Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Meadow Creek during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, diabetes, impaired mobility, and an unstageable left heel pressure ulcer did not receive wound care consistent with current NP and physician orders. Initial betadine and open-to-air orders were not consistently documented as provided, and there were days with no wound care signatures and a gap in eTAR treatment orders. When the NP later changed the treatment to collagen hydrogel and then to honey hydrogel with silicone bordered dressings three times weekly, these new orders were not entered into the eTAR. An RN was observed continuing to perform wound care using the outdated betadine/open-to-air order, and interviews confirmed that the DON was responsible for updating orders but had not ensured the eTAR reflected the NP’s most recent wound care recommendations, contrary to the facility’s wound care policy.
Surveyors found multiple deficiencies in kitchen operations, including improper storage and labeling of food, failure to discard prepared foods after 72 hours, lack of temperature checks before serving, uncovered food on the steam table, use of bare hands to handle food, and improper dishwasher temperatures. Staff interviews revealed gaps in knowledge and adherence to food safety protocols, and personal food items were found stored in kitchen refrigerators.
Several residents who required mechanical lifts for transfers were left in bed due to a shortage of clean or available slings, as confirmed by resident and staff interviews. This resulted in residents missing activities and experiencing emotional distress. The facility had more residents needing slings than could be reliably accommodated, and complaints about sling shortages were documented.
A resident with recurrent C. difficile infection was placed on contact isolation, but multiple staff members, including CNAs and housekeeping, entered the room without required PPE, and the resident's door was left open. Despite in-services and clear signage, staff failed to consistently follow contact isolation protocols, and the care plan did not address the resident's isolation needs.
Two residents did not have comprehensive care plans addressing all of their needs. One resident, with cognitive impairment and mobility limitations, used a gait belt across his wheelchair without this being included in his care plan, despite staff awareness. Another resident, with recurrent C. difficile infections and requiring contact isolation, also lacked a care plan addressing her isolation status. The facility's policy requires such care plans, but these were not developed or implemented for these residents.
A resident with moderate cognitive impairment and mobility deficits was allowed to strap himself into his wheelchair with a gait belt, a practice known to staff but not addressed in his care plan. Staff did not recognize this as a hazard, and no policy or assessment was in place to address the risks associated with the resident's use of the gait belt as a restraint.
The facility failed to develop and implement comprehensive care plans for two residents taking diuretic medications, neglecting to include necessary details such as diagnosis, side effects, and monitoring requirements.
The facility failed to obtain informed consent from three residents before administering psychotropic medications, including Zoloft and Depakote. The Director of Nursing confirmed that the consents were not signed and scanned into the residents' electronic medical charts, indicating a lapse in the facility's process for obtaining informed consent.
The facility failed to ensure the accurate administering of all drugs, as expired medications and wound care supplies were found on a medication cart. An LVN acknowledged the expired items, and both the ADON and DON confirmed that nurses are responsible for checking and discarding expired items. The DON could not provide a policy on medication storage and labeling upon request.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed that food items in the dry storage were not sealed, labeled, or dated appropriately. The Dietary Manager was unaware of the requirement to date, label, and seal opened food items.
A facility failed to maintain an infection control program when an LVN did not change gloves or perform hand hygiene during incontinent care for a resident with multiple diagnoses, including dementia. The LVN admitted to not knowing the correct steps, and the ADON and DON confirmed the importance of following proper procedures to prevent infections.
