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Avir At Bay City

700 12th St, Bay City, TX 77414 · Government - Hospital district · 120 certified beds · (979) 245-7800 Medicare & Medicaid certified

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2 immediate-jeopardy citations$23,689 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $23,689 in federal fines (most recent 2024-02-26)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1701 Golden Ave · (979) 323-9900 · Call to confirm hours
Pharmacy
1415 Avenue G · (979) 245-5501 · Call to confirm hours
Grocery
1812 Avenue F · (979) 244-4009 · Call to confirm hours
Park
1209 10th St · (979) 323-1660 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.3%15.8%15.4%better
Long-stay residents who lose too much weight3.1%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%2.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.7%3.3%3.3%worse
Long-stay residents whose ability to walk worsened6.0%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.3%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers0.7%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control7.4%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.4%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%88.0%79.4%better
Short-stay residents rehospitalized after admission27.8%25.7%22.6%worse
Short-stay residents with an outpatient ER visit18.0%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.852.171.67worse
Long-stay outpatient ER visits per 1,000 resident days2.022.061.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

38.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.0%U.S. median 51.5%
Got home and stayed home
14.1%U.S. median 10.7%
Went back to hospital
0.44U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF38.0%CMS range 28.3–49.351.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.1%CMS range 10.4–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.23
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.19
RN hoursweekends
54.2%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 77.4 residents a day — about 65% occupied, or roughly 43 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.50 on weekdays — 11% thinner on weekends. RN hours go from 0.25 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2026-02-26)
6
at the previous standard inspection (2024-12-05)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-02-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 resident of 17 residents (Resident #1) reviewed for quality of care. The facility failed to assess Resident #1, who was prescribed daily anticoagulant medication, before lifting her up off the floor when she had an unwitnessed fall and sustained facial injuries and a bleeding hematoma to the back of her head. An Immediate Jeopardy (IJ) was identified on 02/22/2024. The IJ template was provided to the facility on [DATE] at 3:22 p.m. While the IJ was removed on 02/24/2024, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective. These failures placed residents who experience falls with injuries at risk of further…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-08-29 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure all residents were provided with a discharge summary for an anticipated discharge for two (CR #1 and CR #3) of six residents reviewed for discharge requirements. -CR #1 was discharged on 8/16/23 to a hotel and facility failed to provide CR#1 with Post-Discharge Plan of Care. -CR #3 was discharged on 8/23/2023 with no documentation of any pre-discharge planning, discharge summary, and an incomplete plan. On 8/25/2023 at 2:17 PM an Immediate Jeopardy (IJ) was identified for discharges. While the IJ was lowered on 8/29/2023 at 10:29 AM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of further unsafe discharge and potential physical, mental, and/or psychosocial harm. Findings include: CR #1 On 08/24/23 at 12:05 p.m. CR# 1 was observed asleep in a local hospital room. He had an IV…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions in accordance with professional standards for 4 of 8 medication carts reviewed for medication storage in that: Medication Carts #1, #2, #3 and #4 contained medications that did not have an open date written on the bottles. The failure to date opened medications placed residents at risk for receiving expired, contaminated, or ineffective medications which could result in medication errors, infection, delayed treatment or adverse drug outcome.Findings:On 2/25/2026 at 10:20 a.m., during a medication storage observation of Medication Cart #1 located on the 400 Hall, in the presence of the DON and RN I, the following medications were observed without a documented date indicating when the medications were opened: Valproic acid solution 250/5ml. (used to treat various types of seizure disorders). Dayquil, Severe Cold and flu…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-26 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to document evidence of receiving or refusal of influenza or pneumococcal immunization for 5 of 5 residents reviewed for immunizations (Resident#12, Resident #2, Resident #39, Resident #7, and Resident #5). The facility failed to document evidence in the electronic medical record the offering or the refusal of the influenza and pneumococcal immunization status for Resident #12 and Resident #2. The facility failed to document evidence in the electronic medical record the offering or the refusal of the pneumococcal immunization status for Resident #7, Resident #39, and Resident #5. The failures could place residents at risk of contracting viral illness, influenza or pneumococcal disease, or of not being informed of the benefits and risk which could cause respiratory complications and lead to potential adverse health outcomes. Record review of Resident #12's face sheet dated 2/26/2026 revealed a [AGE] year-old female admitted into the facility on 2/12/2026…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-26 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to implement their policy to ensure residents were offered, received, or refused Covid-19 immunization, for 3 of 5 residents who were reviewed for immunization compliance. (Resident #12, Resident #7, and Resident#2). The facility failed to document