Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At San Angelo during CMS and state inspections, most recent first.
PASRR screening was not accurately completed for a resident admitted with schizophrenia, depression, anxiety, and dementia. The resident had a positive PL1 for MI, but the MDS Coordinator did not ensure a corrected screening was sent to the local authority for a Level II review. The DON and Administrator stated PASRR accuracy and follow-through were the MDS Coordinator's responsibility, and facility policy required notification of the LIDDA within 2 calendar days when a PL1 indicated possible MI or ID/DD.
A resident with severe cognitive impairment and diagnoses including dementia had a bed alarm ordered and care planned, but surveyors observed the alarm unplugged while he was in bed on multiple occasions. The DON said staff unplugged it when getting him up and forgot to reconnect it, and the Administrator said the resident was supposed to have the alarm per the care plan and MD orders. Surveyors also found sharps containers in nine rooms filled to or above the full line, with one container showing needles and gloves sticking out; the DON and Administrator said nurses were responsible for replacing full containers.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies: Surveyors observed multiple kitchen sanitation and food storage problems, including opened or unlabeled dry goods, refrigerated and frozen foods that were not properly sealed or dated, uncovered clean dishes and utensils, a staff member’s personal drink stored in a food refrigerator, and an LDM without a beard cover. The dietary manager also rinsed a blender between pureeing different foods instead of washing it, creating a cross-contamination concern. Facility policy required hair restraints, proper labeling and dating, and discarding leftovers within 72 hours.
Improper Garbage Disposal: The facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed. An outside roll off dumpster was observed without a lid, with trash piled above the rim. The Administrator stated there was no garbage disposal policy, staff had been told not to use the dumpster, and he had contacted city offices to have it hauled off.
A resident with PTSD did not have a trauma-informed assessment completed on admission, and the care plan did not identify trauma history or triggers. The resident had intact cognition, clear speech, and no behaviors or refusal of care noted, while the Social Services Director acknowledged the required screening had not been done and the DON and Administrator confirmed the assessment responsibility rested with social services staff.
Incomplete Care Plans for ADL Dependence and Hospice Services: A resident with multiple myeloma, depression, Parkinsonism, cognitive impairment, full ADL dependence, incontinence, and a mechanically altered diet had a care plan that did not clearly address ADL dependence or psychosocial needs. Another resident with Parkinson’s disease and CKD was receiving hospice care per the MDS and hospice order, but hospice was not included in the care plan. The DON, MDS Coordinator, and Administrator all acknowledged the missing care plan information.
Medication Error Rate Exceeded 5% During PEG Medication Administration: The facility had a 7.14% medication error rate after an LPN did not fully administer crushed meds to a resident via PEG tube. The LPN crushed Carvedilol and Lisinopril, but left medication residue in the cups and did not add more water to obtain the remaining dose. The DON observed the residual medication and stated the nurse should have attempted to get more of the medication from the cups.
Unlocked Medication Cart Left Unattended: A hall 2 med cart was observed unlocked and unsupervised with OTC meds in the top drawer and prescribed meds in other drawers. MA C said she used the cart that day and believed she had locked it, while the DON and Administrator stated carts are expected to be locked when unattended. The facility policy also states meds and biologicals must be stored in locked compartments and carts are not to be left unattended if open or otherwise accessible.
Infection control was deficient when a CNA did not change contaminated gloves during incontinent care for a resident who was always incontinent and had dementia and unsteadiness on feet. After cleaning the resident's soiled peri-area and rectal area, the CNA used the same gloves to apply a clean brief before removing them. The CNA said she should have changed gloves, and the DON stated staff were expected to change gloves and sanitize hands when moving from dirty to clean.
A resident with a recent below-knee amputation, DM2, malnutrition, and multiple lower-extremity wounds (surgical site, unstageable heel pressure ulcer, venous calf ulcer, and arterial toe ulcer) was admitted from another facility with existing wound treatment orders, but the receiving facility failed to obtain and enter those wound care orders into the EHR on admission. The care plan identified wound management needs and called for wound care per treatment orders, yet no wound care orders appeared in the record for several days, until a wound care NP assessed the wounds and wrote new orders. Facility leadership and clinical staff, including the ADON, DON, NP, wound care NP, and Regional Nurse Consultant, acknowledged that admission orders should have been carried over or obtained from the MD at admission and that the admitting/charge nurse was responsible for this process, in contrast to the facility’s wound care policy requiring verified physician orders and documentation for wound treatments.
