Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At San Augustine during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate when an LPN failed to give several ordered meds and gave incorrect doses to two residents during an observed med pass. Errors included omitted vitamins and GI meds, a missed injection, and incorrect oral and eye drop dosages. The DON and Administrator stated nurses were responsible for accurate, timely administration and for following the EMAR and facility policy.
Staff failed to follow hand hygiene and glove-change practices during resident care and meal service. An LVN and a treatment nurse provided ostomy and wound care to a resident with an abdominal wound and ostomy without sanitizing or washing hands between glove changes, and a CNA provided incontinent care to a dependent resident without changing gloves or performing hand hygiene during the task. The same CNA also passed meal trays to multiple residents without sanitizing hands between rooms.
A resident with an indwelling urinary catheter and severe neurologic impairment was observed in bed with the urinary drainage bag hanging on the side of the bed and touching the floor. Staff stated the bag should be kept off the floor because it is an infection control issue, and the facility policy required catheter tubing and drainage bags to be kept off the floor.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions (EBP) for two residents requiring such measures. Despite training, CNAs and LVNs were observed providing care without PPE, risking infection spread. The DON confirmed the training but acknowledged the non-compliance.
The facility failed to maintain a clean and safe environment in the main dining room and a resident room. Observations showed dust-covered ceiling fans, fogged windows, unpainted sheetrock, and cracked floor tiles. Staff interviews revealed a lack of awareness and action to address these issues, despite the facility's policy to maintain a clean environment.
The facility failed to enforce proper smoking safety policies, as cigarette butts were discarded into a regular trash can in the smoking area, posing a fire hazard. Observations and staff interviews revealed that maintenance was responsible for ashtray management, but the facility's smoking policy lacked guidance on safe disposal of cigarette butts.
A resident with severely impaired cognition was exposed to the hallway during incontinent care when a CNA failed to pull the privacy curtain, and a hospice nurse entered the room without waiting for permission. Both staff members acknowledged the lapse, which could cause embarrassment to the resident.
The facility did not act on pharmacy consultant recommendations for two residents. One resident's SSRI doses were not evaluated as suggested, and another resident's medications linked to falls were not reviewed. The facility lacked policies for timely medication regimen reviews, and the DON was responsible for tracking physician responses.
A resident with a history of respiratory failure and anxiety was found unresponsive with a partially disconnected ventilator in a LTC facility. The resident's care plan did not adequately address her ventilator use or anxiety, and the ventilator alarms failed to activate, leading to a critical incident. Despite resuscitation efforts, the resident was transported to the hospital and later passed away.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent. Surveyors found a medication error rate of 21.62%, based on 8 errors out of 37 opportunities, involving 3 of 5 residents reviewed for medication errors and 1 of 2 nurses reviewed. The errors were identified during medication administration observation and record review, and involved Resident #16, Resident #19, and Resident #39. Resident #16 was a female with cerebrovascular disease and severely impaired cognition, with orders for vitamin C 500 mg daily, calcium carbonate 500 mg daily, and vitamin B12 1000 mcg daily. During medication administration, LVN B did not administer the ordered vitamin C or calcium carbonate and gave vitamin B12 500 mcg instead of the ordered 1000 mcg. Resident #19 was a male with traumatic subdural hemorrhage and intact cognition, with orders for docusate sodium 250 mg twice daily and Systane Ultra eye drops 2 drops in both eyes twice daily. LVN B gave docusate sodium 100 mg instead of 250 mg and administered 1 drop in each eye instead of 2 drops in each eye. Resident #39 was a female with severe protein calorie malnutrition and moderately impaired cognitive skills, dependent on staff for all ADLs. Her orders included acidophilus/citrus pectin by gastrostomy tube twice daily, octreotide injection daily on Tuesday, and multiple vitamins with minerals by gastrostomy tube in the morning. During the observed medication pass, LVN B did not administer the ordered octreotide injection, multivitamins with minerals, or acidophilus. During interview, LVN B stated she had been trained on medication administration, was nervous, forgot the octreotide was in the refrigerator, and did not read the orders accurately to ensure all medications were given and dosages were correct. The DON and Administrator stated nurses were responsible for administering medications accurately and timely and for following the EMAR and facility policy.
