Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Western Hills during CMS and state inspections, most recent first.
Failure to disinfect a reusable BP cuff between residents occurred during med administration when an MA used the same automatic cuff on two residents without cleaning it in between. The MA stated she knew the cuff should be disinfected between uses but did not do so, and the ADM, DON, and RNC confirmed staff are expected to clean reusable equipment between residents under standard precautions.
Failure to Provide Timely Incontinence Care: A resident with cerebral palsy, quadriplegia, aphasia, dysphagia, and epilepsy was found with a soiled brief after the ADON observed a fresh BM and said an aide would be told. The resident remained in the soiled brief with wet bedding and clothing later, while family reported the call light had been on and staff had not responded. Staff interviews described long call light delays, staffing shortages, and unclear communication about who was responsible for the change.
A resident with CP, urinary retention, obstructive uropathy, and an indwelling catheter had her Foley bag left uncovered and visible from the hallway while it was partially filled with urine. Staff stated Foley/privacy bags were supposed to be used at all times to protect resident dignity, and the DON said the facility expected the bag to be covered because it was a dignity issue.
The facility did not provide written findings or resolutions to residents who filed grievances, despite documentation of follow-up and resolution in the grievance logs. Residents reported not receiving written or, in some cases, verbal updates about the outcomes of their complaints, and the administrator responsible for grievances was unaware of the policy requiring written notification.
A resident with a documented allergy to raw tomatoes and a religious preference to avoid pork was repeatedly served meals containing these items, despite clear documentation and meal tickets indicating her restrictions. Staff interviews and photographic evidence confirmed that dietary staff, including new and agency aides, did not consistently follow meal tickets or resident preferences, resulting in the resident experiencing allergic reactions and receiving food contrary to her beliefs.
A resident with cognitive impairment and a known risk for elopement exited the facility unsupervised after a malfunctioning magnetic door lock failed to secure the front entrance, despite the alarm sounding. Staff responded to the alarm but did not prevent the resident from leaving, and there was no clear procedure in place for responding to such alarms. The resident was found outside and returned to the facility after being unsupervised for approximately 15 minutes.
A resident with severe cognitive impairment and a high risk for wandering was admitted with no interventions for elopement included in the care plan, and management was not notified of the risk. The resident eloped from the facility and was later found with minor injuries. Staff interviews revealed confusion about risk assessment procedures and a lack of clear policy for follow-up actions after identifying high elopement risk.
A resident with chronic pain and impaired cognition had her PRN oxycodone medication misappropriated when a hospice nurse discovered the blister pack and narcotic count sheet missing. Staff interviews and narcotic count reviews revealed a counting error and failure to detect the loss, despite policies prohibiting drug diversion and requiring accurate controlled substance reconciliation.
A resident with Parkinsonism and cognitive impairment fell during incontinent care when a CNA asked her to hold onto the bed, contrary to her care plan. The resident, who required substantial assistance, lost grip and fell, sustaining injuries. The incident highlighted a failure to adhere to care plans and policies, leading to the CNA's suspension and eventual termination.
A long-term care facility failed to protect residents from the misappropriation of controlled opioid medications, affecting six residents. The facility discovered that a nurse, RN M, was suspected of tampering with medication blister packs, replacing narcotic pills with non-narcotic substitutes. This misappropriation placed residents at risk of not receiving their prescribed pain relief medications. The facility's investigation revealed that the tampering was difficult to detect, and RN M was suspended pending further investigation.
The facility failed to provide adequate pharmaceutical services, resulting in missed doses of Rifaximin for a resident and the misappropriation of controlled opioid medications for several others. The resident did not receive ten doses of Rifaximin due to pharmacy supply issues and lack of documentation. Additionally, a nurse tampered with or stole narcotics, replacing them with non-narcotic pills, affecting the residents' pain management.
A long-term care facility failed to provide timely lunch meals to residents, with significant delays observed on a specific day. Several residents, including those with diabetes and chronic conditions, expressed hunger and concern due to the late meal service. Staff interviews revealed inconsistencies in meal service times, despite the facility's policy to serve meals at regular intervals.
Two residents experienced foul odors and unclean conditions in their rooms, with one room smelling of vomit and the other of urine and feces. Despite daily cleaning protocols, housekeeping staff failed to document deep cleaning, and management did not effectively address complaints. The residents, one with severe cognitive impairment and the other with moderate impairment and blindness, reported persistent odors, impacting their quality of life.