Three residents with complex medical and behavioral needs did not have comprehensive, person-centered care plans addressing all required areas such as dialysis, diabetic care, mental health, wound care, pain management, ADL assistance, and vaccination status. Staff interviews revealed that care plans were incomplete due to recent turnover and lack of consistent processes.
Two residents at high risk for falls did not receive care planned anti-slip devices—one lacked anti-slip strips in her room and another did not have an anti-slip sheet in his wheelchair. Both deficiencies were confirmed by observation and DON interview, showing the facility did not follow its own fall prevention protocols.
A resident with severe cognitive impairment and hearing loss did not receive an audiologist appointment despite a request from her Responsible Party. The facility's Social Worker forgot to arrange the appointment, leading to the resident feeling ignored and not treated as a human. Staff relied on speaking loudly to communicate, but no communication tools were used, and the resident's hearing aids were found dirty and with dead batteries.
A facility failed to arrange an audiologist appointment for a resident with hearing loss, despite a request from the resident's Responsible Party. The resident, who had severe cognitive impairment, experienced communication difficulties and feelings of isolation due to the staff's lack of alternative communication methods. The Social Worker admitted to forgetting to contact the audiologist, and the facility's policies on social services and accommodation of needs were not upheld.
The facility failed to maintain a stove burner in the kitchen, which did not ignite automatically and had been non-functional for at least two years. The Dietary Manager attempted to light it manually, but it failed to ignite, with gas escaping and a buildup of grease observed. The issue was not reported to Maintenance, and the Administrator was unaware of the problem. The malfunction posed risks of foodborne illnesses and potential injuries.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper glove use and hand hygiene during resident care. A CNA did not change gloves after contamination during incontinent care for a resident, while another CNA improperly used double gloves. An RN failed to follow proper hand hygiene and glove use protocols during wound care, leading to potential cross-contamination. These actions were not in line with the facility's infection control policy.
A resident was moved to another room after an incident with a roommate, but the guardian was not informed of the specific reason for the change. The resident, with severe cognitive impairment and a complex medical history, was dependent on staff for care. The facility failed to ensure the guardian was aware of the roommate's inappropriate behavior, leading to a deficiency in resident rights.
A resident with severe cognitive impairment was subjected to abuse by another resident who poured water on him. The incident was reported by a CNA, but another CNA suspected multiple occurrences and failed to report them immediately. The facility's policy requires immediate reporting of abuse, but the delay in addressing the issue led to a deficiency in resident protection.
A resident with severe cognitive impairment was reportedly abused by a roommate who sprinkled water on him. A CNA failed to report her suspicions immediately, violating the facility's policy on abuse and neglect. The incident was eventually reported by another CNA, leading to an investigation and the discharge of the abusive roommate.
PASRR Screening Not Updated for Resident With Schizophrenia
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not accurately completed for one resident who was admitted with diagnoses including schizophrenia, depression, anxiety, and unspecified dementia. The resident's quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and the record review showed a PASRR Level I screening completed by the referring hospital on 7/26/2023 that indicated mental illness. The resident stated she had not received services through PASRR before. During interviews, the MDS Coordinator stated the resident had a mental illness diagnosis and that the PASRR screening was positive, but a corrected screening should have been completed and sent to the local authority for evaluation. She stated the resident was admitted with schizophrenia and that she needed to complete a form to notify the Local Authority of the diagnosis. The DON and Administrator stated PASRR accuracy and follow-through were the MDS Coordinator's responsibility, and the facility policy stated that when a PL1 indicates possible MI or ID/DD, the MDS Coordinator will notify the LIDDA within 2 calendar days of admission and initiate the PASRR evaluation process.