Infection Control Failures During Resident Care and Meal Service
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three staff members observed during resident care and meal service. During colostomy care for a resident with an indwelling catheter, ostomy, and surgical abdominal wound, LVN B removed soiled gloves and then put on clean gloves multiple times without sanitizing or washing her hands between glove changes while cleaning bowel movement from the abdomen and applying a new colostomy appliance and bag. The resident’s record showed moderate cognitive impairment and a care plan addressing skin integrity concerns related to the abdominal wound and colostomy. During wound care for the same resident, the Treatment Nurse sanitized her hands and donned gloves, but each time she removed gloves after cleaning the abdominal surgical wound, she put on clean gloves again without sanitizing or washing her hands. The wound care included cleaning the abdominal wound with normal saline and gauze, patting it dry, packing it with wet gauze, and applying an island dressing. In interview, the Treatment Nurse stated she should have sanitized or washed her hands each time she removed and donned clean gloves, and LVN B stated the same regarding the colostomy care. The facility also observed CNA D providing incontinent care to a resident who was always incontinent of bladder and bowel, had severe impairment in thinking, and was dependent on staff for ADLs. CNA D donned PPE and performed perineal care, removed the soiled brief, placed a clean brief, repositioned the resident, and secured the brief without changing gloves or performing hand hygiene during the care. In a separate observation during meal service, CNA D passed trays to multiple residents on the hall without sanitizing her hands before entering the rooms. CNA D stated she had not been taught to change gloves during incontinent care and did not recall training about hand hygiene during that care, and she acknowledged that germs could be passed to other residents if hands were not sanitized during meal service.
Urinary drainage bag left touching the floor
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident who was incontinent of bladder and had an indwelling urinary catheter. Resident #36 was a male admitted with a diagnosis of traumatic brain injury and was documented as being in a persistent vegetative state with an indwelling urinary catheter. His care plan included monitoring for signs and symptoms of infection, and the physician’s order required catheter care each shift and as needed. During an observation, Resident #36 was lying in bed with the urinary drainage bag hanging on the side of the bed and touching the floor. Staff interviews confirmed that urinary drainage bags should be kept off the floor because contact with the floor was an infection control issue and could increase the risk of infections. The facility policy also stated that the catheter tubing and drainage bag should be kept off the floor.
Infection Control Deficiency Due to Non-Compliance with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of adherence to enhanced barrier precautions (EBP) by staff members when providing care to two residents. Resident #5, a male with dementia and intact cognition, required EBP as per his care plan and physician's order. However, during an observation, CNA A and CNA B did not apply personal protective equipment (PPE) while transferring Resident #5, despite the presence of a pink dot indicating the need for EBP. Both CNAs acknowledged their training on EBP but admitted to forgetting to use PPE, which could lead to the spread of infection. Similarly, Resident #20, a female with impaired cognition and a diagnosis of aneurysm of the descending aorta, also required EBP during contact care. Despite this, LVN C and LVN D were observed assessing Resident #20's oral cavity without wearing PPE, even though a pink dot indicated the need for EBP. Both LVNs admitted to being trained on EBP but were confused about the requirements, leading to non-compliance with infection control measures. The Director of Nursing, who is also the infection prevention nurse, confirmed the training provided to staff and acknowledged the risk of infection spread due to non-compliance with EBP.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment in the main dining room and a specific resident room. Observations revealed that the dining room ceiling fans and vents were covered with thick dust and dirt, and the windows were obstructed due to fogging between the glass panes. Additionally, there were areas of patched sheetrock on the dining room walls and ceiling that were not painted, and cracked floor tiles were present. In the resident room, there was a missing and broken floor tile in the middle of the room. These conditions were noted during observations and interviews with staff, who acknowledged the issues but had not taken action to address them. Interviews with the Dietary Manager, Housekeeper, and Maintenance Man revealed a lack of awareness and action regarding the maintenance and cleanliness issues. The Dietary Manager admitted responsibility for the dining room's cleanliness but had not noticed the dust buildup on the ceiling fans. The Housekeeper acknowledged the need to clean the red substance on the ceiling and the ceiling fans, while the Maintenance Man admitted to not having painted the repaired sheetrock and not addressing the fogged windows. The Administrator confirmed the facility's policy to maintain a clean and orderly environment but noted that no maintenance requests had been logged for the observed issues.