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 San Angelo during CMS and state inspections, most recent first.
A resident with a recent below-knee amputation, DM2, malnutrition, and multiple lower-extremity wounds (surgical site, unstageable heel pressure ulcer, venous calf ulcer, and arterial toe ulcer) was admitted from another facility with existing wound treatment orders, but the receiving facility failed to obtain and enter those wound care orders into the EHR on admission. The care plan identified wound management needs and called for wound care per treatment orders, yet no wound care orders appeared in the record for several days, until a wound care NP assessed the wounds and wrote new orders. Facility leadership and clinical staff, including the ADON, DON, NP, wound care NP, and Regional Nurse Consultant, acknowledged that admission orders should have been carried over or obtained from the MD at admission and that the admitting/charge nurse was responsible for this process, in contrast to the facility’s wound care policy requiring verified physician orders and documentation for wound treatments.
Three residents with complex medical and behavioral needs did not have comprehensive, person-centered care plans addressing all required areas such as dialysis, diabetic care, mental health, wound care, pain management, ADL assistance, and vaccination status. Staff interviews revealed that care plans were incomplete due to recent turnover and lack of consistent processes.
Two residents at high risk for falls did not receive care planned anti-slip devices—one lacked anti-slip strips in her room and another did not have an anti-slip sheet in his wheelchair. Both deficiencies were confirmed by observation and DON interview, showing the facility did not follow its own fall prevention protocols.
A resident with severe cognitive impairment and hearing loss did not receive an audiologist appointment despite a request from her Responsible Party. The facility's Social Worker forgot to arrange the appointment, leading to the resident feeling ignored and not treated as a human. Staff relied on speaking loudly to communicate, but no communication tools were used, and the resident's hearing aids were found dirty and with dead batteries.
A facility failed to arrange an audiologist appointment for a resident with hearing loss, despite a request from the resident's Responsible Party. The resident, who had severe cognitive impairment, experienced communication difficulties and feelings of isolation due to the staff's lack of alternative communication methods. The Social Worker admitted to forgetting to contact the audiologist, and the facility's policies on social services and accommodation of needs were not upheld.
The facility failed to maintain a stove burner in the kitchen, which did not ignite automatically and had been non-functional for at least two years. The Dietary Manager attempted to light it manually, but it failed to ignite, with gas escaping and a buildup of grease observed. The issue was not reported to Maintenance, and the Administrator was unaware of the problem. The malfunction posed risks of foodborne illnesses and potential injuries.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper glove use and hand hygiene during resident care. A CNA did not change gloves after contamination during incontinent care for a resident, while another CNA improperly used double gloves. An RN failed to follow proper hand hygiene and glove use protocols during wound care, leading to potential cross-contamination. These actions were not in line with the facility's infection control policy.
A resident was moved to another room after an incident with a roommate, but the guardian was not informed of the specific reason for the change. The resident, with severe cognitive impairment and a complex medical history, was dependent on staff for care. The facility failed to ensure the guardian was aware of the roommate's inappropriate behavior, leading to a deficiency in resident rights.
A resident with severe cognitive impairment was subjected to abuse by another resident who poured water on him. The incident was reported by a CNA, but another CNA suspected multiple occurrences and failed to report them immediately. The facility's policy requires immediate reporting of abuse, but the delay in addressing the issue led to a deficiency in resident protection.
A resident with severe cognitive impairment was reportedly abused by a roommate who sprinkled water on him. A CNA failed to report her suspicions immediately, violating the facility's policy on abuse and neglect. The incident was eventually reported by another CNA, leading to an investigation and the discharge of the abusive roommate.
Failure to Obtain and Transcribe Admission Wound Care Orders for Resident With Multiple Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter wound care treatment orders upon admission for a resident with multiple existing wounds, contrary to professional standards and the facility’s own wound care policy. The resident, an older male admitted from another nursing facility, had documented diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes mellitus, and unspecified protein-calorie malnutrition. Discharge records from the sending facility showed active treatment orders for a left below-knee amputation surgical site, an unstageable pressure ulcer on the right heel, a venous ulcer on the right calf, and an arterial ulcer on the right great toe at the time of transfer. On admission, the resident’s care plan identified a wound management problem with a goal for wounds to remain free from infection and an intervention to provide wound care per treatment orders. However, review of the electronic health record for January showed no wound care orders entered, and wound treatment orders did not appear in the record until several days later in February, when a wound care NP assessed the resident and wrote new orders. The wound care NP documented that all wounds were present on admission and that she could tell wound care was being performed based on the condition of the dressings, but there were no corresponding physician orders in the record prior to her assessment. Interviews with facility staff confirmed that admission orders from the discharging facility should have been carried over and entered into the electronic health record on the day of admission. The ADON, DON, NP, wound care NP, and Regional Nurse Consultant each stated that wound care orders should have been obtained or transcribed at admission and that it was the admitting or charge nurse’s responsibility, with oversight by the DON. The facility’s wound care policy required verification of a physician’s order before providing wound care and documentation of wound care in the medical record. Despite this, the resident’s wound care orders were not entered into the electronic health record until several days after admission, resulting in a period during which wound care was being provided without documented physician orders in place.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required. For one resident, the care plan did not address critical needs such as dialysis (including shunt monitoring and care), diabetic care (including blood sugar checks, dietary restrictions, and insulin needs), glaucoma, seizure management, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. This resident had multiple diagnoses including dialysis dependence, epilepsy, diabetes, depression, glaucoma, and heart failure, and was receiving a complex medication regimen and therapies, yet the care plan only included code status, allergy, and personal care/activity preferences. Another resident, with a history of stroke, dementia with behaviors, malnutrition, hypothyroidism, and on hospice care, also lacked a comprehensive care plan. The care plan did not address the resident's mental health and behavioral issues, pain management, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin integrity, incontinence, or vaccination status. This resident had severe cognitive impairment, was at risk for pressure sores, had a catheter, and required substantial assistance with ADLs, but the care plan only included code status, allergies, personalized care preferences, and a fall prevention plan. A third resident, with multiple chronic conditions including stroke, diabetes, depression, kidney disease, hypertension, and vision impairment, also did not have a care plan addressing code status, mental and behavioral needs, kidney disease, pain, dietary or fluid restrictions, low thyroid, hypertension, diabetic care, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. Interviews with facility staff revealed that there had been significant turnover in management and MDS coordinators, resulting in incomplete and outdated care plans. Staff acknowledged that care plans were lacking and that the process for developing and updating them had not been consistently followed.
Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision and assistive devices as care planned for two residents. For one resident with dementia, diabetes, and a history of falls, the care plan required anti-slip strips to be placed in front of her recliner and dresser/shelving due to her poor balance, impaired mobility, and previous falls. However, observation revealed that these anti-slip strips were not present in her room. The resident had recently sustained a significant head injury from a fall, and both the DON and the resident confirmed the absence of the required anti-slip strips. The DON acknowledged that the facility was not following the care plan for this resident. Another resident, who was severely cognitively impaired, had a history of falls and required staff assistance for transfers. His care plan included the use of an anti-slip device (sheet) in his wheelchair to aid in positioning and prevent falls. Observation and interview with the DON confirmed that the anti-slip sheet was not present in the resident's wheelchair, despite being a documented intervention in his care plan. The DON stated that if an intervention was on the care plan, it should have been implemented. The facility's own policy on fall prevention required staff to implement and monitor interventions identified in the care plan to reduce the risk of falls and accident hazards. In both cases, the facility did not follow through with the care planned interventions intended to prevent accidents, as evidenced by the absence of anti-slip devices for both residents who were at high risk for falls.
Failure to Assist Resident with Audiology Appointment
Penalty
Summary
The facility failed to assist a resident in making an appointment with an audiologist, despite a request from the resident's Responsible Party. The request was made on 8/20/24, but the Social Worker admitted to forgetting to reach out to the audiologist. This oversight resulted in the resident not receiving the necessary audiological care, which was ordered as needed since 5/24/24. The resident, who has severe cognitive impairment and hearing loss, expressed feelings of being ignored and not treated as a human, highlighting the impact of the facility's inaction on her quality of life. The resident's care plan identified a communication problem related to her hearing deficit, with interventions including referring to audiology for a hearing consult as ordered. However, interviews with staff revealed that no communication tools were used with the resident, despite her difficulty hearing. Staff members relied on speaking loudly and getting close to the resident to communicate, but this was not always effective. The resident's hearing aids were found to be dirty and in need of battery replacement, further indicating a lack of attention to her hearing needs. The facility's policies on social services and accommodation of needs emphasize assisting residents in maintaining or improving their abilities to manage their everyday needs. However, the failure to arrange the audiologist appointment and the lack of effective communication strategies demonstrate a deficiency in meeting these policies. The resident's Responsible Party expressed concern about the resident's depression and social isolation due to her hearing issues, underscoring the importance of addressing these needs promptly.
Failure to Arrange Audiologist Appointment for Resident with Hearing Loss
Penalty
Summary
The facility failed to assist a resident in making an appointment with an audiologist, despite a request from the resident's Responsible Party. This oversight occurred after the Responsible Party asked the Social Worker on 8/20/24 to arrange an audiologist appointment for the resident, who had a diagnosis of hearing loss and wore hearing aids. The resident's care plan included a referral to audiology for a hearing consult as ordered, but the Social Worker admitted to forgetting to reach out to the audiologist. As a result, the resident experienced difficulty in communication, which was exacerbated by the staff's lack of alternative communication methods, such as using a notebook or dry erase board. The resident, who had severe cognitive impairment with a BIMS score of 5 out of 15, expressed feelings of being ignored and unimportant due to the staff's failure to communicate effectively. The resident reported that staff frequently entered her room without explaining their actions, leading to feelings of social isolation and depression. The Social Worker acknowledged the resident's moderate cognitive impairment and the need to communicate closely on the resident's right side but had not explored other communication tools. The facility's policies on social services and accommodation of needs emphasize assisting residents in maintaining their physical, mental, and psychosocial well-being, which was not upheld in this case.