Unplugged bed alarm and overfilled sharps containers
Penalty
Summary
The facility failed to keep the resident environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for one resident with severe cognitive impairment and for sharps containers in multiple rooms. Resident #11 was a male with diagnoses including unspecified dementia, senile degeneration of the brain, and anxiety disorder. His quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, and he was dependent on staff for transfers and changing positions from sitting to standing. His care plan and physician’s orders included use of a bed and chair alarm, with checks for placement and functionality twice daily. During observations, Resident #11 was found lying in bed with his eyes closed while his bed alarm was not plugged into the box that would sound. This was observed more than once over the course of the survey. The DON stated staff unplugged the alarm when getting him up and forgot to plug it back in, and identified nurses and CNAs as responsible for ensuring alarm functionality. The Administrator stated the resident was to have a bed alarm as indicated in the care plan and physician’s orders, and that not having the alarm could result in a fall and staff not knowing the resident was not in bed. The Administrator also stated there was no policy for bed alarms because he did not agree with having them in the facility. The survey also found sharps containers in nine rooms filled to or above the full line, with one container containing needles and gloves sticking out of the top. The DON stated all nurses were responsible for changing full sharps containers, and an LVN stated she would change a full container if she had the key, but did not have keys for the sharps containers in resident rooms. The Administrator stated changing full sharps containers was a nurse function and that the deficiency could cause preventable injuries to staff, residents, and visitors. The facility’s Sharps Disposal Policy stated designated individuals were responsible for sealing and replacing containers when they were 75% to 80% full.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During the initial kitchen tour, surveyors observed multiple food storage and sanitation issues, including stored foods that were not properly labeled, dated, covered, or sealed. Examples included opened items in the milk refrigerator, dry storage items such as pasta, powdered sugar, cereal, flour, corn meal, and dry milk that were unlabeled, undated, or stored in open containers or bags, and refrigerated and frozen foods that were not sealed or were dated beyond the facility’s stated requirements. Clean dishes, muffin pans, baking sheets, and cooking utensils were also observed uncovered or faced up in the kitchen areas. Surveyors also observed a personal beverage stored in the milk refrigerator, and the dietary manager stated that the tea belonged to a staff member and that staff were aware personal items were not allowed in that refrigerator. The dietary manager was observed without a beard cover while in the kitchen. During the follow-up kitchen visit, the dietary manager did not wash the blender after pureeing carrots and instead rinsed it with water before using it to puree chicken and broccoli rice casserole. The report states this created a concern for cross-contamination during food preparation. The facility’s policies required hair restraints, proper labeling and dating of dry, refrigerated, and frozen foods, and discarding leftovers within 72 hours. The dietary manager stated his expectations for labeling included the received date, open date, and use-by date, and said staff had been trained in labeling, personal food items, and storage of food items. The administrator stated the dietary manager was responsible for kitchen operations and that conditions had improved over the prior 6 months.
Improper Garbage Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed in the environment. During observation on 05/05/2026 at 10:15 AM, the garbage area outside showed a large rectangle roll off dumpster without a lid, with bags of trash piled higher than the rim. During an interview on 05/07/2026 at 4:12 PM, the Administrator stated the facility did not have a garbage disposal policy, was aware of the roll off dumpster, and had instructed staff not to use it. He also stated he had emailed city offices to have it hauled off and acknowledged that using it for regular daily trash could cause pests and allow trash to be scattered by the wind and/or pests.
Missing Trauma Screening for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD received trauma-informed care that included a completed trauma screening on admission and identification of possible triggers. Resident #8 was a female resident with an active PTSD diagnosis, intact cognition with a BIMS score of 14, clear speech, and no behaviors or refusal of care noted on the MDS. The comprehensive care plan, revised 10/9/2025, noted a history of hallucinations and delusions related to PTSD and a goal for the resident not to experience distress from these symptoms, but it did not identify any triggers or trauma history. Record review showed no assessment completed to identify the resident’s trauma or triggers that could lead to re-traumatization. During interview, the Social Services Director stated she was responsible for completing the initial trauma-informed assessments on admission and acknowledged that the Trauma Informed Assessment had not been completed for Resident #8. She stated there was no trauma screening completed on admission that she was aware of and explained that identifying triggers was important to prevent aggravation, frustration, or other behaviors. The DON and Administrator stated the Social Worker was responsible for the trauma-informed care assessments and that the Social Services Director was responsible for the initial social history assessment, including trauma screening questions.
