin inspections and prompt reporting of abnormalities to nursing staff. Despite these interventions, a significant bruise was noted by both staff and a family member, but the required notifications and assessments were delayed. The family member also reported not being contacted by the facility after raising concerns about the bruise, and the Director of Nursing (DON) was unaware of the incident until contacted by the family. Interviews with staff revealed confusion and lack of clarity regarding the reporting protocol. The CNA believed he had fulfilled his duty by informing the charge nurse, while the charge nurse denied receiving the report. The DON and Administrator confirmed that the expected protocol was not followed, resulting in a delay in the investigation and notification process for an injury of unknown origin.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living, including incontinence care, did not receive timely personal hygiene assistance. The resident, a cognitively intact male with paraplegia, flaccid hemiplegia, and muscle atrophy, was not provided with incontinence care from 6:30 a.m. to 11:30 a.m. on the specified date. The resident reported not having a diaper change during this period, and staff interviews confirmed that he had not been changed since the start of the shift. The resident's care plan required regular checks for incontinence and assistance with toileting, but these interventions were not carried out as scheduled. Staff interviews revealed confusion regarding assignment responsibilities, with one CNA stating that another CNA was assigned to the resident and vice versa. Both the ADON and DON confirmed that the facility's expectation was for incontinent residents to be checked every two hours. The facility's policy also required management of incontinence in accordance with clinical guidelines. The failure to provide timely incontinence care was directly observed and confirmed through interviews and record review.
Failure to Implement Comprehensive Care Plan for Resident's Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in a deficiency. The resident, a female with a history of pressure ulcers, heart failure, and peripheral vascular disease, was admitted to the facility with an unstageable deep tissue injury (DTI) on her right heel. The care plan for this resident included specific treatment orders from the physician to cleanse the wound and apply Skin Prep three times a week. However, the Wound Care Nurse documented administering the treatment on a specific date but failed to actually provide the treatment as ordered. This oversight was discovered during an observation and interview, where the nurse admitted to forgetting to apply the Skin Prep, despite signing off on the treatment. The deficiency was further highlighted during an interview with the Director of Nursing (DON), who emphasized the importance of following physician orders to promote wound healing. The DON stated that treatments should be administered by referencing computer orders rather than relying on memory, and that it is crucial to sign off on each order only after the treatment has been completed. The facility's Wound Care policy, which was revised in October 2010, outlines the procedure for wound care to promote healing, but the failure to adhere to this policy and the physician's orders resulted in a deficiency in the resident's care plan.
Infection Control Lapses in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the Wound Care Nurse and the Wound Care Doctor during the treatment of a resident with a stage 4 pressure ulcer. The Wound Care Nurse did not perform hand hygiene after removing soiled gloves and before applying new ones while providing wound care. This lapse in protocol occurred despite the nurse having received recent in-service training on infection control. Additionally, the Wound Care Doctor left the resident's wounds uncovered after evaluation, and soiled dressings were improperly disposed of on the resident's bed. The resident involved was an elderly female with a history of pressure ulcers, heart failure, and peripheral vascular disease. She was admitted to the facility with a stage 4 pressure ulcer on her right ankle and required substantial assistance for personal care due to moderately impaired cognition. The resident was also incontinent of bowel and had an indwelling catheter, increasing her risk for infection. Observations revealed that the Wound Care Nurse gathered supplies from the treatment cart and entered the resident's room without ensuring proper hand hygiene between glove changes. The Director of Nursing acknowledged that the nurse should have sanitized her hands after touching a dirty area before moving to a clean area. The facility's infection control policies emphasize hand hygiene as a primary means to prevent infection spread, yet these protocols were not followed, placing residents at risk for infection.
Failure to Provide Medical Records to Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's legal representative had access to and could obtain copies of the resident's medical records upon request. The responsible party for a resident, who had been admitted with conditions including type 2 diabetes mellitus, hypertension, and bed confinement, submitted a request for the resident's medical records on October 6, 2023. However, as of November 19, 2024, the facility had not provided the requested records. This failure was identified during an interview with the resident's family member, who confirmed that the request had been made but not fulfilled. Interviews with facility staff revealed a breakdown in the process for handling medical record requests. The medical records staff, who began their role in May 2024, stated that requests were sent to the corporate office for approval before being processed. The administrator acknowledged the request but was unable to confirm if the records had been mailed, as the resident's binder could not be located. The facility's policy required that such requests be fulfilled within 24 hours, excluding weekends and holidays, but this was not adhered to in this case.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. The resident, a male with severe cognitive impairment and multiple medical conditions including cerebral infarction, atrial fibrillation, acute kidney failure, and vascular dementia, was frequently incontinent and required partial to moderate assistance with toileting hygiene and transfers. Despite these needs, the facility did not ensure that the resident's adult brief was checked and changed as needed, leading to poor hygiene and potential skin breakdown. Observations revealed that the resident's room had a strong urine odor, and he was found sitting in his wheelchair, wiping his wet bed sheets with paper towels. Interviews with the staff, including CNAs and the RNA, indicated that the resident was checked every two hours, but there was a lack of consistent care to ensure he remained clean and dry. The CNAs responsible for the resident's care claimed to have checked on him, but the resident was still found in a wet state, suggesting a lapse in the care routine. The Director of Nursing and the Administrator were aware of the situation and expressed expectations that residents should be kept clean and dry. However, the report highlights that the facility's policy on providing appropriate care and services for residents unable to carry out ADLs independently was not effectively implemented, as evidenced by the resident's condition and the staff's inconsistent adherence to care protocols.
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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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At Westbury | 3 mi | ★★★★★ | 18 | 1 |
| Terra Bella Health And Wellness Suites | 3.2 mi | ★★★★★ | 16 | 2 |
| The Colonnades At Reflection Bay | 3.9 mi | ★★★★★ | 21 | 3 |
| Bayou Manor | 4.2 mi | ★★★★★ | 4 | 0 |
| Holly Hall | 4.3 mi | ★★★★★ | 15 | 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.