Failure to Implement and Update Wound Care Orders for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care according to physician and wound nurse practitioner (NP) orders for a resident with an unstageable left heel pressure ulcer. The resident, an elderly female with severe cognitive impairment, type 2 diabetes, impaired mobility, and a history of left hip fracture, was admitted with a left heel pressure ulcer and was care planned to receive pressure injury care, including weekly wound measurements and monitoring for skin changes. The care plan also documented that she required maximum assistance for turning, repositioning, and transfers. Record review showed that the initial wound NP orders dated 02/17/2026 for the left heel pressure ulcer were to cleanse with soap and water, apply betadine, leave open to air, and change daily. These orders were entered into the eTAR, but wound care was not documented as provided until 02/18/2026, and there were missing signatures on multiple dates in February, indicating wound care was not completed on those days. Additionally, there was no wound care treatment order in the eTAR from 02/11/2026 through 02/17/2026. Subsequent NP wound evaluations on 03/03/2026 and 03/10/2026 changed the treatment orders to collagen hydrogel with silicone bordered dressing, and later to honey hydrogel sheet dressing with silicone bordered dressing, to be changed three times per week, but these updated orders were not entered into the eTAR. On 03/12/2026, observation of wound care revealed an RN performing treatment based on the outdated betadine and open-to-air order still present in the eTAR. The RN removed a loose bandage with brownish-red drainage, cleansed the wound, applied betadine, and left the wound open to air with the heel floated, consistent with the old order rather than the NP’s more recent recommendations. Interviews with the RN, DON, wound NP, corporate regional nurse, and administrator confirmed that the DON was responsible for updating wound care orders, that the NP had communicated updated orders and noted they were not implemented, and that the eTAR did not reflect the most current wound care orders. The facility’s wound care policy required verification of physician orders and documentation of wound care, but the orders were not timely updated and wound care was not consistently documented as provided.
Deficient Food Storage, Preparation, and Service Practices Identified in Kitchen
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food storage, preparation, and service. During an initial tour, several dry storage items such as butterscotch pudding powder, cherry gelatin powder, citrus gelatin powder, and dry potato pearls were found opened and not sealed. In the freezer, a drinking glass containing an unidentified frozen liquid was not labeled or dated. In the refrigerators, various food items including cooked sausage, eggs, meat sauce, soups, pimento cheese, sliced ham, and grated cheese were either not dated, improperly labeled, or stored beyond the facility's 72-hour policy for leftovers. Additionally, personal food items were found stored in one of the kitchen refrigerators, contrary to facility policy. Further observations revealed that the facility did not consistently check or record food temperatures prior to serving. Lunch items on the steam table, such as fortified soup and white gravy, were not covered, not temped, and appeared dried out, indicating improper holding practices. Chicken strips and fries were also not temperature-checked before service. During lunch service, a staff member dropped a hot mitten on the floor, picked it up, and used it to handle food, and another staff member touched a baked potato with a bare hand while preparing it, both actions violating food safety protocols. Interviews with dietary staff and the Dietary Manager confirmed a lack of knowledge and adherence to proper procedures, including the correct dishwasher temperatures and food labeling requirements. The dishwasher was observed operating below the manufacturer's recommended temperature for several cycles. Facility policy and federal food code require proper labeling, dating, and storage of food, as well as discarding leftovers after 72 hours, but these standards were not consistently met during the survey.
Insufficient Mechanical Lift Slings Result in Residents Left in Bed
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not having sufficient mechanical lift slings available for all residents who required them. Multiple residents who depended on mechanical lifts for transfers, including those with conditions such as multiple sclerosis, osteoporosis, Alzheimer's disease, and osteoarthritis, reported being left in bed due to the unavailability of clean or accessible slings. These residents were cognitively intact and expressed frustration and emotional distress over missing activities and being unable to participate in daily routines because of the lack of slings. Interviews with residents revealed that the issue of missing slings occurred intermittently, with some residents stating it happened once or twice a month, and others recalling being left in bed for several days. Staff interviews confirmed that the facility occasionally ran out of clean slings, particularly when laundry could not keep up with demand or when shifts overlapped and slings were not yet available. Staff also noted that the number of residents requiring mechanical lifts had increased, further straining the supply of slings. Documentation review showed that the facility had 14 residents using slings and 19 slings available, with new slings being ordered monthly. However, there was no policy or list provided regarding essential equipment, and complaints about sling shortages had been documented in the facility's complaint book. The lack of sufficient slings led to residents being left in bed and missing out on activities, as confirmed by both resident and staff interviews.