Incomplete Care Plans for ADL Dependence and Hospice Services
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and time frames for 2 residents. For Resident #23, the record showed admission on 2/17/2026 with diagnoses including multiple myeloma, depression, Parkinsonism, collapsed vertebra, constipation, muscle weakness, acute cough, and abnormal weight loss. The MDS documented moderate cognitive impairment with a BIMS score of 8, full dependence on staff for bathing, toileting hygiene, eating, and personal hygiene, use of a manual wheelchair, urinary incontinence, occasional bowel incontinence, and a mechanically altered diet. However, the most up-to-date care plan only had two focus sections and did not specify whether the resident was independent or fully dependent for ADLs; the only care planning decision listed was interventions/tasks for ADLs. For Resident #23, the care plan did not comprehensively address the resident’s ADL dependence or psychosocial needs. During interview, the resident said she had been at the facility for about two or three weeks and had lived there in the past. The MDS Coordinator stated the care plans were "a mess" when she started, that the facility had been trying to address the issue through QAPI, and that a care plan should include "just about everything," including Section B concerns, code status, higher-risk medications, and individualized information that would identify the resident’s needs. The DON stated care plans should include as much as possible with IDT input and that missing care and needs information could mean the resident missed services that could have benefited her. For Resident #42, the record showed diagnoses of Parkinson’s disease and chronic kidney disease, and an order dated 03/26/2026 to admit the resident to hospice services for Parkinson’s disease with dyskinesia. The MDS indicated hospice care was being received, but the comprehensive care plan dated 04/15/2026 did not include hospice care. The DON stated the MDS Coordinator was responsible for including hospice in the care plan, while the MDS Coordinator said she was not aware the resident was receiving hospice care and acknowledged hospice should have been included. The Administrator stated hospice care should have been care planned and that care plans were part of nursing services.
Medication Error Rate Exceeded 5% During PEG Medication Administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with a documented error rate of 7.14% based on 2 errors in 28 opportunities involving one LVN and one resident reviewed during medication pass observation. Resident #3 was admitted with diagnoses including stroke and essential hypertension, and had physician orders for Lisinopril 40 mg via PEG tube daily and Carvedilol 25 mg via PEG tube twice daily. During observation, the LVN prepared the crushed medications on the medication cart, then administered them via the resident’s PEG tube. After pouring the crushed Carvedilol and Lisinopril into separate medicine cups and giving them through the PEG tube with water, residual medication remained in the cups. When questioned, the LVN stated she did not add more water to try to obtain the remaining medication because she had previously been cited at another facility for giving too much water to a resident. The DON later observed the residual medication and stated the nurse should have attempted to get more of the medication from the cups, and the Administrator was informed that the medication error rate was 7.14% due to the LVN not fully administering the crushed medications.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments when a hall 2 medication cart was observed unlocked and unsupervised on 05/05/2026 at 9:14 AM. During the observation, the DON was notified and the cart was inspected with the DON present. The top drawer contained several over-the-counter medication bottles, and other drawers contained blister packs with several prescribed medications. The DON stated that staff were expected to lock medication carts whenever they left them unattended. During interview, MA C stated that the hall 2 medication cart was the cart she had used that day and that she believed she had locked it when she stepped away. MA C also stated she was the only person with keys for that cart and acknowledged that if the cart was left unlocked and unattended, medications could be robbed and residents could access the medications. Later interviews with the DON and Administrator confirmed that medication carts were expected to be locked when left unattended, and the facility policy stated that medications and biologicals are stored in locked compartments and that carts are not left unattended if open or otherwise potentially available to others.
