Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Knox City during CMS and state inspections, most recent first.
The facility failed to maintain the required RN coverage of at least eight consecutive hours a day, seven days a week, for 34 days over a three-month period. The DON was the only RN employed and covered some shifts, but recruitment efforts for additional RNs were unsuccessful. The facility faced challenges with their contracted staffing agency, and many agency staff did not show up for shifts. Despite having access to Telehealth and a responsive Medical Director, the lack of RN coverage violated the facility's policy.
A facility failed to maintain an effective infection control program when an LVN did not sanitize a multi-use wrist blood pressure device between residents during medication administration. The DON admitted that staff were not trained to sanitize these devices between residents, as the facility's policy did not require it. The ADM was unaware of this practice and could not quote the facility's policy on sanitizing multi-use devices.
A resident with COPD did not have their oxygen tubing replaced weekly as ordered, posing a risk for infection. Despite the facility's policy, the tubing had not been changed since 09/22/24. Interviews with staff revealed a lack of adherence to the policy, with the DON acknowledging the increased infection risk.
A facility failed to accurately document an oxygen tubing change for a resident with multiple health conditions, including COPD. The resident's records inaccurately showed a tubing change that did not occur, as confirmed by LVN A, who admitted to pre-charting and failing to update the record. The facility's policy requires accurate documentation, which was not followed, leading to potential risks for the resident.
The facility failed to maintain a clean and safe environment in the North patio smoking area, as surveyors observed trash and cigarette butts over two days. The Housekeeping and Maintenance Supervisors, responsible for cleaning, did not perform their duties due to survey obligations. The Administrator acknowledged the issue but attributed it to frequent winds. The facility's policy requires immediate debris cleanup, which was not followed.
A facility failed to properly store and label medications when an LVN took a blister pack of Depakote from one resident and placed another resident's label on it to prevent a missed dose. This action was against facility policy and occurred due to a delay in medication delivery. The DON confirmed that emergency supplies were available, making the LVN's actions unnecessary.
A resident with bilateral below-knee amputations fell during an improper transfer by an LVN using a bear hug method, resulting in a bleeding surgical wound. The incident was not documented as a fall, and facility policies on safe lifting and fall prevention were not followed.
A resident's medication was misappropriated by an LVN who took Synthroid/Levothyroxine from an unlocked medication cart for personal use. The LVN admitted to taking the medication due to a shortage in her own prescription, despite being aware of the facility's policy against such actions. The incident was witnessed by another nurse and reported to the appropriate authorities.
A medication cart in the facility was left unlocked and unattended, allowing an LVN to access and take medication for personal use. The LVN, under investigation by the Texas Board of Nursing, admitted to taking Levothyroxine from the cart due to a shortfall in her own prescription. Despite in-service training on medication security, the cart was not secured, violating facility policy.
A resident with multiple medical conditions, including a recent leg amputation, experienced a fall during an improper transfer by an LVN, resulting in bleeding from the incision site. The incident was not documented in the medical records, violating professional standards and facility policy.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage of at least eight consecutive hours a day, seven days a week, for 34 days over a three-month period. This deficiency was identified through interviews and record reviews, which revealed that there were no RNs scheduled on specific days in April, May, and June 2024. The Director of Nursing (DON) confirmed that she was the only RN employed during this time and covered some shifts herself, but there were no other RNs available to meet the coverage requirement. The DON stated that the facility was actively trying to recruit RNs through various means, including online recruitment, job fairs, and communication with the Texas Workforce Commission. Despite these efforts, the facility struggled to hire RNs, and their weekend RN had quit. The facility also faced challenges with their contracted staffing agency, which was inconsistent, and many agency staff did not show up for their assigned shifts. The DON was aware of the coverage gaps and informed the corporate office, but was not required to fill all the shifts herself. The Administrator (ADM) acknowledged the issues with RN coverage and mentioned that a Performance Improvement Plan was implemented. The ADM and DON both noted that the facility had access to Telehealth and a responsive Medical Director, and they believed that the Licensed Vocational Nurses (LVNs) and other staff could meet residents' needs. However, the facility's policy required RN coverage, and the lack of RNs on certain days was a clear violation of this policy.
