Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Waco during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including DM2, sepsis history, epilepsy, hyperlipidemia, HTN, polyneuropathy, and anemia, received perineal care during which a CNA repeatedly changed gloves without performing required hand hygiene between front and back cleansing, during application of moisture barrier cream, dressing, transfer, and grooming. The CNA acknowledged not performing hand hygiene after glove changes, while an RN stated that hands should be washed when gloves are changed. Facility policies on perineal care and PPE required discarding soiled gloves, sanitizing hands, and re-gloving before touching clean areas, and performing hand hygiene before donning and after removing gloves, which were not followed.
A resident with severe cognitive impairment and obstructive sleep apnea required nightly CPAP therapy with distilled water in the humidifier, as ordered and care planned. One night, an RN could not locate the usual distilled water in the room, found a large bottle labeled as purified water stored under a refrigerator, and poured it into the CPAP reservoir without confirming it was distilled water. The bottle actually contained a tap water and sugar mixture prepared by the family as hummingbird water and had been kept in the room for months. Video and staff interviews confirmed the RN’s actions and the presence of the unlabeled hummingbird water, and clinicians noted that CPAP humidifiers are intended to be filled only with sterile or distilled water per facility policy.
A resident with severe cognitive impairment and obstructive sleep apnea, ordered to use CPAP nightly, did not receive respiratory care consistent with professional standards and the care plan when an RN filled the CPAP humidifier with hummingbird sugar water stored in a bottle labeled as purified water instead of using distilled water as required. The RN acknowledged knowing purified water was not the same as distilled water and attempted to clean the reservoir after learning the bottle contained hummingbird food. The CPAP was then taken out of service, and the resident was without the ordered CPAP therapy for at least one night. Staff interviews and video review confirmed the use of the incorrect fluid, the presence of the misleadingly labeled hummingbird water in the room, and the facility policy requiring the humidifier to be refilled with fresh distilled water in the evening before use.
The facility failed to ensure timely administration of ordered medications for three residents, including antipsychotic, antiseizure, and antidepressant drugs, which were repeatedly given more than one hour outside the prescribed administration times. One resident with schizophrenia and severe cognitive impairment received Risperidone late on multiple consecutive mornings, while another resident with schizophrenia and depression had late doses of Risperidone documented on audit reports. A third resident with a seizure disorder and depression received Valproic Acid and Venlafaxine outside the standard time frame over several days. A medication aide described a two-hour window for "on time" dosing, and the DON acknowledged that late medication reports were not monitored daily, despite facility policy requiring administration within one hour of the scheduled time.
Surveyors found that kitchen staff failed to follow food storage, labeling, dating, and sanitation standards. Opened cereal and cornstarch were left inadequately sealed and exposed in the pantry, while chopped squash in bags lacked labels and use-by dates and an opened box of frozen biscuits was exposed in the freezer. The top of the low-temperature dishwasher had visible food particle buildup at both the dirty and clean dish doors. The DM, DON, and ADM each confirmed expectations that food items be properly labeled, dated, sealed, and stored, and that kitchen sanitation, including cleaning the dishwasher, follow facility policy.
A resident with Alzheimer’s disease, influenza, and a UTI had physician orders for antibiotic therapy and droplet isolation, and was observed with droplet precaution signage and PPE outside the room. The comprehensive care plan included goals and interventions related to influenza and dehydration but did not document that the resident was on droplet precautions, and a separate UTI care plan listed a goal for resolution of the infection without any interventions. The MDS nurse and DON, who shared responsibility for care planning, acknowledged that droplet precautions and UTI interventions should have been included but were omitted, while CNAs and LVNs reported they rely on electronic care plans to guide care. The facility’s written policy required comprehensive, person-centered care plans with measurable objectives, timeframes, and interventions based on assessment data, which was not fully implemented for this resident’s droplet precautions and UTI.
A resident with multiple comorbidities and a chronic non-healing wound required Enhanced Barrier Precautions (EBP) per the care plan and facility policy, which mandated gown and gloves for high-contact care such as wound care. During an observed wound dressing change to the resident’s lower extremity, the infection prevention nurse did not use EBP despite posted signage indicating their need. In interviews, the nurse admitted she should have used EBP and had been educated on infection control, and the DON confirmed that all nurses are expected to use EBP for wound care.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including unlabeled and undated food items, improper hair restraint use by staff, and incomplete equipment temperature logs. Observations revealed dirty equipment, unsecured trash cans, and improper storage of food items, potentially placing residents at risk of foodborne illness.