in Resident #12, Resident #7, and Resident #2's electronic medical records for having received or having had not received the Covid-19 immunization due to medical contraindication or refusal.This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Record review of Resident #12's face sheet dated 2/26/2026 revealed a [AGE] year-old female admitted into the facility on 2/12/2026 with diagnoses that included Unspecified Atrial Fibrillation (irregular heart beat), Type 2 diabetes mellitus (a condition where the body's cells do not respond properly to insulin leading to high blood sugar levels), Hypertensive Heart Disease with heart failure (a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record the facility failed to review and revised the person-centered comprehensive care plan for 1 (Resident #22) of 5 residents reviewed for comprehensive care plan revisions.The facility failed to update Resident #22's care plan to reflect the status of Resident #22's NPO status. This failure could place residents at risk of not receiving the appropriate care and interventions they need. Record review of Resident #22's face sheet dated 2/26/2026 revealed a [AGE] year old male admitted to the facility originally on 8/7/2024 and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive movement disorder of the nervous system that worsens over time), Dysphagia Oropharyngeal phase (the inability to swallow food or drink), and Unspecified Dementia (a decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities).Record review of Resident #22's Order Summary dated 2/26/2026 revealed a dietary order of a NPO diet…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-05 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours 7 days a week reviewed for RN coverage for 5 of 30 days reviewed for nursing services. (11/9/24, 11/10/24, 11/23/24, 11/24/24 and 11/30/24). The facility failed to have an RN for 8 consecutive hours 7 days a week for 5 days from November 9, 2024, through November 10, 2024, November 23, 2024, through November 24, 2024, and November 30, 2024. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of a Detailed Calculated Time form from 11/1/24 through 11/30/24 indicating RN hours worked indicated no RN hours for 11/9/24, 11/10/24, 11/23/24, and 11/24/24. The report indicated less than 8 hours a day worked on 11/30/24- 2.25 hours. Further review of the report indicated the DON did not work any hours on 11/9/24, 11/10/24, 11/23/24, 11/24/24, and 11/30/2024. Record Review of the facility's Civil Rights form (3761) (Texas Health and Human Services form that list the facility staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-05 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #11 and Resident #45) of 25 residents reviewed for pharmacy services. The facility failed to ensure Resident #11's medications were reordered timely to prevent the medications being unavailable for administration to the resident. The facility failed to administer two doses of Hydrocodone-acetaminophen- Schedule II tablet; 10-325 mg; oral on 12/04/2024 at 1 AM and 7 AM for Resident #11. The facility failed to monitor the blood pressure and pulse before administering Diltiazem (a blood pressure (BP) medication given to control high blood pressure and chest pain) and Amiodarone (prevents fast or irregular heartbeat) to Resident #45 as ordered by the physician. The facility failed to monitor the blood pressure and pulse before administering…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure on 12/03/2024 at 8:15 AM that a container of bacon grease, chicken noodle soup and French toast were labeled and dated with the preparation date and expiration date. The facility failed to ensure a bag of open tortillas was sealed. The facility failed to ensure the label on the ground beef in the freezer was legible. These failures had the potential to place residents at risk of serious complications from foodborne illness because of their compromised health status. Record review of Food Receiving and Storage policy dated November 2022 read in part . Foods shall be received and stored in a manner that complies with safe food handling practices. 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded .…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the coordination of assessments with the Pre-admission Screening and Resident Review (PASRR) program was provided for 1 of 4 residents reviewed for PASRR screenings (Resident #49). The facility did not correctly identify Resident #49 as having mental illness in his PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting. Findings included: Record review of Resident #49's face sheet, not dated revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement), psychosis (a mental disorder characterized by a disconnection from reality), scabies (a contagious skin condition caused by microscopic mites), muscle weakness, Dementia (a group of thinking and social symptoms that interferes with daily functioning),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 7% based on 2 errors out of 28 opportunities, which involved 1 of 4 residents (Residents #45) reviewed for medication errors. 1. The facility failed to ensure MA A administered the correct dose of Clonazepam to Resident #45. 2. The MA failed to administer Methimazole to Resident #45 according to physician orders and administered the medication after meal instead of before meal. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings include: Record review of Resident #45's face sheet, dated 12/05/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to carry out daily tasks:),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident #69) of 5 resident reviewed for infection control. The facility failed to ensure that CNA A, used appropriate PPE during urinary catheter care to Resident #69. These failures could place residents at-risk for infection due to improper care practices. Findings Included: Record review of Resident #36's face sheet dated 12/03/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old. Resident #69 had a diagnosis of Malignant neoplasm of liver (a cancerous tumor that can start in the liver or spread to the liver from another part of the body). Record review of Resident #69 doctor's order dated 11/19/2024 revealed that Resident was ordered Enhanced Barrier Precautions for Foley Catheter. Enhanced Barrier Precautions for a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2024-09-12 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 as identified in the Care Area Assessment of the admission MDS assessment. This failure could place residents at risk of not having personalized plans developed to address their specific care needs. Findings included: Record review of Resident 1#'s undated face sheet revealed an [AGE] year-old male admitted on [DATE] with a readmission on [DATE] and primary diagnosis of Chronic diastolic congestive heart failure (a condition that occurs when the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-12 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment, for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 within 7 days of the completed admission MDS assessment and no more than 21 days after admission. This failure could place residents at risk for not receiving the required person-centered care. The findings were: In an interview and observation on 09/12/2024 at 1:20 pm, of Resident#1 in his room at the facility. He said that he did not have any care concerns. In an interview on 09/12/2024 at 2:25 p.m. with the MDS Coordinator, she said that she was an LVN, and started at the facility in May of 2021. She said that she was tasked to complete all MDS assessments and comprehensive care plans for the facility. She said that the comprehensive care plan is due within 21 days of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) of five residents reviewed for physician orders received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. -Resident #2 was given supplements for colonoscopy preparation but had no order for them. -The colonoscopy preparation supplement had been ordered for a different resident. The deficient practice could place residents at risk of ingesting medications not prescribed resulting in severe abdominal distress and diarrhea. Findings include: Record review of the Face Sheet (printed 11/22/2023) for Resident #2 revealed she was [AGE] years old, and was originally admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unspecified psychosis, dysphagia (difficulty swallowing), and dementia. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was rarely understood,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed on the secured unit for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: -The door of the nurses' office on the secured unit was open and accessible to residents. -Resident #1, a confused resident, was in close proximity to a bag of medications on the nurses' desk, with no staff within line of sight of the nurses' office. The deficient practice placed residents at risk for ingesting medications that could be detrimental to his or her health, resulting in illness or hospitalization. Findings included: Record review of the Face Sheet for Resident #1 (printed 11/22/23) revealed she was [AGE] years old,and was originally admitted to the facility on [DATE]. She resided on the secured unit. Diagnoses included, but were not limited to, paranoid schizophrenia,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-27 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 10 days in April 2023 and two days in May 2023 of 60 days reviewed for RN coverage. The facility failed to ensure RN coverage for all Saturdays and Sundays in April 2023 and one Saturday and one Sunday in May 2023. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2023, run date 10/20/2023 revealed RN coverage was triggered (four or more days within the quarter were with no RN coverage). Record review of the monthly staffing schedule dated April 2023 revealed no RN coverage on the following dates:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that licensed nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 18 residents (Resident #52) reviewed for nursing competency, in that: -The facility failed to ensure LVN C was competent in medication administration skills by failing to perform pre and post treatment vital signs, observing resident while administering Handheld nebulizer treatment, and documenting that the medication was administered and completed. These failures could put residents at risk for inadequate care, result in ineffective treatment, worsening of symptoms and/or medical complications. Findings included: Record review of Resident #52's electronic medical record revealed a [AGE] year-old male who was admitted…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include administering of medications to meet the needs of 1 resident (Resident #52) of 18 residents reviewed for pharmacy handheld nebulizer treatments, in that: -Resident #52's scheduled medication was not administered timely and according to facility policy. -The facility failed to change Resident #52's HHN equipment weekly per policy. This deficit practice could affect the resident by not receiving a therapeutic dose and could prevent the resident from receiving the highest possible benefit from their medication. Findings included: Record review of the Face Sheet dated 10/25/23 reflected Resident #52 was a [AGE] year-old male admitted [DATE] with diagnoses of (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing, Cerebral infarction (Also…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments for one (Nurse medication cart 500 Hall) of 7 medication carts observed for storage of medications. The facility failed to ensure the nurse 500 hall medication cart was secured when unattended. This failure could place residents at risk for loss of medications, resident's safety, and drug diversion. Findings included: An observation on the 500 hall on 10/24/2023 at 4:16 PM, revealed LVN D at the nurse medication cart for 500 hall. The medication cart was parked in the hall in front of room [ROOM NUMBER]. As the observation continued LVN D walked into room [ROOM NUMBER]. LVN D closed the room door. The medication cart was observed unlocked and unattended. There were no residents, visitors, or staff in the hall at this time. An observation and interview on 10/24/2023 at 4:19 PM, revealed LVN D returned to the medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards of practice. The facility did not maintain medical records that were