Inadequate Infection Control Practices with Multi-Use Devices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during medication administration. LVN A did not sanitize a multi-use wrist blood pressure device between residents, which was observed during medication pass observations. Specifically, LVN A used the device on three residents consecutively without cleaning it before or after each use. During an interview, LVN A acknowledged the failure to sanitize the device and admitted that she had been trained on cross-contamination through her nursing education. She also mentioned that she received training from the DON on infection control practices as needed. The Director of Nursing (DON) admitted that staff had not been trained to sanitize multi-use blood pressure cuffs between residents, as the facility's policy did not require it. The DON stated that blood pressure cuffs were considered non-critical items, and the facility's policy only required sanitizing them at the end of each shift or when they became soiled. However, the DON acknowledged that the best practice would be to sanitize all multi-use devices between residents to prevent infection. The DON was responsible for conducting staff training on infection control practices, which was usually done on a one-to-one basis. The facility's Administrator (ADM) was unaware that staff were not sanitizing multi-use blood pressure devices between residents. The ADM could not quote the facility policy for sanitizing multi-use devices and stated that nursing administration was responsible for staff training on infection control practices. The facility's policy on cleaning and disinfection of non-critical resident-care items outlined the use of intermediate and low-level disinfectants for such items, but it did not specifically require sanitizing blood pressure cuffs between residents. The ADM expected staff to follow orders regarding proper sanitization practices.
Failure to Replace Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not replacing the resident's oxygen tubing every seven days as per the physician's orders. The resident, a cognitively intact male with multiple health conditions including Chronic Obstructive Pulmonary Disease, was observed using oxygen therapy with tubing that had not been changed since 09/22/24, despite the order to change it weekly. This oversight was confirmed through multiple observations and interviews with the resident, who could not recall when the tubing was last changed. Interviews with facility staff, including the Administrator and the Director of Nursing (DON), revealed a lack of clarity and adherence to the facility's policy on changing oxygen tubing. The Administrator was unsure of the policy details, while the DON stated that the tubing should be changed every Sunday night and as needed, with the night shift nurse responsible for this task. The DON acknowledged that failure to change the tubing as ordered could increase the risk of infection. The facility's policy on oxygen administration, revised in October 2010, was reviewed but did not appear to be followed in this instance.
Inaccurate Documentation of Oxygen Tubing Change
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically regarding the documentation of an oxygen tubing change for Resident #28. Resident #28, a cognitively intact male with multiple health conditions including Chronic Obstructive Pulmonary Disease, was observed using oxygen therapy. The facility's records indicated that an oxygen tubing change was documented by LVN A on a specific date, but the change did not occur. The resident's oxygen tubing was observed to have not been changed for over a week, contrary to the weekly change order. During interviews, LVN A admitted to pre-charting her initials for routine tasks and failing to update the record when the tubing change was not performed. The facility's policy requires accurate and complete documentation, which was not adhered to in this instance. The Director of Nursing (DON) was unaware of the inaccurate documentation and emphasized the importance of accuracy in health records. The facility's policy on charting and documentation stresses the need for objective, complete, and accurate records, which was not followed in this case.
Failure to Maintain Cleanliness in Smoking Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the North patio smoking area, as observed during a survey. On multiple occasions, surveyors noted the presence of trash, including a plastic spoon, miscellaneous pieces of trash, and cigarette butts in the grass area of the smoking section. These observations were made over two consecutive days, indicating a lack of regular maintenance and cleanliness in this area. Interviews with the Housekeeping Supervisor (HS) and Maintenance Supervisor (MS) revealed that both were responsible for keeping the grounds clean but had not done so due to survey duties. The HS admitted that the area had not been cleaned since the previous Wednesday, and both supervisors were unaware of any potential negative outcomes for residents due to the trash. The Administrator (Adm) also confirmed the responsibility of the HS and MS for maintaining cleanliness but attributed the trash to frequent winds in the area. The facility's policy on maintenance emphasized the immediate cleanup of debris to prevent hazards, yet this was not adhered to in the smoking area.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, specifically involving two residents. The issue arose when an LVN took a blister pack of Depakote, a medication for mood and behavior, from one resident and placed another resident's pharmacy label on top of it. This action was taken to prevent the first resident from missing their medication due to a delay in delivery from the pharmacy. The LVN did not notify the physician or the Director of Nursing (DON) about this action, which was against the facility's policy. The first resident, a female with schizophrenia, mild cognitive impairment, and generalized anxiety disorder, was prescribed Divalproex for mood and behavior. Her medication was running low, and the pharmacy had not delivered the refill on time. The second resident, a male with neuroleptic parkinsonism and schizoaffective disorder, had a supply of the same medication. The LVN borrowed from this supply without proper authorization or notification to ensure the first resident did not miss her dose. The facility's policy requires that all medications be properly labeled and only the dispensing pharmacy can alter labels. The DON was informed of the situation and confirmed that the StatSafe, an emergency medication kit, had enough supply to cover the shortage, making the LVN's actions unnecessary. The pharmacist and physician involved confirmed that the medication was not administered incorrectly, but the administrative handling of the medication was inappropriate.