Non-Functional Stove Burner in Kitchen
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically in the kitchen where one of the six stove top burners did not ignite automatically. During an observation and interview, it was noted that the burner had not been functional for a significant period, with the Dietary Manager (DM) acknowledging that it had been non-functional for at least two years. The DM attempted to light the burner manually, but it failed to ignite, and there was a noticeable smell and sound of gas escaping. The burner was observed to have a buildup of grease and debris, which may have contributed to its malfunction. The DM admitted to not reporting the issue to the Maintenance department. Further inspection revealed that the burner remained non-functional despite attempts to clean it. The DM mentioned that a service repair person was scheduled to address the issue. The Administrator, who had been at the facility for two months, was unaware of the problem until informed during the survey. The DM expressed concerns about the potential for an explosion or injury due to the malfunctioning burner. The failure to maintain the stove in proper working condition could pose risks to residents and staff, including foodborne illnesses and potential injuries.
Infection Control Deficiencies in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper glove use and hand hygiene during resident care. For Resident #14, CNA F did not change her gloves or sanitize her hands after they became contaminated during incontinent care. This oversight occurred after she wiped the resident's rectal area and then proceeded to apply a new brief and assist with changing the resident's pants without changing gloves, which she acknowledged could lead to cross-contamination. In the case of Resident #28, CNA D improperly used double gloves during incontinent care. After removing the first pair of gloves, she placed a new pair over the second pair without sanitizing her hands, and then continued with the care process. This practice was not in line with the facility's infection control policy, as confirmed by the DON, who stated that double gloving could lead to cross-contamination and was not acceptable. For Resident #288, RN K failed to follow proper hand hygiene and glove use protocols during wound care. She used the same gloves throughout the procedure, contaminating various surfaces and supplies, including the resident's bed and personal items. RN K admitted to not washing her hands during the process and acknowledged that her gloves were dirty throughout the wound care. The DON confirmed that the expected procedure was not followed, which included changing gloves and sanitizing hands at appropriate times during wound care.
Failure to Notify Guardian of Room Change Reason
Penalty
Summary
The facility failed to honor a resident's right to receive written notice before a change in room or roommate was made. This deficiency was identified for a resident who was moved to another room following an incident with his roommate. The resident's guardian was not informed of the specific reason for the room change, which was due to the roommate's inappropriate behavior of sprinkling water on the resident. The guardian was only told that the facility wanted to try the resident in another room without being given the specifics of the incident. The report highlights that the facility did not ensure that the resident's legal guardian was informed in advance of the risks and benefits of the proposed room change. The social worker documented the room change but did not notify the guardian of the alleged incident between the resident and his roommate. The Director of Nursing (DON) assumed the social worker had informed the guardian of the situation, but this was not the case. The resident involved had a medical history that included muscle wasting, dementia, schizoaffective disorder, anxiety disorder, and major depressive disorder. The resident was dependent on staff for various activities and had severe cognitive impairment. The failure to inform the guardian of the specific reason for the room change could place the resident at risk of remaining in an inappropriate situation if the guardian did not give permission for the move.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, as evidenced by an incident where one resident poured water on another resident. The affected resident, who had severe cognitive impairment and was dependent on staff for various activities, was subjected to this behavior by a cognitively intact resident who admitted to sprinkling water on him to 'train him like a dog.' This incident was reported by a CNA to the LVN, who then informed the administrator. However, another CNA suspected multiple occurrences of this behavior but did not report it immediately, leading to a delay in addressing the abuse. The facility's investigation revealed that the incident was reported late, and the resident who committed the abuse was eventually discharged. The administrator stated that the expectation was for any suspicion or allegation of abuse to be reported immediately. The facility's policy on abuse and neglect emphasizes the responsibility of the administrator and designee to prevent occurrences of abuse through training, investigation, and policy maintenance. Despite these policies, the failure to promptly report and address the abuse led to a deficiency in protecting residents from harm.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator, as evidenced by the case of a resident with severe cognitive impairment and multiple health conditions, including dementia and schizoaffective disorder. The resident was dependent on staff for various activities and was always incontinent. An incident occurred where the resident was reportedly sprinkled with water by his roommate, who claimed to be training him like a dog. This incident was initially reported by a CNA to the LVN, who then informed the Administrator. However, another CNA, who had suspicions of similar abuse, failed to report her concerns immediately, only doing so when called upon during an investigation. The facility's policy on abuse and neglect requires immediate reporting of any suspicions or allegations, which was not adhered to in this case. The Administrator confirmed that the CNA who failed to report was reprimanded and terminated for her inaction. The facility's investigation revealed that the resident's roommate had been issued a discharge notice, and following the investigation, the roommate was discharged. The facility's policy emphasizes the responsibility of the Administrator and designees to maintain policies prohibiting abuse and neglect, including training employees and investigating allegations.
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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) |
|---|---|---|---|---|
| St. Juanita Retirement And Rehab | 1.5 mi | — | 3 | 0 |
| Avir At Meadow Creek | 1.9 mi | — | 1 | 0 |
| Regency House | 2.9 mi | — | 1 | 0 |
| Park Plaza Nursing And Rehabilitation Center | 4.8 mi | — | 0 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 5 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.