Avir at Lancaster

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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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.

Staffing

How full it usually is: this home is certified for 110 beds and averages 56.6 residents a day — about 51% occupied, or roughly 53 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.87 hrs/resident/day on weekends vs 3.56 on weekdays — 19% thinner on weekends. RN hours go from 0.81 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above 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

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.

29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · J2026-04-11 · tag F0776 — isolated
  Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
  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 or obtain radiology and other diagnostic services to meet the needs of its residents for 1 (Resident #1) of 3 residents reviewed for radiology services.The facility failed to obtain the x-ray and results for Resident #1's leg and knee in a timely manner, resulting in a delay to diagnoses of Resident #1's right femur and right knee. The STAT x-ray should be completed as soon as possible. On 04/11/26 at 2:14 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/11/26, the facility remained out of compliance at a severity level of Immediate Jeopardy to resident health or safety and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.On 04/11/26 at 2:14 PM an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. This…

  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
• Immediate jeopardy · J2025-06-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically and allegedly sexually assaulted her on 06/18/25. An IJ was identified on 06/19/25. The IJ began on 06/18/25 and removed on 06/19/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 06/19/25, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff had not been trained on resident-to-resident abuse prevention. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's face sheet, dated 06/19/25, reflected Resident #1 was a [AGE] year-old female who originally admitted to 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-09-18 · 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 record reviews, and interviews, the facility failed to ensure a resident's environment remained free of accidents or hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #22) reviewed for transfers in that: 1. The facility failed to ensure CNA O provided adequate supervision and transfer assistance for Resident #22 attempting to conduct a transfer without assistance or without an assistive device. 2. The facility failed to ensure that CNAs were knowledgeable about locating the resident's safe transfer status requirements for Resident #22. An immediate jeopardy existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, and hospitalization. Findings included: Review of Resident #22's Face sheet dated [DATE] reflected 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-04-11 · 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, observation and record review, the facility failed to provide a safe environment and adequate supervision for 1 (Resident #1) of 5 residents reviewed for falls. The facility failed to ensure Resident #1 received adequate supervision when she had a fall that resulted in a fractur to her right thigh and right knee. This failure could place residents at risk for injuries and a decline in health. Findings included:Record review of Resident #1's electronic admission record, 04/11/2026 revealed an [AGE] year-old female, admitted [DATE], with diagnoses that included traumatic hemorrhage of cerebrum (a life threatening, often fatal emergency caused by bleeding within the brain tissue), fracture of left femur (a severe injury causing intense, immediate thigh pain, inability to bear weight), anxiety disorder (mental health condition characterized by excessive persistent fear or worry), hypothyroidism (the thyroid gland fails to produce sufficient hormones, slowing the body's metabolism), dementia (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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-30 · 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 observation and interview the facility failed to store all drugs and biologicals in locked compartment and permit only authorized personnel to have access to the keys for 1 (medication cart #1) and 1 (crash cart #2) of 3 medication carts observed for medication and biological storage. On 06/30/26, LVN A failed to ensure medications were secured or attended to by authorized staff when LVN A did not lock medication cart #1. On 06/30/26, the facility failed to ensure crash cart #2 (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was secured. These failures place residents at risk of unauthorized access to medications and biologicals. Findings Included: During an observation on 06/30/26 at 6:42 A.M., one medication cart #1 and one crash cart #2 were unlocked with drawers facing outward towards the hallway at the North nursing station. The red dot was visible on the lock mechanism of both carts.During an observation on 6/30/26 at 6:43 A.M., nursing staff left the North nursing station with the medication cart #1 and crash cart#2 unlocked…

  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 · D2026-06-30 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1(Resident #1) of 6 residents reviewed for baseline care plan. The facility failed to include on baseline care plan that Resident #1 was placed in the secure unit.The facility failed to include on baseline care plan that Resident # 1was an elopement risk.The facility failed to include Resident #1 Behaviors on baseline care plan. These failures place residents at risk of not receiving the care needed. Findings included: Record review of Resident #1's face sheet dated 06/30/26 reflected, Resident #1 was a [AGE] year-old male, initially admitted on [DATE] and readmitted on [DATE]. Resident#1 was diagnosed with Schizophrenia unspecified, (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations,…

  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 before2026-06-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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 observations, interviews and record reviews, the facility failed to ensure the residents had a right to a safe, clean, comfortable and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for four (Residents #1, # 2, #3 and anonymous) of eight residents reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3's and anonymous' rooms and bathrooms were free from accumulated dirt, uneven/mix matched and missing floor tiles, rust stained bathroom fixtures and broken ceiling panel. These failures could place residents at risk of preventing residents from having a homelike experience which could cause illnesses, infections and hazards and could result in deteriorating health and decreased psycho-social well-being. Findings included:During an interview and observation on an undisclosed date and time, Anonymous stated they had issues with the flooring, but had not fallen or tripped over…

