Avir at Arden Wood

Location & what’s nearby

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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

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.

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.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 53% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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.

Staffing

How full it usually is: this home is certified for 174 beds and averages 134.3 residents a day — about 77% occupied, or roughly 40 beds typically open. It usually has some room. 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 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.60 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 2.69 hrs/resident/day on weekends vs 3.20 on weekdays — 16% thinner on weekends. RN hours go from 0.46 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below the national median of 45%.

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

Deficiencies are more than at the previous inspection — worsening. 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.

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.

32 citations, most serious first. The 22 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-02-19 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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 each resident was free from neglect for one (Resident #1) of eight residents whose records were reviewed for abuse and neglect. The facility failed to supervise Resident #3 and Resident #2, which ended in an unwitnessed resident to resident altercation. Resident #3 was struck on the head with a trashcan and sustained a laceration and hematoma to the forehead which required a hospital visit. On 02/14/24 at 10:45 am an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/17/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness their Plan of Removal. This failure affected 2 residents and could place 13 residents who require supervision inside the memory care unit at risk for abuse, neglect, and a decreased…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-02-19 · 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for two (Resident #2 and #3) of eight residents reviewed for care plans. 1.) The facility failed to update Resident #2's care plan after he demonstrated a history of aggressive behaviors regarding resident care and his personal space to staff and residents. 2.) The facility failed to include that Resident #3 was a fall risk in the care plan. On 02/12/24 at 01:50 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.…

  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
• Immediate jeopardy · K2024-02-19 · 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 and record review the facility failed to review and revise the person-centered care planning for one (Resident #2) of eight residents reviewed for care plan revision. 1. Resident #2's care plan had not been revised to include behavioral triggers and aggression. On 02/12/24 at 01:50 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for decreased quality of care and quality of life. Findings included: Resident #2 Record Review of Resident #2's face sheet revealed an eighty-four-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were schizoaffective disorder (a mental health condition including schizophrenia and…

  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
• Immediate jeopardy · J2024-02-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Resident # 1 and Resident #2) of 5 residents reviewed for environment. -The facility failed to ensure staff had access to memory care Residents #1 and #2, for approximately 50 minutes, in the event of an incident or emergency when their bedroom door became wedged with their bathroom door preventing the bedroom door from opening. On 01/30/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/01/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of not receiving appropriate care, interventions, and/or death. The findings included: Resident #1 Record review of Resident #1's admission Record, dated 01/30/24,…

  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 Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2023-12-23 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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 each resident was free from neglect for 13 of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #49, Resident #51, Resident #61, Resident #84, Resident #100, Resident #107, Resident #109) across 3 out of 3 units (100-Hall, 200-Hall and 300 Hall) reviewed for neglect. - The facility failed to take the appropriate actions of: retaining an IP with qualified training, complete tracking and trending of infections from August to October of 2023, treat diagnosed and presumptive scabies ( an infestation with the scabies mite), isolate of resident's with presumptive and diagnosed scabies, implement of environment controls to limit the spread of scabies and infection control surveillance to prevent a scabies outbreak even though the facility administration was aware that residents and staff had contracted the same unspecified rash over multiple months. This failure to take action…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2023-12-23 · tag F0880 — failed to prevent and control infections — widespread
  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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 13 out of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #95, Resident #100, Resident #107, Resident #109) and 4 of 5 Staff ( CNA AA, CNA BB, CNA CC, CNA D and CNA S) reviewed for infection control. - The facility failed to implement environment controls and surveillance to prevent a scabies outbreak. Resulting in 13 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #100, Resident #107, Resident #109) and 4 Staff ( CNA AA, CNA BB, CNA CC and CNA S). -…

  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
• Immediate jeopardy · L2023-12-23 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  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 a person designated as the infection preventionist had completed specialized training in infection prevention and control for 1 of 1 staff (DON) reviewed for Infection Preventionist qualifications and role. - The facility failed to ensure the DON had completed the required Nursing Facility Infection Preventionist training course IP which resulted in failure to implement an effective Infection Control Program, resulting in Residents #107, #39, #25, #37, #100, #51, #61, #81, #16, #84, #109, #20, and #1 contracting and being treated for scabies. - The facility failed to ensure the Infection Preventionist completed tracking and trending of infections for August through October of 2023. - The facility failed to ensure that there was a qualified Infection Preventionist from November 4th to December 15th 2023. An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, 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
• Immediate jeopardy · J2023-12-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 Residents (Resident #49) reviewed for tracheostomy care, in that:. -the facility failed to immediately reposition the oxygen mask over Resident #49's tracheostomy when the resident was found in distress. -the facility failed to immediately suction Resident #49's tracheostomy when the resident was found in distress, with copious (abundant) amounts of secretions at the tracheal tube. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. -the facility failed to maintain sterile procedure prior to tracheostomy suctioning for Resident #49. An Immediate Jeopardy (IJ) situation was…