The facility did not adhere to posted cycle menus for two lunch services, serving meals that differed from the planned menus. Residents reported issues with the food, such as squash being too hard to eat. The dietary manager acknowledged making substitutions without detailed documentation. The facility's policy requires noting any menu changes, but this was not done. The Director of Nursing and Administrator expected the kitchen staff to follow menus and inform residents of changes, which was not consistently practiced.
The facility failed to provide meals that were palatable and attractive, with observations revealing unappealing and flavorless food, missing condiments, and improperly cooked items. A resident on a pureed diet received an unappetizing meal, while two residents complained about hard-to-eat squash. The dietary manager was unaware of these issues, despite the facility's policy emphasizing visually appealing and varied food service.
A facility failed to ensure a resident's gastric tube was flushed according to physician's orders during medication administration, risking tube clogging and potential replacement. Despite clear orders and previous grievances, RN-A omitted the pre-flush step, although a post-medication flush was conducted. Staff interviews confirmed the importance of flushing to prevent complications.
The facility failed to remove expired medical supplies from the medication storage room, as observed with three expired IMED Dressing Change Kits. Staff interviews revealed that the policy required expired items to be destroyed or given to the DON, but the responsibility for checking the room was not effectively executed. The use of expired supplies could lead to negative outcomes for residents.
The facility failed to maintain an effective infection prevention and control program in the laundry area, as clean linens were improperly stored on the designated dirty side. Staff interviews confirmed awareness of the importance of separating clean and dirty laundry to prevent cross-contamination, yet the practice was not followed, leading to a deficiency in the infection control program.
A resident with complex medical conditions was verbally abused by a CNA in a discouraging manner when requesting assistance to use the toilet. The incident was recorded by the resident's family member, and the DON confirmed the inappropriate tone used by the CNA. The resident's care plan required calm and positive interactions, which were not followed, leading to the resident's distress.
Failure to Perform Hand Hygiene During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed infection prevention and control practices, specifically hand hygiene during perineal (incontinence) care. Resident #1, who had a history of Type 2 diabetes mellitus without complications, sepsis, epilepsy, hyperlipidemia, hypertension, polyneuropathy, and anemia, was observed receiving perineal care from CNA-A. During this care, CNA-A cleansed the resident’s anterior perineal area, then repositioned the resident to provide posterior care without performing hand hygiene during glove changes. CNA-A put on a new pair of gloves without hand hygiene and proceeded to continue care and handle the resident’s personal items. CNA-A later stated she changed gloves three times during the care episode but did not perform hand hygiene between cleaning the front and back areas, and did not perform hand hygiene after changing gloves. She reported applying moisture barrier cream with the second pair of gloves, then dressing and transferring the resident from bed to wheelchair with the same gloves, and subsequently changing to a third pair of gloves without hand hygiene before putting on the resident’s socks and shoes and brushing the resident’s hair. CNA-A acknowledged that failure to follow proper hand hygiene could result in passing germs to the resident and herself. RN-B stated that handwashing should occur as soon as gloves are changed. Review of facility policies on Perineal Care and Personal Protective Equipment showed that staff were required to discard soiled gloves, sanitize hands, and re-glove prior to touching clean areas, and to perform hand hygiene both before applying and after removing non-sterile gloves, which was not followed in this instance.