accurately documented for 1 of 3 (Resident #6) residents reviewed for DNR status, in that: -The facility failed to ensure Resident #6's electronic records were correctly updated and complete with a Full Code/DNR status. -The facility failed to ensure Resident #6s DNR/Full Code status was correctly verified based on the order in the electronic medical record (EMR). This failure could place residents at risk for inaccurate clinical records regarding effective Full Code and/or DNR status. The findings included: Record review of Resident #6's face sheet dated 10/27/2023 revealed: Resident # 6 was a [AGE] year-old Female, with an original admit date to the facility of 01/14/2020, and most recently admitted [DATE]. Diagnoses included Type 2 Diabetes Mellitus (Type 2 diabetes is a condition that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-29 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals and a system of medication records that enables periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 3 of 10 residents (Residents #27, Resident #22 and Resident #26) reviewed for pharmacy services, in that: -The facility failed to ensure MA W did not sign off on control medication before the administration time for Resident #27, Resident #22, and Resident #26. This failure could place residents at risk of not receiving their medication and drug diversion. Findings include: Resident #27 Record review of Resident #27's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted om 01/23/21. Resident #27 had diagnoses which included mononeuropathy (damage that happens to a single nerve) heart failure (when…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-29 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to honor residents' preferences in choosing hospice care in 2 (Resident #30 and Resident #32) of 5 residents reviewed for hospice care. The facility failed to allow Residents #30 and Resident #32 choose their own hospice provider. The facility took Resident #30 off hospice services against family wishes and Resident #30 expired within 6 months. These failures could place other residents at risk for not receiving hospice services of their choice and not receiving appropriate end of life care. Findings include: Record review of Resident #30's Face Sheet revealed a [AGE] year-old female who was admitted [DATE] with diagnoses of Heart Failure (Inadequate pumping of the heart), Anxiety Disorder (Excessive Worry), Urinary Tract Infection (Infection in urine drainage tract), Pressure Ulcer of Sacral Region Stage 3 (Skin breakdown below spine), Dementia (Memory loss). Status: Expired. discharged [DATE]. Record review of Resident #30's quarterly MDS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 5 Staff (CNA H, CNA M, NA R, and Laundry aide J) reviewed for infection control. - The facility failed to ensure CNA H and CNA M followed proper infection control procedures and did not completely clean Resident #24 during incontinent care. - The facility failed to ensure outside contractors(podiatrist) followed proper infection control while providing care (toenail care) to residents. - The facility failed to ensure NA R followed proper infection control and PPE procedures while walking on the hallway and making a resident's bed. - The facility failed to ensure laundry aide J followed proper infection control procedures while picking up dirty laundry from different halls. These deficient practices could affect residents and place them at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-29 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, and including measurable objectives and timeframes to meet the residents' medical, nursing, and mental an psychosocial needs identified in the comprehensive assessment for one (CR #2) of six residents reviewed for care plans. CR #2 had no care plan created while in care. This failure could lead to declining health or negative outcomes due to staff not having an understanding of the resident's care needs. Findings include: Record review of CR #2's face sheet dated 8/26/2023 revealed an [AGE] year-old woman admitted on [DATE] and discharged on 8/10/2023. The face sheet documented her diagnoses included metabolic encephalopathy (a brain disorder caused by various diseases or toxins that affect the body's chemistry and disrupt the brain's function), cerebral atherosclerosis (build-up of plaque in the blood vessels of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 4 residents (CR #24, and, Resident #23) reviewed for ADLs. -The facility failed to ensure Resident #24 was provided incontinent care in a timely caused her pants to be wet from front to back. -The facility failed to ensure Resident #23 was provided grooming (shaving) This failure could place residents at risk for discomfort, and dignity issues. Findings include: Resident #24 Record review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 05/19/23. Resident #24 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #24) reviewed for incontinent care. - The facility failed to ensure CNA H and CNA M followed proper infection control procedures and did not completely clean Resident #24 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted om 05/19/23. Resident #213 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally high) hypertension (a condition in which the blood vessels have persistently raised pressure), heart failure (the heart is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-29 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 out of 2 medication carts (medication aide cart for 200 and 500 hall cart), reviewed for medication storage. - The facility failed to ensure MA W did not leave discontinued control medication in the 200/500 hall medication cart, and one of the tablets was punched out and taped back to the blister packet. This failure could place residents at risk of getting discontinued medication and drug diversion. Findings Include: Record review of Resident #25's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted om 08/12/23. Resident #25 had diagnoses which included diabetes mellitus (body does not produce enough or respond normally to insulin, causing blood sugar(glucose)levels to be abnormally…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$23,689 in federal fines across 2 penalties.