Infection Control Glove Change Failure During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when CNA A did not change contaminated gloves during incontinent care for a resident admitted with diagnoses of dementia and unsteadiness on feet. The resident's record showed he was always incontinent of urine and bowel, and his care plan directed staff to clean the peri-area with each incontinence episode and keep him free from skin breakdown due to incontinence and brief use. During observation, CNA B and CNA A performed incontinent care together. After washing hands and putting on new gloves, CNA A removed the resident's brief, cleaned the penis and scrotum, and then cleaned the rectal area after the resident had a bowel movement. While still wearing the same gloves, CNA A then took a clean brief and fastened it on the resident before removing her gloves. CNA A stated she should have changed her gloves after they became contaminated, and the DON and Administrator stated staff were expected to change gloves and sanitize hands when going from dirty to clean.
Failure to Obtain and Transcribe Admission Wound Care Orders for Resident With Multiple Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter wound care treatment orders upon admission for a resident with multiple existing wounds, contrary to professional standards and the facility’s own wound care policy. The resident, an older male admitted from another nursing facility, had documented diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes mellitus, and unspecified protein-calorie malnutrition. Discharge records from the sending facility showed active treatment orders for a left below-knee amputation surgical site, an unstageable pressure ulcer on the right heel, a venous ulcer on the right calf, and an arterial ulcer on the right great toe at the time of transfer. On admission, the resident’s care plan identified a wound management problem with a goal for wounds to remain free from infection and an intervention to provide wound care per treatment orders. However, review of the electronic health record for January showed no wound care orders entered, and wound treatment orders did not appear in the record until several days later in February, when a wound care NP assessed the resident and wrote new orders. The wound care NP documented that all wounds were present on admission and that she could tell wound care was being performed based on the condition of the dressings, but there were no corresponding physician orders in the record prior to her assessment. Interviews with facility staff confirmed that admission orders from the discharging facility should have been carried over and entered into the electronic health record on the day of admission. The ADON, DON, NP, wound care NP, and Regional Nurse Consultant each stated that wound care orders should have been obtained or transcribed at admission and that it was the admitting or charge nurse’s responsibility, with oversight by the DON. The facility’s wound care policy required verification of a physician’s order before providing wound care and documentation of wound care in the medical record. Despite this, the resident’s wound care orders were not entered into the electronic health record until several days after admission, resulting in a period during which wound care was being provided without documented physician orders in place.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required. For one resident, the care plan did not address critical needs such as dialysis (including shunt monitoring and care), diabetic care (including blood sugar checks, dietary restrictions, and insulin needs), glaucoma, seizure management, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. This resident had multiple diagnoses including dialysis dependence, epilepsy, diabetes, depression, glaucoma, and heart failure, and was receiving a complex medication regimen and therapies, yet the care plan only included code status, allergy, and personal care/activity preferences. Another resident, with a history of stroke, dementia with behaviors, malnutrition, hypothyroidism, and on hospice care, also lacked a comprehensive care plan. The care plan did not address the resident's mental health and behavioral issues, pain management, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin integrity, incontinence, or vaccination status. This resident had severe cognitive impairment, was at risk for pressure sores, had a catheter, and required substantial assistance with ADLs, but the care plan only included code status, allergies, personalized care preferences, and a fall prevention plan. A third resident, with multiple chronic conditions including stroke, diabetes, depression, kidney disease, hypertension, and vision impairment, also did not have a care plan addressing code status, mental and behavioral needs, kidney disease, pain, dietary or fluid restrictions, low thyroid, hypertension, diabetic care, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. Interviews with facility staff revealed that there had been significant turnover in management and MDS coordinators, resulting in incomplete and outdated care plans. Staff acknowledged that care plans were lacking and that the process for developing and updating them had not been consistently followed.
Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision and assistive devices as care planned for two residents. For one resident with dementia, diabetes, and a history of falls, the care plan required anti-slip strips to be placed in front of her recliner and dresser/shelving due to her poor balance, impaired mobility, and previous falls. However, observation revealed that these anti-slip strips were not present in her room. The resident had recently sustained a significant head injury from a fall, and both the DON and the resident confirmed the absence of the required anti-slip strips. The DON acknowledged that the facility was not following the care plan for this resident. Another resident, who was severely cognitively impaired, had a history of falls and required staff assistance for transfers. His care plan included the use of an anti-slip device (sheet) in his wheelchair to aid in positioning and prevent falls. Observation and interview with the DON confirmed that the anti-slip sheet was not present in the resident's wheelchair, despite being a documented intervention in his care plan. The DON stated that if an intervention was on the care plan, it should have been implemented. The facility's own policy on fall prevention required staff to implement and monitor interventions identified in the care plan to reduce the risk of falls and accident hazards. In both cases, the facility did not follow through with the care planned interventions intended to prevent accidents, as evidenced by the absence of anti-slip devices for both residents who were at high risk for falls.