Unlabeled Hummingbird Water Used in CPAP Humidifier
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents, specifically related to the use of a CPAP machine. An elderly female resident with severe cognitive impairment, dementia, and a diagnosis of obstructive sleep apnea required nightly CPAP therapy with distilled water in the humidifier reservoir, as ordered by her physician and reflected in her care plan. The care plan and facility policy required the CPAP humidifier to be filled with fresh distilled water in the evening before use. Despite this, a large plastic bottle containing a mixture of tap water and granulated sugar, prepared by the family as hummingbird water and stored under the resident’s refrigerator near bird seed, was present in the resident’s room in a container labeled as purified water. On the evening in question, video evidence showed an RN entering the resident’s room, waking the resident, and assisting her with the CPAP mask. The RN observed that the CPAP water reservoir was empty and did not see the usual distilled water bottle on the nightstand or floor. The RN searched the room, verbally asked where the water was, and then located a bottle labeled purified water under the refrigerator. Without verifying that it was distilled water or otherwise confirming its contents, the RN poured this liquid into the CPAP reservoir and returned the bottle to its place. The RN later stated she believed purified water was acceptable because it was not tap water, acknowledged that purified water is not the same as distilled water, and reported she had not received specific CPAP training at the facility. She also reported attempting to clean the reservoir with water and tissues after being informed that the bottle contained hummingbird water. Subsequent interviews and observations confirmed that the bottle used by the RN was the family’s hummingbird water, which had been in the room since approximately July of the previous year. The resident’s responsible party reported this to staff, prompting another nurse to enter the room, remove the CPAP from the resident, and take the hummingbird water bottle to the medication room. Staff, including the RT, MD, FNP, and DON, described the mixture as tap water and sugar stored in a bottle labeled purified water and noted that it was not clearly labeled as hummingbird water. The RT and other clinicians explained that CPAP humidifiers are intended to be filled with sterile or distilled water and that the presence of this sugar-water mixture in the machine could lead to bacterial buildup over time. The facility’s own CPAP/BiPAP policy specified the use of distilled water in the humidifier, but this was not followed when the RN used the unlabeled hummingbird water from the resident’s room in the CPAP reservoir.
Improper CPAP Humidifier Water Use and Interruption of Ordered CPAP Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and the resident’s care plan for a resident requiring CPAP therapy for obstructive sleep apnea. The resident was an elderly female with severe cognitive impairment, dementia, and a cognitive communication deficit, who had a physician’s order for nightly CPAP use at a prescribed setting. A prior sleep study documented severe obstructive sleep apnea with numerous obstructive apneas and hypopneas, significant respiratory arousals, and oxygen desaturations, leading to the order for nightly CPAP use. The resident’s comprehensive care plan required that the CPAP humidifier reservoir be filled with distilled water only each night and that the CPAP equipment be cleaned according to specified procedures. On the evening in question, RN A entered the resident’s room, woke the resident, and had her apply the CPAP mask. RN A observed that the CPAP water reservoir was empty and did not see the usual distilled water bottle on or near the nightstand. Instead of obtaining distilled water from the medication room as per her training and facility practice, RN A located a bottle labeled “purified water” under the resident’s refrigerator and used it to fill the CPAP reservoir. This bottle was later identified as hummingbird water, a mixture of tap water and granulated sugar that had been prepared by the family months earlier and stored near bird seed in the resident’s room. Video footage showed RN A searching for water, picking up a blue-labeled bottle from beneath the area of the camera, pouring its contents into the CPAP reservoir, and returning the bottle to where she found it. RN A acknowledged in interview that she knew purified water was not the same as distilled water and that she had been trained that distilled or sterile water was to be used in CPAP humidifiers. She stated she thought using purified water was acceptable because it was not tap water and reported attempting to clean the reservoir with water and tissues after being informed that the bottle contained hummingbird food. The respiratory therapist confirmed that CPAP humidifier water should be sterile or distilled and that she had initially set up the resident’s CPAP. Following discovery of the incident, the resident’s CPAP was taken out of service, and the resident was without CPAP use for at least one night. Medical providers, including the RT, MD, and FNP, described the situation as dangerous or potentially problematic if the sugar water mixture were used repeatedly, and the facility’s own policy specified that the humidifier chamber was to be refilled with fresh distilled water in the evening before use. These actions and inactions by RN A, and the presence of an unlabeled or misleadingly labeled container of hummingbird water in the resident’s room, led directly to the deficiency in providing safe and appropriate respiratory care. The deficiency also included the resident being without her prescribed CPAP therapy for at least one night after the machine was removed from service. The RT stated it was her understanding that the resident had been without CPAP for two nights, and the DON stated the resident went one night without CPAP after it was taken out of service and before a replacement machine was delivered and used. The resident herself reported that she did not wear her CPAP often and did not recall the incident. Nonetheless, the documented physician order required nightly CPAP use, and the care plan interventions were based on the resident’s severe obstructive sleep apnea. The combination of using an inappropriate fluid in the CPAP humidifier and the subsequent interruption of ordered CPAP therapy constituted the failure to provide respiratory care in accordance with professional standards and the resident’s care plan. Interviews with staff further clarified the circumstances leading to the deficiency. LVN B reported that she did not usually work on the resident’s hall and was unaware that hummingbird water was kept in the room. After being notified by the resident’s representative that hummingbird water had been poured into the CPAP, she entered the room, removed the CPAP from the resident, and took the hummingbird water to the medication room, noting that the room was somewhat dark and that the water appeared discolored. The DON stated that the hummingbird water bottle was not clearly labeled, that the water appeared cloudy, and that the facility sometimes used similar bottles for distilled water obtained from a supplier or grocery store. The facility’s policy on CPAP/BiPAP support required the humidifier chamber to be emptied, rinsed, and refilled with fresh distilled water in the evening, underscoring that the use of hummingbird water and the failure to ensure availability and correct identification of distilled water in the resident’s environment were central factors leading to the cited deficiency.