Failure to Adhere to Contact Isolation Protocols for C. difficile
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the care of a resident with recurrent Clostridium difficile (C. difficile) infection who was placed on contact isolation. Multiple staff members, including CNAs and housekeeping staff, were observed entering the resident's room without donning the required personal protective equipment (PPE) such as gowns, gloves, and masks, despite clear signage and a PPE station outside the room. The resident's door was repeatedly left open, contrary to expectations for contact isolation, and regular, non-disposable meal trays were used for meal service. Interviews with staff and medical professionals revealed inconsistent understanding and implementation of contact isolation protocols. Some staff admitted to not wearing PPE when entering the room, and housekeeping staff reported only wearing gloves, not gowns, when cleaning the room. The facility's management and nursing leadership stated that in-services and training on infection control and C. difficile precautions had been conducted, but staff continued to fail to adhere to the required protocols. There was also confusion regarding the use of disposable meal service items for residents on contact isolation, and the facility lacked a current policy specifically addressing contact isolation procedures. The resident involved had a history of recurrent C. difficile infections, was cognitively intact, required moderate assistance with activities of daily living, and was receiving antibiotics at the time of the deficiency. The care plan for the resident did not address contact isolation for C. difficile, and the facility's infection tracking log showed multiple cases of C. difficile in recent months. The lack of adherence to established infection control practices was observed on several occasions and confirmed through staff interviews and record review.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for two residents. For one resident, who was admitted with a thoracic vertebra fracture and had moderate cognitive impairment, range of motion limitations, and was totally dependent on staff for transfers, there was no care plan addressing his use of a gait belt secured across his wheelchair. Observations and interviews revealed that the resident used the gait belt to prevent himself from falling out of the wheelchair, and staff, including the DON, DCO, PT, and Administrator, were aware of this practice. However, none of them identified it as a risk or ensured it was addressed in the care plan. For another resident, who had chronic respiratory failure, Alzheimer's disease, and recurrent C. difficile infections, there was no care plan addressing her contact isolation status. This resident was cognitively intact, required moderate assistance with most ADLs, was frequently incontinent, and was receiving antibiotics. Despite her need for isolation due to recurrent infections, the care plan did not include any interventions or objectives related to her isolation status. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including measurable objectives and timetables to meet their needs. In both cases, the facility did not follow its policy, resulting in the absence of care plans for significant aspects of the residents' care, specifically the use of a gait belt as a restraint and the management of contact isolation.
Failure to Address Resident's Unsafe Use of Gait Belt as Wheelchair Restraint
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards for a resident with moderate cognitive impairment, upper and lower extremity range of motion impairment, and total dependence on staff for transfers. The resident, who used a wheelchair and was admitted for rehabilitation services, was observed strapping himself into his wheelchair with a gait belt, a device typically used by aides for transfers. The resident reported using the gait belt to prevent falling out of the wheelchair and stated that staff were aware and approved of this practice. However, there was no care plan addressing the use of the gait belt in this manner, and the resident had only been educated about removing the belt, not about the risks associated with its use as a restraint. Interviews with facility staff, including the DON, DCO, physical therapist, and administrator, revealed that they were aware of the resident's use of the gait belt but did not recognize it as a hazard. The DON and DCO did not perceive a risk since the resident could remove the belt himself, and no policy addressing accident hazards related to this practice was provided. The physical therapist acknowledged the potential for injury if the resident fell while restrained by the gait belt. Despite staff awareness, there was no documented assessment or care planning to address the safety risks associated with the resident's self-use of the gait belt as a restraint in his wheelchair.