Improper Transfer Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident who experienced a fall during an improper transfer. The resident, who had multiple medical conditions including bilateral below-knee amputations, was dependent on staff for transfers. Despite this, a Licensed Vocational Nurse (LVN) attempted to transfer the resident using a bear hug method, which was not an approved or safe technique according to facility policy. During the transfer, the LVN lost balance and both she and the resident fell, resulting in the resident's surgical wound bleeding. The incident was not documented in the resident's progress notes, and there was no immediate medical treatment or emergency assistance provided. The facility's Director of Nursing (DON) and other staff were aware of the incident but did not document it as a fall, citing it as a transfer issue instead. Interviews with staff and the resident revealed that the resident typically used a sliding board or mechanical lift for transfers, and the bear hug method was not appropriate given the resident's condition. The facility's policies on safe lifting and fall prevention were not followed, and there was a lack of communication and documentation regarding the incident, which could have placed the resident at risk for further harm.
Misappropriation of Resident Medication by Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medication by a staff member. A Licensed Vocational Nurse (LVN B) took Synthroid/Levothyroxine, a thyroid medication, from a medication cart for her personal use. This incident was witnessed by another nurse, LVN C, who observed LVN B taking the medication from the cart. The resident involved was a male with multiple health conditions, including heart failure, diabetes, hypothyroidism, schizoaffective disorder, and kidney failure. He was moderately cognitively impaired, as indicated by his BIMS score. The incident occurred when LVN C left her medication cart unattended and unlocked while attending to another resident. Upon returning, she found LVN B at the cart, who admitted to taking the medication because she was short on her own prescription. LVN B initially intended to consume the pill but later claimed to have discarded it in a sharps container. Despite being trained on the facility's policy against misappropriation of resident property, LVN B took the medication, which was a violation of the facility's procedures. Interviews with the Director of Nursing (DON) and other staff confirmed that LVN B had taken the medication and that such actions were against the facility's policies. The facility's policy clearly prohibits staff from taking or borrowing medications from residents for personal use. The incident was reported to the Health and Human Services Commission (HHSC), and LVN B was suspended pending investigation. The facility's policies emphasize the protection of residents' health, welfare, and rights, including the prevention of abuse, neglect, and misappropriation of property.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically for one of the two medication carts located on the front hall. This deficiency was identified during a period when the medication cart was left unsecured and unattended, allowing unauthorized access to medications. The incident involved a Licensed Vocational Nurse (LVN B) who was reported to have taken medication from the cart for personal use. Interviews revealed that LVN B was under investigation by the Texas Board of Nursing for taking a resident's medication, specifically Synthroid, from the medication cart. The Director of Nursing (DON) stated that LVN B had informed another nurse, LVN C, of her intention to take the medication for herself. LVN C confirmed that she had left the medication cart unlocked and unattended, which allowed LVN B to access it. LVN C witnessed LVN B taking Levothyroxine from the cart, claiming she needed it to make up for a shortfall in her own prescription. The facility's records showed that LVN B had signed in-service training documents that emphasized the importance of not taking medications for personal use and keeping medication carts locked. Despite this training, LVN B admitted to taking a resident's pill but claimed she later discarded it in a sharps container. The facility's policy on administering medications clearly stated that medication carts should be kept locked when out of sight, which was not adhered to in this case.
Failure to Document Resident Fall and Injury
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards, specifically regarding a fall incident involving a resident. The incident involved a Licensed Vocational Nurse (LVN) who attempted to transfer a resident without using the recommended mechanical lift, resulting in a fall. The resident, who had recently undergone a leg amputation, suffered bleeding from the incision site after the fall. Despite the incident, there was no documentation in the resident's medical records or progress notes about the fall or the injury. Interviews with staff members revealed that the LVN attempted to transfer the resident by bear-hugging him, which led to both the LVN and the resident falling. The incident was witnessed by several staff members, who assisted in getting the resident back into bed. The Director of Nursing (DON) was notified, and the resident's wound was treated, but the incident was not documented as a fall in the facility's records. The facility's policy on assessing falls and their causes was not followed, as there was no incident report completed within 24 hours, and the fall was not documented in the resident's medical record. The resident involved in the incident had multiple medical conditions, including chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, and was moderately cognitively intact. The resident typically used a sliding board for transfers and had expressed discomfort with using a mechanical lift. Despite this, the LVN attempted the transfer alone, contrary to the facility's policy and the resident's care plan, which contributed to the fall and subsequent injury.
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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 Knox City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Munday Nursing Center | 11.1 mi | — | 0 | 0 |
| Avir At Haskell | 18 mi | — | 0 | 0 |
| Stonewall Living Center | 30.1 mi | — | 2 | 0 |
| Harmony Care At Stamford | 33 mi | — | 0 | 0 |
| Seymour Rehabilitation And Healthcare | 33.5 mi | — | 1 | 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 August 2026) and official state health department websites.