Failure to Administer Psychotropic and Antiseizure Medications Within Prescribed Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely administration of medications as prescribed for three residents. For one male resident with schizophrenia, acute kidney failure, moderate intellectual disabilities, and severe cognitive impairment (BIMS score of 1), the care plan included monitoring for medication side effects and providing medications as ordered. His active order for Risperidone 1 mg twice daily for schizophrenia was not administered within the facility’s required one-hour window on three consecutive mornings, with doses scheduled for 9:00 a.m. instead given at 10:20 a.m., 11:36 a.m., and 10:16 a.m. respectively. A female resident with muscle weakness, schizophrenia, major depression, and moderate cognitive impairment (BIMS score of 10) also had an active order for Risperidone 0.5 mg twice daily for schizophrenia and a care plan that included observing for side effects and providing medications as ordered. The medication administration audit report for this resident, filtered for administrations more than one hour late, showed that her antipsychotic medication was not consistently given within the prescribed time frame, although the specific late times are partially truncated in the report. Another resident with a history of seizures and depression had active orders for Valproic Acid 15 ml twice daily and Venlafaxine 75 mg once daily, and the audit report showed these medications were administered outside the standard time frame over several days. Interviews and policy review further described the circumstances leading to the deficiency. A medication aide stated that medication aides were responsible for ensuring residents received medications on time, which she defined as within a two-hour window, and that if medications were going to be late, she would notify the nurse, who would then notify the physician. The DON stated that all nurses and medication aides were responsible for timely medication administration, that administration did not run late medication reports daily and therefore had not monitored late medications, and that medications should be given within one hour before or after the designated time on the order. The facility’s written policy on administering medications required that medications be administered in a safe and timely manner, within one hour of their prescribed time unless otherwise specified.
Food Storage, Labeling, and Dishwashing Sanitation Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, dating, and sanitation practices in the kitchen. During an observation of the pantry, opened bags of cereal were found placed inside plastic labeled and dated bags that were not properly sealed, allowing exposure to outside air. An opened package of cornstarch was observed in the dry pantry with its contents exposed to the air rather than being placed inside a clear plastic bag and labeled and dated. In the freezer, two bags of chopped yellow squash had no label or use-by date, and an opened box of frozen biscuits was left exposed to freezer air. These conditions were inconsistent with the facility’s written policy, which required all refrigerated and frozen foods to be covered, labeled, and dated, and dry foods to be stored in a manner that maintains the integrity of the packaging until use. In a separate observation of the facility’s only kitchen, the top of the low-temperature dishwashing machine, at about eye level, was found covered in food particle buildup at both the door where dirty dishes were inserted and the door where clean dishes were removed. In interviews, the Dietary Manager stated that kitchen staff were normally expected to individually label and date food items in the pantry or freezer after serving a meal and acknowledged that the cereal and cornstarch were not properly sealed or stored. The DON reported that she did not oversee the kitchen and that the ADM was responsible, but stated her understanding that all food items should be dated and stored to prevent debris from getting into the food and to avoid serving expired or contaminated foods. The ADM stated that kitchen staff were expected to label and date food items when delivered and per facility policy, and that improperly sealed food could allow bugs into the packaging. He also stated that the kitchen was expected to follow company policies for cleaning and sanitation and that the top of the dishwasher should probably be cleaned after each meal, noting that cross-contamination could occur if clean dishes passed through a dirty machine.