  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 · J2023-12-23 · 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 observation, interviews and record reviews the facility failed to ensure that licensed nurses possess the specific competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and in a manner that promotes each resident's rights, physical and mental well-being as identified through resident assessments, and described in the plan of care for one of 16 (LVN R) facility staff reviewed for competencies and skill sets for assessments, in that: LVN R failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49 was observed to be in distress for an unknown period of time. LVN R failed to ensure Resident #49 was receiving continuous oxygen prior to leaving the resident alone. LVN R failed to ensure sterile gloves were used prior to handling the sterile suction catheter for Resident #49. An Immediate Jeopardy (IJ) situation was identified on 12/17/23. The IJ template was provided to the facility on [DATE] at 11:36 AM.…

  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
• Actual harm · Gcited before2026-05-22 · 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 interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 residents (Resident #8) reviewed for quality of care. The facility failed to properly notify MD of Resident #8's radiology results reporting a fracture to the resident's leg resulting in a delay in the resident's need for hospital transfer (27-hrs.) after a reported fall. This failure placed residents at risk for injuries, infections, unwanted hospitalization, and amputation leading to a decrease in quality of life. Findings Included:Record review of Resident #8's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included spinal stenosis (pressure on the spinal cord and nerves), chronic obstructive pulmonary disease (progressive irreversible lung disease that restricts airflow and makes breathing difficult), sacral (pressure ulcer injury to…

  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
• Actual harm · G2026-05-22 · 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 interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 of 9 (Resident #8) resident reviewed for quality of care. The facility failed to safely secure the locking mechanisms on Resident #8's bed wheels on a bed in high position, resulting in resident's fall with injury fracture on 04/09/2026. This failure could place residents at risk of injury or anxiety due to unstable environmental hazard. Findings included:Record review of Resident #8's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included right knee pain, spinal stenosis (pressure on the spinal cord and nerves), chronic obstructive pulmonary disease (progressive irreversible lung disease that restricts airflow and makes breathing difficult), pressure ulcer (injury to skin and underlying tissues) of sacral region (a large, triangular bone at the base 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-05-22 · tag F0777 — isolated
  Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
  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 promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for 1 of 7 residents (Resident #8) reviewed for diagnostic services. The facility failed to ensure LVN K notified the physician/ NP of the Resident #8's femur fracture using the facility's approved notification methods leaving Resident #8 with an undiagnosed/untreated femur (longest bone in th body that extends from the hip to the knee) fracture and in pain documented up to 5 out of 10 for 18 hours before she was transported to the hospital on [DATE]. This failure could place residents who required radiology services at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering. Findings included: Record review of Resident #8's Face Sheet dated 05/20/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE]…

  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 before2026-05-22 · tag F0644 — pattern
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid for 1 of 12 resident (Resident #4) reviewed for PASRR services. - The facility failed to refer Resident #4 to identify and update Resident #4's PL1 when she had a newly evident mental illness diagnoses of MDD with severe psychotic symptoms on 04/29/21 and Schizophrenia in 09/23/21 until 05/21/26, preventing a PASRR (a screening required that ensures individuals with MI or ID/DD are not inappropriately placed in nursing homes and received required specialized services) evaluation and determination of services needed. This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #4's Face Sheet date 05/21/26 revealed, a [AGE] year-old…

  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 before2026-05-22 · 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 ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 8 residents (Resident #4) reviewed for care plan revisions. - The facility failed to ensure Resident #4 care plan was comprehensive and updated to reflect Resident #4's diagnosis of schizophrenia that dated back to 09/13/2021. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #4's Face Sheet date 05/21/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with a primary/principal/admission diagnosis of PVD ( a slow progressive circulation disorder where there is reduced blood flow to the legs and feet), additional admission diagnosis of: vitamin deficiency, and asthma (a chronic breathing disease…

  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 before2026-05-22 · 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

  Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals,) for 1 of 1 medical supply reviewed for medication storage and labeling. The facility failed to ensure the medication room was free from expired medical supplies on 05/22/2026. This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition (change of a substance into something else, often making it weaker, useless, or harmful), and could cause infections due to compromised sterile equipment. Findings included: An observation of 200 hall's medication cart and interview on 05/22/2026 at 10:58 a.m., revealed staff stored unopened expired eSwab collection tubes (a system of a liquid-based device for collecting and transporting wound cultures) count 13, all expired on 07/12/2025. In an interview on 05/22/2026 at 11:03 a.m., ADON A A stated she…

  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 · D2026-05-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 based on the comprehensive assessment of a resident that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 3 residents (Residents #25) residents reviewed for pressure ulcers. - The facility failed to ensure the pressure redistributing function of Resident #25's air mattress was not interrupted by a fitted sheet on 05/19/26. This failure could place residents at risk of developing, reopening and worsening of pressure ulcers. Findings includedRecord review of Resident #25's Face Sheet dated 05/21/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: type 2 diabetes, and morbid obesity due to excess calories. Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed, severely impaired…

  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 before2026-05-22 · 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 in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 25 Residents (Resident #16) reviewed for -pharmacy services. - The facility failed to ensure a tube of numbing medicine, Lidocaine and Prilocaine 2.5%/2.5% was not left unattended on Resident #16's bedside table. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications. Findings include:Record review of Resident #16's Face Sheet dated 05/19/26 revealed, a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: type 2 diabetes, paralysis of both legs and left sided weakness after a stroke (lack of blood flow to the brain), obesity, MDD, anxiety disorder and partial amputation of the left midfoot. Record…

  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 before2025-12-30 · 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 the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3(Resident #19, Resident #4, and Resident #22) residents reviewed for infection control. The facility failed to have signs to acknowledge EBP for rooms [ROOM NUMBER] needed for PPE. This failure had the potential to result in staff not following appropriate PPE, increasing the risk of transmission of infectious organisms. Findings included: On 12/30/2025 at 9:45 am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room. On 12/30/2025 at 9:48am it was observed room [ROOM NUMBER] had no EBP signage posted outside the room to indicate required PPE, with no equipment placed outside of the room.On…

  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 · F2025-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure the ice machine was free from personal drink items (bottled water) within the stored ice. These failures could place residents at risk for food borne illness. The findings included: During an observation/interview on 03/25/2025 at 08:43 a.m., of the kitchen's initial tour, 1 of 1 ice machines contained a bottled water buried under the ice. Once identified, the Dietary Manager (DM) used the ice scooper and scooped out an 8oz bottle of water. The DM stated that the bottled water should not have been within the ice. He stated he was not aware of who placed the bottled water within the ice. He stated that the reason items were not to be within the ice was to prevent contaminated. Next to the ice machine was a cart full of various beverages all containing ice for the morning meal. He stated that he would inform…

  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 · Dcited before2025-03-28 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 residents (Resident #119) reviewed for PASRR services. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #119's Specialized Pressure-Reducing Support Surface Mattress by a specific deadline of 12/04/2024 This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #119's face sheet dated 03/26/2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Diabetes Type 2, Pain, Muscle Weakness, Major Depressive Disorder, Severe Intellectual…

  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 before2025-03-28 · 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 — the official record, unedited, may be distressing

  Resident #98 General 03/28/25 01:41 PM resident did not have upper parameter for blood sugar monitoring in MD orders, did call MD for clarification and had high blood sugar for consecutive days.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2025-03-28 · tag F0710 — isolated
  Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
  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 medical care of each resident was supervised by a physician and a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for the resident's immediate care and needs for one of seven residents (Resident #98) reviewed for physician services . The facility failed to ensure Resident #98 had an order for blood sugar parameters for when to report blood glucose levels to the physician according to their policy. This failure placed residents at risk for potential lack of medical supervision by a physician. The findings were: Record review of Resident #98's face sheet dated 03/27/2025 reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood), chronic kidney disease (kidneys aren't working properly and are beginning to lose their function), hemiplegia (is 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.

  Nursing and Physician Services 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.

Fines & penalties

$130,388 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $22,895 — penalty dated 2026-05-22
• $107,493 — penalty dated 2023-12-23
• Medicare payment denial — starting 2024-02-10 for 10 days

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 →

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

CMS files one row per role, so the 18 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 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.

About 95% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $147K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

Straight from this home’s Medicare cost report (CMS, FY2024). 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