Failure to Assist Resident with Audiology Appointment
Penalty
Summary
The facility failed to assist a resident in making an appointment with an audiologist, despite a request from the resident's Responsible Party. The request was made on 8/20/24, but the Social Worker admitted to forgetting to reach out to the audiologist. This oversight resulted in the resident not receiving the necessary audiological care, which was ordered as needed since 5/24/24. The resident, who has severe cognitive impairment and hearing loss, expressed feelings of being ignored and not treated as a human, highlighting the impact of the facility's inaction on her quality of life. The resident's care plan identified a communication problem related to her hearing deficit, with interventions including referring to audiology for a hearing consult as ordered. However, interviews with staff revealed that no communication tools were used with the resident, despite her difficulty hearing. Staff members relied on speaking loudly and getting close to the resident to communicate, but this was not always effective. The resident's hearing aids were found to be dirty and in need of battery replacement, further indicating a lack of attention to her hearing needs. The facility's policies on social services and accommodation of needs emphasize assisting residents in maintaining or improving their abilities to manage their everyday needs. However, the failure to arrange the audiologist appointment and the lack of effective communication strategies demonstrate a deficiency in meeting these policies. The resident's Responsible Party expressed concern about the resident's depression and social isolation due to her hearing issues, underscoring the importance of addressing these needs promptly.
Failure to Arrange Audiologist Appointment for Resident with Hearing Loss
Penalty
Summary
The facility failed to assist a resident in making an appointment with an audiologist, despite a request from the resident's Responsible Party. This oversight occurred after the Responsible Party asked the Social Worker on 8/20/24 to arrange an audiologist appointment for the resident, who had a diagnosis of hearing loss and wore hearing aids. The resident's care plan included a referral to audiology for a hearing consult as ordered, but the Social Worker admitted to forgetting to reach out to the audiologist. As a result, the resident experienced difficulty in communication, which was exacerbated by the staff's lack of alternative communication methods, such as using a notebook or dry erase board. The resident, who had severe cognitive impairment with a BIMS score of 5 out of 15, expressed feelings of being ignored and unimportant due to the staff's failure to communicate effectively. The resident reported that staff frequently entered her room without explaining their actions, leading to feelings of social isolation and depression. The Social Worker acknowledged the resident's moderate cognitive impairment and the need to communicate closely on the resident's right side but had not explored other communication tools. The facility's policies on social services and accommodation of needs emphasize assisting residents in maintaining their physical, mental, and psychosocial well-being, which was not upheld in this case.
Non-Functional Stove Burner in Kitchen
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically in the kitchen where one of the six stove top burners did not ignite automatically. During an observation and interview, it was noted that the burner had not been functional for a significant period, with the Dietary Manager (DM) acknowledging that it had been non-functional for at least two years. The DM attempted to light the burner manually, but it failed to ignite, and there was a noticeable smell and sound of gas escaping. The burner was observed to have a buildup of grease and debris, which may have contributed to its malfunction. The DM admitted to not reporting the issue to the Maintenance department. Further inspection revealed that the burner remained non-functional despite attempts to clean it. The DM mentioned that a service repair person was scheduled to address the issue. The Administrator, who had been at the facility for two months, was unaware of the problem until informed during the survey. The DM expressed concerns about the potential for an explosion or injury due to the malfunctioning burner. The failure to maintain the stove in proper working condition could pose risks to residents and staff, including foodborne illnesses and potential injuries.