Failure to Care Plan Droplet Precautions and UTI Interventions for a Cognitively Impaired Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple acute and chronic conditions. The resident was an elderly female with diagnoses including Alzheimer’s disease, anemia, osteoporosis, influenza, and a urinary tract infection (UTI). A Quarterly MDS assessment documented that she was severely cognitively impaired with a BIMS score of 00, required supervision or touching assistance with eating, was dependent for toileting, needed substantial to maximum assistance with showering and personal hygiene, and was always incontinent of bowel and bladder. Physician’s orders dated 01/30/26 showed that the resident was on antibiotic therapy for UTI/flu, was receiving levofloxacin 750 mg orally with an end date of 02/06/26, and was ordered to be on droplet isolation with specific PPE and equipment handling requirements. Record review showed that the resident’s care plan dated 01/31/26 addressed Influenza A with a goal that the resident would be free from signs and symptoms of dehydration, and included interventions such as encouraging fluid intake, offering favorite beverages, administering antipyretics and analgesics as ordered, and monitoring for side effects and signs of dehydration. However, despite the physician’s order for droplet isolation, the comprehensive care plan did not include that the resident was on droplet precautions. Additionally, a care plan dated 02/04/26 documented that the resident had a UTI with a goal that the infection would resolve without complications by the review date, but this UTI care plan contained no interventions. Observations on 02/04/26 confirmed that droplet precaution signage and a PPE cart were present outside the resident’s room, and the resident was observed sitting in a wheelchair in her room, pleasantly confused, clean, groomed, and with her call light in reach. Interviews with facility staff further clarified the deficiency. The MDS nurse stated she was responsible for care plans, had been trained on completing them, and that droplet precautions should be care planned; she believed she had care planned droplet precautions for this resident but was not aware they were missing, and she also was not aware that no interventions had been added for the UTI care plan. The DON confirmed that she, the MDS nurse, the ADON, and the care plan nurse were responsible for completing care plans, that staff were regularly in-serviced on following care plans, and that droplet precautions should be part of a resident’s care plan when applicable. She acknowledged that she had care planned the resident for the flu but failed to include droplet precautions, and that she had entered the UTI care plan but had not added interventions. Multiple CNAs and LVNs reported they had been in-serviced on following residents’ care plans, knew where to find them in the electronic record, and relied on them to provide care. The facility’s written policy on comprehensive person-centered care plans required measurable objectives, timeframes, and interventions derived from comprehensive assessment data, and stated that care plans must be revised as residents’ conditions change, which was not fully carried out for this resident’s droplet precautions and UTI. The facility’s own policy, revised in March 2022, specified that the IDT, in conjunction with the resident and representative, must develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet physical, psychosocial, and functional needs. It further required that care plan interventions be based on thorough assessment, reflect recognized standards of practice, and be revised as resident conditions change. In this case, despite clear physician orders and observable implementation of droplet precautions at the room level, the omission of droplet precautions from the written care plan and the absence of any documented interventions for the resident’s UTI demonstrated a failure to follow the facility’s own care planning policy and to ensure that all necessary care and services were captured in the comprehensive care plan.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program when the infection prevention nurse (IP A) did not follow the facility’s Enhanced Barrier Precautions (EBP) policy during wound care for Resident #68. Resident #68 was an adult male with heart failure, hypertension, diabetes mellitus, and depression, with a BIMS score of 15 indicating intact cognition. His comprehensive care plan documented a chronic non-healing wound or indwelling medical device, placing him at increased risk for transmission of multidrug-resistant organisms (MDROs), and included interventions requiring staff to change personal protective equipment (PPE) before caring for other residents and to use PPE, including gown and gloves, during specific resident care activities such as dressing changes. The facility’s written EBP policy, dated March 2024, specified that gown and gloves are required for high-contact resident care activities, including wound care for any skin opening requiring a dressing. On the observed date and time, IP A performed wound care to Resident #68’s right lower extremity wound, cleansing the wound, drying it, applying calcium alginate, and covering it with a dry dressing. During this procedure, IP A did not use enhanced barrier precautions, despite EBP signage being posted at the resident’s door indicating the need for such precautions. In a subsequent interview, IP A acknowledged that she should have used enhanced barrier precautions during the wound care, stated that it “slipped her mind,” and confirmed she had been educated on EBP and infection control, as well as that not using EBP could spread infection. The DON later confirmed that all nurses are expected to use enhanced barrier precautions when performing wound care and that nurse management is responsible for monitoring infection control and EBP use.