A facility failed to conduct an accurate skin assessment for a resident upon readmission, resulting in six insect bites on the resident's right hip going unnoticed. The resident, who was cognitively intact and had a history of diabetes, renal disease, and paraplegia, reported being bitten by ants during a hospital stay. The ADON conducted the readmission assessment but focused only on the dryness of the resident's feet, failing to document the insect bites. The DON later confirmed the oversight, which could risk residents not receiving necessary medical care.
Failure to Disinfect Reusable Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program when a MA did not disinfect a reusable blood pressure cuff between residents during medication administration. During observation on 7/15/2026 at 8:20 AM, the MA used the automatic blood pressure cuff on Resident #70 and then on Resident #64 without cleaning the cuff between uses. Facility policy stated that reusable equipment is not to be used for more than one resident until it has been appropriately cleaned and reprocessed, and standard precautions require disinfection of reusable medical equipment between residents. Resident #64 was an [AGE] year old female admitted with diagnoses including acute posthemorrhagic anemia, dementia, iron deficiency, duodenal ulcer, polyp in colon, and lesion of sciatic nerve of the left leg. Resident #79 was an [AGE] year old female admitted with hypertension. In interviews, the MA stated she was frequently in-serviced on infection control and knew it was policy to disinfect the blood pressure cuff between each use, but did not know why she did not clean it. The ADM, DON, and RNC all stated that staff are frequently in-serviced on infection control and that reusable equipment, including blood pressure cuffs, is expected to be cleaned between residents to prevent the spread of germs.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received needed incontinence care and assistance with hygiene. The resident was a 43-year-old woman with cerebral palsy, aphasia, dysphagia, muscle weakness, muscle wasting and atrophy, epilepsy, and quadriplegia. Her care plan stated she was dependent on staff for emotional, intellectual, physical, and social needs related to her disease process, immobility, and physical limitations, and that she was unable to voice her needs. During observation, the ADON checked the resident for skin breakdown and found her brief soiled with a fresh BM, with pink, blanchable skin and white cream visible on the skin. The ADON said she would tell an aide and stated the resident would be okay because an aide would be there shortly. Later, the resident was still sitting in the soiled brief, with wet bedding and clothing, and the family stated this had happened frequently and that the call light had been on before entering the room without anyone responding. Additional observations showed call lights sounding at the nurses’ station while staff were talking and not checking on the residents. Staff interviews indicated call lights could take 40 to 60 minutes to answer, that the ADON had told an aide about the need for a change, and that there was disagreement about whether the resident had been changed. The ADMIN stated the facility was at fault for the resident not being changed in a timely manner.
Uncovered Foley Bag Exposed Resident to Loss of Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when her Foley bag was left uncovered and visible to passersby from the hallway while it was about one-quarter full of yellow urine. The resident was a female admitted to the facility with diagnoses including cerebral palsy, obstructive and reflux uropathy, urinary retention, and presence of a catheter. Her quarterly MDS reflected she was dependent for toileting hygiene and had an indwelling catheter, and her care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. Observation of the resident’s room showed the uncovered urinary bag exposed in view from the hallway. CNA interviews reflected that Foley bags were supposed to be covered at all times and that nursing staff were responsible for ensuring privacy covers were in place, with staff stating that an exposed urinary bag could affect dignity and self-respect. The DON stated the facility expected Foley bags to be covered because it was a dignity issue and that staff had been in-serviced on Foley bags, but the bag was still uncovered at the time of observation.