Failure to Implement Comprehensive Care Plans for Diuretic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents who were taking diuretic medications. Resident #4, a male with end-stage renal disease, congestive heart failure, and benign prostatic hyperplasia, did not have a care plan in place for his use of Furosemide. Despite being independent in most activities of daily living and receiving hemodialysis, his care plan lacked any mention of the diuretic medication, its associated diagnosis, potential side effects, and necessary monitoring. This oversight was confirmed by the MDS Nurse, who acknowledged that all medications should be care planned with relevant interventions and monitoring guidelines. Similarly, Resident #5, a female with chronic peripheral venous insufficiency, pulmonary heart disease, and high blood pressure, also did not have a care plan for her use of Furosemide. Despite her severe cognitive impairment and occasional incontinence, her care plan did not address the diuretic medication. The DON confirmed that diuretic use should be included in a resident's care plan, detailing the diagnosis, side effects, and monitoring requirements. The facility's policy on comprehensive, person-centered care plans was not followed, leading to these deficiencies.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from three residents before administering psychotropic medications. Resident #34, who was cognitively intact with a BIMS score of 15, did not provide consent before receiving Zoloft for depression. Similarly, Resident #47, who had impaired cognitive function and was receiving hospice services, did not provide consent before receiving Zoloft for obsessive-compulsive disorder. Resident #260, who had impaired cognitive function, did not provide consent before receiving Depakote for anxiety. The facility's records revealed that there were no consents on file for the administration of these medications. The Medication Administration Records showed that the medications were administered to the residents without their consent on multiple occasions. The Director of Nursing (DON) confirmed that the consents were not signed and scanned into the residents' electronic medical charts, indicating a lapse in the facility's process for obtaining informed consent. The facility's policy on psychotropic medication use requires that residents and their representatives be informed of the risks and benefits of the medications and that they have the right to decline treatment. The DON acknowledged that it is the responsibility of the admission nurse or the nurse who takes the order to obtain the consent prior to medication administration. The failure to obtain informed consent could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party.
Expired Medications and Supplies Found on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of all drugs to meet the needs of the residents. During an observation of the Hall 100 medication cart, it was found to contain expired medications and wound care supplies, including an 86-gram tube of antimicrobial wound gel expired on 12/8/2022, eight 3-milliliter vials of sodium chloride inhalation solution expired on 7/8/2022, and a 5x9 inch Xeroform Petrolatum dressing expired in 2/2023. LVN B, who was responsible for the cart, acknowledged the presence of expired items and stated that expired medications may not have benefits for residents. The ADON and DON confirmed that nurses are responsible for checking and discarding expired medications and supplies. The DON was unable to provide a policy on medication storage and labeling upon request by the surveyor.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Specifically, food items in the dry storage were not sealed, labeled, or dated appropriately. Observations revealed that a package of pancake and waffle mix and a package of Creamy Wheat were opened and partially dated. The Dietary Manager was unaware of the requirement to date, label, and seal opened food items. The facility's policy mandates that opened and bulk items be stored in tightly covered containers, labeled, and dated.
Infection Control Deficiency Due to Improper Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of LVN B during incontinent care for Resident #1. LVN B did not change her gloves after they became contaminated and failed to wash or sanitize her hands before putting on gloves and after removing them. This occurred while assisting Resident #1, who was frequently incontinent and had diagnoses including a fracture of the acetabulum, dementia, major depressive disorder, and anxiety disorder. The resident's care plan emphasized the importance of thorough perineal cleaning to prevent infections, but LVN B did not follow these guidelines. During the observation, LVN B placed a soiled brief on the resident's wheelchair and did not perform hand hygiene before touching clean items. LVN B admitted to not knowing the correct steps for changing a brief and acknowledged the importance of proper incontinent care to prevent infections. The ADON and DON confirmed that staff were expected to follow the facility's policies for perineal care and hand hygiene, and acknowledged that improper care could lead to cross-contamination. The facility's policies on hand hygiene and perineal care were reviewed, highlighting the importance of these practices in preventing infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Angelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency House | 1.2 mi | — | 1 | 0 |
| Avir At San Angelo | 1.9 mi | — | 2 | 0 |
| St. Juanita Retirement And Rehab | 2.4 mi | — | 3 | 0 |
| Park Plaza Nursing And Rehabilitation Center | 3.5 mi | — | 0 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 3.9 mi | — | 5 | 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.