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple sanitation and food storage deficiencies observed in the kitchen. Observations revealed that the hand wash sink near the kitchen entrance was out of paper towels, and several food items in the refrigerator were unlabeled and undated, including sandwiches, drinks, and a pitcher of tea. The juice dispenser machine had sticky buildup, and the can opener had black and brown buildup. Additionally, trash cans in the kitchen were found without secured lids, and the microwave was dirty with rust and peeling paint. Further observations highlighted that the kitchen's equipment temperature logs were incomplete, and several food items were improperly stored, unlabeled, and undated. A dented can of mandarin oranges was found in the dry storage area, and various cereals and other food items were not properly labeled or dated. The dish machine was found to have undetectable sanitizer levels, and the ice machine in the nourishment room had mold-like substances. Staff were observed not wearing hair restraints properly, with beard guards not covering facial hair as required by the facility's policy. Interviews with staff and management confirmed the facility's policies on hair restraints, labeling, and dating of food items, and the importance of maintaining proper sanitation practices. However, the observed deficiencies indicate a failure to consistently implement these policies, potentially placing residents at risk of foodborne illness. The facility's expectations for sanitation, labeling, and equipment temperature monitoring were not met, as evidenced by the numerous observations of non-compliance during the survey.
Failure to Follow Posted Menus and Document Substitutions
Penalty
Summary
The facility failed to adhere to the posted cycle menus for two observed lunch services, which could potentially place residents at risk of poor intake and weight loss. On two separate occasions, the meals served did not match the posted menus. On Sunday, the menu listed roast turkey, cheesy squash casserole, crumb-topped Brussels sprouts, fruit cobbler, and a beverage, but the meal served included roast turkey, cubed butternut squash, steamed plain Brussels sprouts, fruit cobbler, and a beverage. Residents reported that the squash was too hard to eat, indicating a deviation from the planned menu. On Tuesday, the posted menu included smothered pork, corn casserole, country green beans with bacon and onion, pineapple upside-down cake, and a beverage. However, the meal served consisted of BBQ pork ribs, creamed corn, black-eyed peas, cornbread, plain pound cake, and a beverage. The facility's dietary manager (DM) acknowledged that menu substitutions were made but were not documented in detail, only noting the number of changes in the QAPI meeting minutes. The DM stated that substitutions were sometimes necessary due to product availability or resident preferences, but a substitution log was not maintained. The facility's policy requires that any meal served that varies from the planned menu should be noted on the posted menu or in a record used for such changes. Additionally, the menus were not printed in a size large enough for residents to read from a reasonable distance. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed expectations that the kitchen staff should follow the menus and inform staff and residents of any changes, offering alternatives of the same nutritive value. The failure to follow the menus as planned could negatively impact residents' nutritional status.
Deficiency in Meal Quality and Presentation
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and prepared in a manner that conserves nutritive value, flavor, and appearance. Observations and interviews revealed that the kitchen test tray of the lunch meal was unappealing, lacked flavor, and was missing condiments. The dessert, a pound cake, was described as very dry and unappealing, with no garnishment on any of the foods or meal tray. Additionally, a resident on a pureed diet received a meal tray that was unappealing, lacked gravy or sauce, and was served with minimal condiments, leading to complaints about the food being unappetizing and often cold. Two residents complained about the lunch meal served on a specific date, which included cubed butternut squash that was not cooked properly and was too hard to eat. One resident, with a diagnosis of neurocognitive disorder with Lewy bodies, expressed dissatisfaction with the meal, noting that the squash was not soft enough to eat. Another resident, with a history of weight changes and malnutrition related to poor dentation, also reported that the squash was too hard to eat and that the food was frequently served cold. The facility's dietary manager (DM) stated that all food items are to be prepared and presented in an appealing manner and that residents who complain of cold food are provided with a hot warmer plate. However, the DM was unaware of the complaints regarding the hardness of the squash and stated that the cooks taste test the food prior to serving. The facility's food service policy emphasizes the importance of providing a well-balanced, flavorful, visually appealing, and varied food service program, yet the observations and resident interviews indicate a failure to meet these standards.