Failure to Provide Written Grievance Resolutions to Residents
Penalty
Summary
The facility failed to ensure prompt and proper resolution of grievances for four residents who filed complaints. Although the grievance logs for November and December documented follow-up dates and noted resolutions, confidential interviews with residents revealed that none received written findings regarding their grievances. Some residents also reported not receiving verbal updates about the investigation outcomes or any actions taken against staff involved in their complaints. The residents recalled being interviewed by the administrator (ADM) serving as the grievance official, but not all were informed of the final outcomes or corrective actions related to their grievances. In an interview, the ADM stated that he communicated grievance findings verbally but did not provide written results, as he was unaware that the facility's policy required written notification. The ADM mentioned that the policies were new due to a company change and that neither he nor his supervisor was familiar with the process of issuing written resolutions. Review of the facility's grievance policy confirmed that both verbal and written communication of investigation findings and corrective actions to the complainant were required.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to provide meals that accommodated a resident's documented food allergies and religious preferences on multiple occasions. The resident, who had a documented allergy to raw tomatoes and a religious preference to avoid pork, was served meals containing these items on several dates. Despite the resident's care plan and food preference assessments clearly indicating these restrictions, meal tickets and photographic evidence showed that the resident received pork and raw tomatoes in her meals. The resident reported experiencing allergic reactions, including swelling of the mouth and hives, after consuming tomato seeds, and required administration of Benadryl as documented in the medication administration record. Interviews with staff revealed that new and agency dietary aides were not consistently following meal tickets or were unfamiliar with resident preferences. The dietary manager and other staff acknowledged awareness of the resident's allergies and preferences, but lapses occurred due to staff turnover, lack of familiarity, and failure to check meal tickets before serving trays. The dietary manager had recently begun reassessing all residents' food preferences and had provided in-service training and counseling to dietary staff regarding the importance of adhering to meal tickets and resident preferences. The facility's own policy required that each resident be provided with meals that meet their nutritional and special dietary needs, including allergies and preferences, and that food trays be inspected to ensure accuracy. Despite this, the resident continued to receive meals containing allergens and foods contrary to her religious beliefs, as confirmed by staff interviews, resident statements, and photographic documentation.
Failure to Prevent Elopement Due to Malfunctioning Door Lock and Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as an elopement risk. The resident, who had a diagnosis of unspecified dementia with behavioral disturbance and a BIMS score indicating cognitive impairment, was care planned as an elopement risk and wore a code alert bracelet. Despite these measures, the resident was able to exit the facility unsupervised and was found across the street in a convenience store parking lot. The facility had a plan to monitor the front door, which was equipped with a magnetic lock and an alarm system intended to activate and lock the door when a resident with a code alert bracelet approached. On the day of the incident, the alarm sounded as the resident neared the door, but the door failed to lock due to a misaligned magnet caused by a loose screw. Staff interviews revealed that, although the alarm was heard and staff responded, the resident had already left the premises and was outside for approximately 15 minutes before being located and returned to the facility. Further review indicated that there was no specific policy or procedure for staff to follow when the alarm was triggered, aside from a general policy for when a resident leaves the building. Staff were aware of which residents wore code alert bracelets and understood the risks associated with unsupervised elopement, but the lack of a functioning door lock and clear procedures contributed to the resident's ability to leave the facility without supervision.
Failure to Provide Adequate Supervision and Elopement Prevention for High-Risk Resident
Penalty
Summary
A resident with a diagnosis of secondary malignant neoplasm of the brain and severe cognitive impairment, as indicated by a BIMS score of 7, was admitted to the facility. Upon admission, the resident was assessed using the facility's Wander Risk Assessment and was determined to be at high risk for wandering. Despite this high-risk score, the resident's Baseline Care Plan did not include any interventions for wandering or elopement, and management was not notified of the resident's high elopement risk. On the day of the incident, the resident was last seen in the facility in the late afternoon and was later discovered missing when medication was to be administered in the evening. Staff initiated a search of the building and grounds, and law enforcement and emergency services were notified when the resident could not be located. The resident was eventually found at a nearby apartment complex and transported to the emergency room, where he was treated for minor injuries sustained from a fall but did not require hospitalization. Interviews with facility staff revealed that there was confusion regarding the interpretation and follow-up of the wandering risk assessment. The nurse who completed the assessment did not believe the resident was exit-seeking and did not obtain a history from the family. There was no specific policy in place for actions to be taken after a resident was identified as high risk for elopement, and the process for notifying management and implementing interventions was not followed. The lack of communication and failure to update the care plan with appropriate interventions contributed to the resident's elopement.