  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
• Potential for harm · E2026-05-04 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  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 resident's right to personal privacy and confidentiality or 3 (Resident #1, #2, and #3) of 3 reviewed for personal privacy. The facility failed to ensure CNA-A did not use her personal phone to record Residents #1, #2, and #3 and posted the images to her public social media platform without permission from the residents or representatives. This failure could place residents at risk of psychological harm.Photo observed on public social media of CNA-A revealed Resident #1 smiling and looking toward the camera with the caption, Memory care everyone daddy [Resident #1's nick name] says he remembers some words. CNA-A's photo was in the middle right side of the photo with 16.5 hearts, 471 comments, 487 saves, and 3,752 shares.Photo observed on public social media of CNA-A revealed Resident #2 standing in the hallway with her hands in a half raised position with the caption, When you live in memory care and a song come on and bring back 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-15 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 3 residents (Resident #44) reviewed for contracture management.The facility failed to provide equipment/services for Resident #44's left hand contracture (a permanent tightening of the muscles). This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures, and a decline in physical capabilities.Findings included:Record review of Resident #44's quarterly MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, non-Alzheimer's dementia, and seizure disorder. Resident #44 had a BIMS of 3 which indicated his cognition was severely impaired. The MDS further reflected the resident used a manual wheelchair and had impairment on one…

  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 before2026-01-15 · 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 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen food processor equipment was clean and free from build-up. [NAME] F placed food containers of the lunch meal in the steamtable that contained contaminated tinted water and burnt food particles floating in it on 01/14/26.These failures could place residents at risk for food contamination and foodborne illness.Findings included:Continuous observations on 01/14/26 from 10:56 AM to 12:15 PM revealed the following:- [NAME] F preparing the pureed lunch meal. [NAME] F pureed sweet potatoes, greens, and ham. The food processor/blender that [NAME] F used to puree the food had a see-through handle, which had a white build-up inside the handle. [NAME] F washed the food processor after every use, but the handle continued to have the white build-up inside the handle. - The kitchen steam table had five compartments, and 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-15 · 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, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 15 residents (Resident #44) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #44's left hand contracture.This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included:Record review of Resident #44's quarterly MDS assessment, dated 11/03/25, reflected the resident was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, non-Alzheimer's dementia, and seizure disorder. The MDS reflected Resident #44 had severe cognitive impairment with a BIMS score of 3.…

  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 · D2026-01-15 · 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 provide treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #8) reviewed for tube feedings. LVN E attempted to feed Resident #8 who was on a g-tube (a tube inserted through the abdomen directly into the stomach for feeding, fluids, or medicine when someone can't eat enough by mouth) a regular texture meal and had an order of NPO (nothing by mouth). This failure could place residents at risk for choking and aspiration.Findings included:Record review of Resident #8's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The residents' diagnoses included heart failure, diabetes, non-Alzheimer's dementia, and schizophrenia. The resident had long and short-term memory impairment and therefore a BIMS was not completed. The MDS further reflected Resident #8 was on a feeding tube. Record review of Resident #8's care plan edited 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-15 · 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

  Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely and had acceptable labeling for 1 of 3 medication carts (North Hall nurse medication cart) reviewed for drug storage and labeling.The facility failed to ensure expired medications, Ondansetron and Naproxen, were removed from North Hall nurse medication cart.This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Observation on 01/14/2026 at 8:26 AM of the North Hall nurse medication cart with LVN C revealed 30 tablets of ondansetron 4 mg (used to prevent nausea and vomiting) with an expiry date of December 2025 and 29 tablets of Naproxen 250 mg (used to reduce pain, fever, and inflammation from conditions like arthritis, gout, menstrual cramps) with an expiry date of December 2025.Interview on 01/14/2026 at 8:40 AM, LVN C revealed she was responsible for checking the cart for expired medications. She stated she checked the cart daily for expired medications. She stated…

  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 · D2025-11-24 · tag F0567 — failed to protect residents' money held by the home — isolated
  Honor the resident's right to manage his or her financial affairs.
  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 hold, safeguard, manage personal funds for 1 of 4 residents (Resident #5) reviewed for management of resident funds. The facility failed to ensure the BOM had a witness when distributing cash from the trust fund for Resident #5. The Facilities policy requires the signatures of 2 staff members when cash is dispersed to residents. The failure could place residents at risk for not having funds available when needed. Findings included:Record review of Resident #5's face sheet dated 09/30/2025 reflected the resident was a [AGE] year-old female admitted on [DATE] with active diagnoses that included Schizoaffective disorder, bipolar, Posterior subcapsular polar age-related cataract, right eye, Posterior subcapsular polar age-related cataract, bilateral, Age-related choroidal atrophy, bilateral, Transient visual loss, right eye, Major depressive disorder.An interview with Resident #5 on 09/30/2025 at 10:20 am. The resident stated that she had been at 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 Rights 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

$42,851 in federal fines across 3 penalties.

• $11,942 — penalty dated 2026-04-11
• $17,282 — penalty dated 2025-06-19
• $13,627 — penalty dated 2024-09-18

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 15 rows in the source record cover these 14 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.

About 88% 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. 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 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

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