Infection Control Deficiencies in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper glove use and hand hygiene during resident care. For Resident #14, CNA F did not change her gloves or sanitize her hands after they became contaminated during incontinent care. This oversight occurred after she wiped the resident's rectal area and then proceeded to apply a new brief and assist with changing the resident's pants without changing gloves, which she acknowledged could lead to cross-contamination. In the case of Resident #28, CNA D improperly used double gloves during incontinent care. After removing the first pair of gloves, she placed a new pair over the second pair without sanitizing her hands, and then continued with the care process. This practice was not in line with the facility's infection control policy, as confirmed by the DON, who stated that double gloving could lead to cross-contamination and was not acceptable. For Resident #288, RN K failed to follow proper hand hygiene and glove use protocols during wound care. She used the same gloves throughout the procedure, contaminating various surfaces and supplies, including the resident's bed and personal items. RN K admitted to not washing her hands during the process and acknowledged that her gloves were dirty throughout the wound care. The DON confirmed that the expected procedure was not followed, which included changing gloves and sanitizing hands at appropriate times during wound care.
Failure to Notify Guardian of Room Change Reason
Penalty
Summary
The facility failed to honor a resident's right to receive written notice before a change in room or roommate was made. This deficiency was identified for a resident who was moved to another room following an incident with his roommate. The resident's guardian was not informed of the specific reason for the room change, which was due to the roommate's inappropriate behavior of sprinkling water on the resident. The guardian was only told that the facility wanted to try the resident in another room without being given the specifics of the incident. The report highlights that the facility did not ensure that the resident's legal guardian was informed in advance of the risks and benefits of the proposed room change. The social worker documented the room change but did not notify the guardian of the alleged incident between the resident and his roommate. The Director of Nursing (DON) assumed the social worker had informed the guardian of the situation, but this was not the case. The resident involved had a medical history that included muscle wasting, dementia, schizoaffective disorder, anxiety disorder, and major depressive disorder. The resident was dependent on staff for various activities and had severe cognitive impairment. The failure to inform the guardian of the specific reason for the room change could place the resident at risk of remaining in an inappropriate situation if the guardian did not give permission for the move.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, as evidenced by an incident where one resident poured water on another resident. The affected resident, who had severe cognitive impairment and was dependent on staff for various activities, was subjected to this behavior by a cognitively intact resident who admitted to sprinkling water on him to 'train him like a dog.' This incident was reported by a CNA to the LVN, who then informed the administrator. However, another CNA suspected multiple occurrences of this behavior but did not report it immediately, leading to a delay in addressing the abuse. The facility's investigation revealed that the incident was reported late, and the resident who committed the abuse was eventually discharged. The administrator stated that the expectation was for any suspicion or allegation of abuse to be reported immediately. The facility's policy on abuse and neglect emphasizes the responsibility of the administrator and designee to prevent occurrences of abuse through training, investigation, and policy maintenance. Despite these policies, the failure to promptly report and address the abuse led to a deficiency in protecting residents from harm.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator, as evidenced by the case of a resident with severe cognitive impairment and multiple health conditions, including dementia and schizoaffective disorder. The resident was dependent on staff for various activities and was always incontinent. An incident occurred where the resident was reportedly sprinkled with water by his roommate, who claimed to be training him like a dog. This incident was initially reported by a CNA to the LVN, who then informed the Administrator. However, another CNA, who had suspicions of similar abuse, failed to report her concerns immediately, only doing so when called upon during an investigation. The facility's policy on abuse and neglect requires immediate reporting of any suspicions or allegations, which was not adhered to in this case. The Administrator confirmed that the CNA who failed to report was reprimanded and terminated for her inaction. The facility's investigation revealed that the resident's roommate had been issued a discharge notice, and following the investigation, the roommate was discharged. The facility's policy emphasizes the responsibility of the Administrator and designees to maintain policies prohibiting abuse and neglect, including training employees and investigating allegations.
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 44 citations issued within 25 miles in the last 12 months — 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 San Angelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Juanita Retirement And Rehab | 1.5 mi | — | 5 | 0 |
| Avir At Meadow Creek | 1.9 mi | ★★★★★ | 3 | 0 |
| Regency House | 2.9 mi | ★★★★★ | 6 | 0 |
| Park Plaza Nursing And Rehabilitation Center | 4.8 mi | ★★★★★ | 3 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 5 mi | ★★★★★ | 8 | 0 |
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