Failure to Prevent Misappropriation of Resident's Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her prescribed oxycodone HCl Oral Tablet 5 MG, which was received through hospice care. The resident, an elderly female with chronic pain, chronic kidney disease stage 5, and a pathological femur fracture, was on a scheduled pain medication regimen and required maximal assistance with hygiene and bathing. Her cognitive status was moderately impaired, as indicated by a BIMS score of 08. The resident had both routine and PRN orders for oxycodone, but no PRN doses were administered during the month in question. On April 10, a hospice nurse counted the resident's medications and confirmed the presence of 16 PRN oxycodone tablets. By April 18, the same nurse discovered that the PRN oxycodone blister pack and the corresponding narcotic count sheet were missing from the narcotic box and book. Nursing management was unable to locate the missing medication or documentation. A review of the narcotics count sheet revealed a mathematical error in the count on April 11, which may have contributed to the loss going undetected. The resident reported always receiving her pain medication when needed and had no concerns regarding her pain management. Interviews with staff confirmed awareness of the drug diversion incident and knowledge of the procedures for narcotic counts and medication cart key transfers. The facility's investigation included interviews and drug testing of all staff with access to the medication cart during the relevant period, but no perpetrator was identified. The facility's policies prohibit misappropriation of resident property, including drug diversion, and require accurate recording and reconciliation of controlled substances. The incident was reported to the police, and the resident's family and medical director were notified.
Resident Fall Due to Inadequate Supervision During Incontinent Care
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident during incontinent care. The incident involved a resident with a history of Parkinsonism, cognitive impairment, and a high risk for falls. The resident was dependent on substantial assistance for bed mobility and toileting. During the incident, a CNA asked the resident to hold onto the bed while providing care, despite the resident's expressed inability to do so. This resulted in the resident losing grip and falling to the floor, sustaining a skin tear and a bump on the forehead. The resident's care plan indicated a need for total assistance with bed mobility and toileting, and the resident was identified as being at high risk for falls. The CNA involved in the incident reportedly asked the resident to hold onto the bed, which was against the facility's policy and the resident's care plan. The resident's family reported that the CNA left the resident's weak side unattended, leading to the fall. The resident experienced significant pain following the fall and was transported to the hospital for further evaluation. Interviews with facility staff revealed inconsistencies in understanding and implementing the resident's care plan. The CNA involved was suspended and later terminated due to performance issues, including inadequate care and professionalism. The facility's policies on perineal care and fall risk management did not explicitly address the appropriateness of asking residents to hold onto the bed during care, contributing to the incident.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically controlled opioid medications, for six residents. Resident #10's Oxycodone and the hydrocodone/APAP tablets of Residents #11, #12, #13, #14, and #15 were misappropriated. This misappropriation occurred over several days, with Resident #10's Oxycodone missing between 10/17/24 and 10/21/24, and the hydrocodone/APAP tablets of the other residents taken on unknown dates. The facility's failure to prevent this misappropriation placed residents at risk of not receiving their prescribed pain relief medications. The investigation revealed that the misappropriation involved tampering with the medication blister packs. RN M, a nurse at the facility, was suspected of replacing the narcotic pills with methocarbamol, a non-narcotic muscle relaxant, which looked similar to the original medication. This tampering was difficult to detect as the foil backing of the blister packs was cut along the edge of the bubble, and the substituted pills had a similar appearance except for the pill imprint. RN M was suspended pending the investigation, and it was noted that she had a history of working at a sister facility where similar incidents had occurred. Interviews with facility staff and a hospice nurse revealed that the missing medications were initially thought to be misplaced. However, further investigation confirmed the tampering and substitution of medications. The facility's policy on identifying exploitation, theft, and misappropriation of resident property was reviewed, which defined misappropriation as the wrongful use of a resident's belongings or money without consent, including drug diversion. The facility's Director of Nursing (DON) initiated drug testing for all nurses with access to the medication cart, but RN M's test was negative for narcotics.
Pharmaceutical Services Deficiency and Medication Misappropriation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of several residents, resulting in missed doses and misappropriation of medications. Resident #16 did not receive ten doses of Rifaximin, an antibiotic crucial for preventing hepatic encephalopathy, during their 34-day stay. The medication was not administered on multiple occasions due to issues with the pharmacy supply and lack of proper documentation by the medical assistant. The Director of Nursing (DON) was unaware of the missed doses, as the medical assistant failed to notify her or document the issue in the progress notes. Additionally, the facility failed to prevent the misappropriation of controlled opioid medications. Resident #10's Oxycodone and the hydrocodone/APAP tablets of Residents #11, #12, #13, #14, and #15 were tampered with or stolen. The investigation revealed that the narcotics were replaced with methocarbamol, a non-narcotic muscle relaxant, by a nurse who had a history of similar incidents at another facility. The tampering was difficult to detect, as the pills were replaced with similar-looking ones, and the foil backing on the blister packs was carefully cut. The facility's policies on medication administration and identifying misappropriation were not effectively implemented, leading to these deficiencies. The DON initiated an investigation after being notified of the missing medications, but the misappropriation had already occurred, affecting the residents' pain management and potentially their overall health. The facility's failure to ensure proper pharmaceutical services and prevent drug diversion posed a significant risk to the residents' well-being.