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to ensure the proper formulation, adoption, and enforcement of policies regarding smoking, smoking areas, and smoking safety, particularly concerning the disposal of cigarette butts. Observations on two consecutive days revealed that cigarette butts, along with cigarette boxes, plastic bags, and other paper trash, were discarded into a regular trash can in the designated smoking area. This trash can was lined with a clear plastic liner and was not intended for the disposal of cigarette butts, which poses a potential fire hazard. Interviews with facility staff, including the Regional MDS Nurse and the Administrator, confirmed that maintenance was responsible for managing the ashtrays and trash cans in the smoking area. The Administrator acknowledged that ashtrays should be emptied into a designated red metal trash can to prevent fire hazards. However, the facility's smoking policy, dated December 2018, did not address the safe disposal of cigarette butts, contributing to the observed deficiency.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of Resident #34 during the provision of incontinent care. On March 4, 2025, CNA A was observed providing care to Resident #34 without pulling the privacy curtain, which resulted in the resident being exposed to the hallway when a hospice nurse entered the room without waiting for permission. Resident #34, a male with severely impaired cognition and requiring assistance with all activities of daily living, was unaware of the exposure but expressed embarrassment at the thought of being seen naked by someone unnecessarily. Interviews with the hospice nurse and CNA A confirmed the lapse in maintaining privacy, with both acknowledging the potential for causing embarrassment to the resident. The Director of Nursing (DON) and the Administrator emphasized the importance of maintaining residents' rights and dignity, noting that staff are trained on these aspects. However, the incident highlighted a failure in practice, as the privacy curtain was not fully utilized, leading to the resident's exposure during personal care.
Failure to Act on Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to act upon the drug regimen review recommendations provided by the pharmacy consultant for two residents. For one resident, the pharmacy consultant recommended evaluating the current doses of Zoloft and Celexa, as the resident was taking two SSRIs. However, the physician's orders did not reflect any changes following this recommendation. For another resident, who had a recent fall, the pharmacy consultant suggested evaluating the medications Buspirone and Mirtazapine due to their potential to contribute to falls. Again, no changes were made to the physician's orders following the recommendation. The facility also lacked policies and procedures to address the timelines for medication regimen reviews (MRR). The Director of Nursing (DON) was responsible for sending the pharmacy consultant's recommendations to physicians and tracking their responses. However, during the period in question, the previous Assistant Director of Nursing (ADON) was responsible for this task. The pharmacy consultant noted that it is the facility's responsibility to ensure timely follow-up with physicians for responses to recommendations. The facility's policy did not specify time frames for obtaining physician responses, contributing to the oversight.
Failure to Provide Adequate Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required tracheostomy and ventilator support, leading to a critical incident. The resident, who had a history of acute and chronic respiratory failure, anxiety, and other medical conditions, was found in distress with a partially disconnected ventilator and no pulse. Despite efforts to resuscitate the resident, she was transported to the hospital and later passed away. The resident's care plan did not adequately address her ventilator use or anxiety, despite her known diagnoses. On the day of the incident, the resident was noted to be anxious and fidgety, but no effective intervention was documented. The ventilator alarms, which should have alerted staff to the disconnection, did not activate, and there were no relevant entries in the nurse's notes between the time the resident was last checked and when she was found unresponsive. Interviews with staff revealed that the resident had a history of anxiety and had previously pulled at her trach tubing. However, the facility's monitoring and response to her anxiety and ventilator needs were insufficient. The lack of alarm activation and the absence of timely monitoring contributed to the resident's critical condition and subsequent death.
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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 San Augustine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonecreek Nursing & Rehabilitation | 1.6 mi | ★★★★★ | 6 | 0 |
| Colonial Pines Healthcare Center | 3.2 mi | ★★★★★ | 9 | 0 |
| Avir At Center | 18.8 mi | ★★★★★ | 0 | 0 |
| Pine Grove Nursing Center | 18.8 mi | ★★★★★ | 3 | 0 |
| Hemphill Care Center | 19.1 mi | ★★★★★ | 4 | 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.