  • $13,627 — penalty dated 2024-02-26
  • $10,062 — penalty dated 2023-08-29

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AVIR HEALTH GROUP — 116 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.3-0.3 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 3 of 53.6-0.6 vs chain
The other 115 homes this chain runs (chain average 2.3★, per CMS)
1 of 5Avir At BanderaBandera, TX 1 of 5Avir At Cowhorn CreekTexarkana, TX 1 of 5Avir At DallasDallas, TX 1 of 5Avir At LindaleLindale, TX 1 of 5Avir At StephenvilleStephenville, TX 1 of 5Avir at AdamsTemple, TX 1 of 5Avir at Arbor TerraceSan Angelo, TX 1 of 5Avir at BeaumontBeaumont, TX 1 of 5Avir at BeltonBelton, TX 1 of 5Avir at BoerneBoerne, TX 1 of 5Avir at BradburnGrand Saline, TX 1 of 5Avir at CaldwellCaldwell, TX 1 of 5Avir at Camp WoodCamp Wood, TX 1 of 5Avir at Citizens TrailTexarkana, TX 1 of 5Avir at ConverseConverse, TX 1 of 5Avir at GainesvilleGainesville, TX 1 of 5Avir at GarlandGarland, TX 1 of 5Avir at GiddingsGiddings, TX 1 of 5Avir at Heritage OaksLubbock, TX 1 of 5Avir at HillsboroHillsboro, TX 1 of 5Avir at HoustonHouston, TX 1 of 5Avir at Johnson CityJohnson City, TX 1 of 5Avir at KennedaleKennedale, TX 1 of 5Avir at KerrvilleKerrville, TX 1 of 5Avir at LongviewLongview, TX 1 of 5Avir at LubbockLubbock, TX 1 of 5Avir at Meadow CreekSan Angelo, TX 1 of 5Avir at MineolaMineola, TX 1 of 5Avir at New BraunfelsNew Braunfels, TX 1 of 5Avir at PatriotEl Paso, TX 1 of 5Avir at PortlandPortland, TX 1 of 5Avir at Rose TrailTyler, TX 1 of 5Avir at San AngeloSan Angelo, TX 1 of 5Avir at SeguinSeguin, TX 1 of 5Avir at TexarkanaTexarkana, TX 1 of 5Avir at Tierra EsteEl Paso, TX 1 of 5Avir at Veterans MemorialHouston, TX 1 of 5Avir at WestonTemple, TX 1 of 5Avir at WinnsboroWinnsboro, TX 1 of 5Avir at WoodlandsEastland, TX

Showing 40 of 115; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
GUADALUPE COUNTY HOSPITAL BOARDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2022
700 12TH STREET PROPERTY OWNER, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER INCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER NNN GROUP, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
WELLTOWER OP, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/01/2025
GANN, KODYIndividualCORPORATE OFFICERsince 04/01/2022
700 12TH STREET OPCO, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
BARKER, BRUCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
FREUND, NOCHUMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2025
TRAVITSKY, AARONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2025
DAGAN, AMITAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/13/2025
GOLDBERGER, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/13/2025
CATES, CLINTIndividualADP OF THE SNFsince 03/01/2025

CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.9M
Net patient revenuemost recent cost report
+21.5%
Operating marginrevenue minus expenses
$1
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 17%Other / private 18%

This home reported $1 paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$253per resident / day
operating cost
$7,702per month
≈ monthly operating cost
$323per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 455643. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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