Delayed Meal Service in LTC Facility
Penalty
Summary
The facility failed to provide timely meals to residents, specifically during the lunch service on January 17, 2025. Observations revealed that lunch was not served according to the posted schedule, which was supposed to start at 11:45 a.m. Instead, residents were served much later, with the last meal tray being served at 1:23 p.m. This delay affected at least five residents who were reviewed for timely meals, all of whom expressed dissatisfaction and hunger due to the late meal service. The affected residents included individuals with various medical conditions that necessitated timely meals. For instance, one resident with diabetes expressed concern about her sugar levels dropping due to the delayed lunch. Another resident with chronic kidney disease and hypertension also experienced discomfort due to the late meal service. Despite the facility's policy to provide meals at regular times comparable to community settings, the residents were not served snacks at the scheduled time of 10:30 a.m., further exacerbating their hunger and discomfort. Interviews with staff members, including CNAs, RNs, and the DON, revealed a lack of consistency in meal service times. While some staff members acknowledged receiving complaints about meal service delays, others claimed not to have received any grievances. The facility's policy mandates that meals be served at specified times, with no more than a four-hour interval between meals, yet this was not adhered to. The failure to provide meals on time was attributed to various reasons, including delays in the kitchen and the meal tray distribution process.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in maintaining cleanliness and odor control. Resident #1's room was observed to have a foul odor of vomit, with dried and wet spills on the floor and bedside table. Despite daily cleaning protocols, the housekeeping staff did not document any deep cleaning for Resident #1's room, and the housekeeping supervisor did not sign off on the deep clean sheets. Resident #2's room also had a persistent smell of urine and feces, with crumpled papers and dried spills on the floor. Both residents and staff reported the foul odors, but no effective action was taken to address the complaints. Resident #1, a female with severe cognitive impairment and multiple medical conditions, including a wound to her sacrum and tube feeding, was unable to communicate effectively about the room conditions. Her representative reported that the room often smelled of urine, feces, and vomit, attributing the odors to infrequent changes by nursing staff and vomiting during tube feedings. Resident #2, a male with moderate cognitive impairment and blindness, expressed frustration over the daily foul odors and lack of housekeeping presence in his room. Interviews with housekeeping staff, nursing staff, and management revealed a lack of consistent communication and documentation regarding the cleaning schedules and odor complaints. The housekeeping department was outsourced, and the housekeeping supervisor had recently left the facility, leading to further disorganization. Despite the facility's policies emphasizing a clean and homelike environment, the staff failed to maintain the required standards, resulting in a diminished quality of life for the affected residents.
Failure to Conduct Accurate Skin Assessment on Readmission
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, upon readmission from the hospital, the facility did not complete an accurate skin assessment for a resident, which resulted in six insect bites on the resident's right hip going unnoticed. The resident, who was cognitively intact and had a history of type II diabetes, end-stage renal disease, paraplegia, and muscle weakness, reported being bitten by ants during his hospital stay. Despite the resident's report and visible insect bites, the readmission assessment conducted by the ADON focused only on the dryness of the resident's feet and failed to document the insect bites. The Director of Nursing (DON) confirmed the presence of the insect bites during an observation and interview, acknowledging that they should have been addressed in the readmission skin assessment. The facility's policies on admission assessment and documentation emphasize the importance of conducting thorough physical assessments, including skin evaluations, and ensuring that documentation is complete and accurate. The failure to document the insect bites could place residents at risk of not receiving necessary medical care, skin breakdown, and pain.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Temple
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Adams | 0.3 mi | ★★★★★ | 9 | 2 |
| Baylor Scott & White Continuing Care Hospital Skil | 1.1 mi | ★★★★★ | 0 | 0 |
| Wellington Rehabilitation And Healthcare | 1.8 mi | ★★★★★ | 1 | 1 |
| Avir At Weston | 2.2 mi | ★★★★★ | 7 | 0 |
| William R Courtney Texas State Veterans Home | 2.5 mi | ★★★★★ | 8 | 0 |
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