Failure to Flush Gastric Tube as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a gastric tube received appropriate treatment and services to prevent complications during medication administration. Specifically, the facility did not adhere to the physician's order and facility policy requiring the gastric tube to be flushed with 30 cc of water before and after medication administration. This deficiency was observed during a medication pass for a resident who was fed by enteral means due to conditions including dysphagia and gastrostomy. The resident's care plan and physician's orders clearly indicated the necessity of flushing the tube to prevent clogging, yet this step was omitted by RN-A during the observed medication administration. Interviews with staff, including RN-A, LVN-A, LVN-B, and the DON, confirmed the importance of flushing the gastric tube to prevent clogging, which could necessitate tube replacement. Despite this understanding, RN-A did not perform the pre-flush as required, although a post-medication flush was conducted using the feeding pump. The facility had previously addressed a similar grievance in September 2024, indicating a recurring issue with adherence to the flushing protocol. The failure to follow the prescribed procedure could lead to complications such as tube clogging, potentially requiring an invasive procedure for tube replacement.
Expired Medical Supplies Not Removed from Medication Storage Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medication administration supplies from the medication storage room. During an observation, it was found that three IMED Dressing Change Kits had expired nearly a year prior. This oversight was identified in the medication storage room located by the nurse's station. Interviews with staff, including an LVN, the Administrator, and the DON, revealed that the facility's policy required expired medical supplies to be destroyed or given to the DON. However, the responsibility for checking the medication room was not effectively executed, as evidenced by the presence of expired supplies. The staff acknowledged that using expired items could lead to negative outcomes for residents, such as reactions, infections, or reduced efficacy of medications.
Improper Linen Storage in Laundry Area
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the laundry area, which is crucial for providing a safe and sanitary environment. During an observation, it was noted that clean linens were improperly stored on the designated dirty side of the laundry room. This included a covered shelf with clean blankets and linens near the door used for bringing in dirty laundry, and an open shelf with neatly folded clean linens, gowns, and sheets located within a few feet of used housekeeping carts. This improper storage practice was confirmed by multiple staff members, including the laundry assistant (LA), laundry supervisor (LS), licensed vocational nurse (LVN-B), administrator (ADM), and director of nursing (DON), all of whom acknowledged the importance of separating clean and dirty laundry to prevent cross-contamination. The facility's policy on linen storage, which was undated, stated that all clean linen should be stored in a secured area and that clean and soiled linens should be stored separately. Interviews with staff revealed a lack of awareness and adherence to this policy, as the LA admitted to organizing extra clean linen on the dirty side due to space constraints. The LS, LVN-B, ADM, and DON all emphasized the potential for cross-contamination and the risk of spreading infections if clean and dirty linens are not properly separated. Despite the facility's policy and staff awareness of the risks, the improper storage of clean linens on the dirty side of the laundry room was a clear deficiency in the infection control program.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The resident, a female with a complex medical history including hepatic encephalopathy, cirrhosis of the liver, end-stage renal disease, and diabetes, was verbally abused by CNA A. The incident occurred when the resident requested assistance to use the toilet, and CNA A responded in a discouraging and assertive manner, questioning the resident's ability to do anything on her own. This interaction was captured on an audio and video recording by the resident's family member, who reported the incident to the facility. The Director of Nursing (DON) confirmed the content of the recording and acknowledged that CNA A's tone was not encouraging. The resident's care plan indicated a need for calm and positive interactions due to her risk for decreased socialization and altered mood related to depression and impaired cognition. Despite this, CNA A's response was not aligned with the care plan's interventions, which included providing positive interaction and validation of feelings. The incident led to the resident feeling upset and calling her family member in distress.
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 69 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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 Waco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Woods Health & Rehabilitation | 0.8 mi | ★★★★★ | 7 | 0 |
| Hewitt Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 2 | 0 |
| St. Anthony's Care Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Woodway Rehabilitation And Healthcare Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Greenview Nursing And Rehabilitation | 3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Waco.
100% money-back within 48 hours.
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.