Avir at Meadow Creek

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.

46.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 128 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 80 beds and averages 53.7 residents a day — about 67% occupied, or roughly 26 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 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.78 hrs/resident/day on weekends vs 3.24 on weekdays — 14% thinner on weekends. RN hours go from 0.53 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

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.

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.

24 citations, most serious first. The 17 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · J2024-03-01 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 protect residents' rights to formulate an advance directive for 1 (Resident #161) of 17 residents reviewed for advanced directives. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. Resident #161 had chosen Do Not Resuscitate status. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm after being unable to locate Resident #161's DNR form. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided…

  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 · J2024-03-01 · 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 interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm (approximately 63 minutes after LVN C was notified she had stopped breathing) due to being unable to locate Resident #161's DNR form. The facility failed to ensure that nursing staff provided Resident #161, who 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-03-01 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement written policies that prohibit abuse and neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm (approximately 63 minutes after LVN C was notified she had stopped breathing) due to being unable to locate Resident #161's DNR form. The facility failed to ensure that nursing staff provided Resident #161, who 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-03-01 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 6 residents (Resident #161) whose records were reviewed for Full code status. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-12-27 · tag F0635 — pattern
  Provide doctor's orders for the resident's immediate care at the time the resident was 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 observation, interview and record review, the facility failed to ensure at the time each resident was admitted , the facility had a physician order for the resident's immediate care for 1 (Resident #1) of 2 residents reviewed for residents receiving necessary care and services upon admission. The facility failed to follow physician orders for Resident #1 to be non-weight bearing to right foot. As a result, Resident #1 had right leg amputated just below knee. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. This failure placed the residents at risk of not receiving adequate care and services, and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 12/27/23 reflected the resident was a [AGE]…

  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 · K2023-12-27 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 2 residents reviewed for quality of care. The facility failed to ensure staff followed Resident #1's physician's orders by wound care physician for non-weight bearing when ambulating which led to Resident #1 having a below the knee amputation. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. This failure could place residents at risk of not receiving adequate care and services, and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 12/27/23 reflected the resident was a [AGE] year-old male 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-06-01 · 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 each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 resident (Resident # 1) reviewed for transfers.The facility failed to ensure LVN C utilized a gait belt to transfer Resident #1 while toileting which resulted in a right dislocated shoulder. This failure could place residents at risk for falls, injury and a diminished quality of life.The findings include:Record review of Resident #1's face sheet dated 5/28/2026 revealed a [AGE] year-old female, admitted on [DATE] with diagnoses which included: pneumonia (an infection that inflames the air sacs in the lungs), age related osteoporosis without current pathological fracture (natural, progressive loss of bone mass and density with age, however no broken bones have broken from the disease yet).Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMs score of 6 which indicated the resident was cognitively impaired. 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
• Potential for harm · D2026-06-01 · 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 interviews and record review the facility failed to develop a baseline care plan within 48 hours of admission that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 5 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop the baseline care plan for Resident #1 within 48 hours following his admission on [DATE]. This failure could place residents at risk for complications due to the potential for their immediate needs not being identified so interventions could be planned and initiated.Findings included: Record review of Resident #1's face sheet dated 5/28/2026 revealed a [AGE] year-old female, admitted on [DATE] with diagnoses which included: pneumonia (an infection that inflames the air sacs in the lungs), age related osteoporosis without current pathological fracture (natural, progressive loss of bone mass and density with age, however no broken bones have broken from…

  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 · D2026-03-12 · 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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcer treatment.The facility failed to ensure Resident #1's wound care treatments were implemented according to physician orders and wound care recommendations.This failure could place residents at risk of delayed wound healing, increased risk of infection, and further skin breakdown.Findings included:During a record review of Resident #1's face sheet, dated 03/12/2026, revealed a [AGE] year-old female, admitted [DATE], with diagnoses of displaced fracture of lateral condyle of left femur, subsequent encounter for closed fracture with routine healing (follow up care after initial surgery of left hip fracture), type 2 diabetes (chronic condition where the body resists insulin…

  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 · Fcited before2025-04-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, 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 kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated. 2. The facility failed to ensure prepared food was discarded after 72 hours (3 days) per facility policy. 3. The facility failed to check temperatures of food items prior to serving food. 4. The facility failed to ensure food was not handled with bare hands. 5. The facility failed to ensure food items remained covered on the steam table prior to food service between breakfast and lunch. 6. The facility failed to ensure personal food items were not stored in 1 of 2 of the kitchen refrigerators. 7. The facility failed to ensure dishes were washed and rinsed at the correct temperatures, per dishwasher manufacturer's instructions. These failures could place residents who received prepared meals…

  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 · E2025-04-10 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 residents (Resident #10 and #11), 2 of 2 residents who used a mechanical lift in the resident council meeting, and one unsampled resident reviewed for the mechanical lift. The facility failed to have sufficient mechanical lift slings to accommodate all residents who required the use of a sling (Resident #10, Resident #11, two residents in the resident council meeting). These failures could place residents at risk of a diminished quality of life due to an environment that is nonfunctional or uncomfortable. The findings included: Review of Resident #10's admission Record dated 4/10/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis included Multiple Sclerosis (an autoimmune disease-causing numbness, weakness, and trouble walking), and osteoporosis (thinning of the bone) without fracture. Review 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-10 · 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 failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #41) of two residents reviewed for transmission-based precautions care in that: 1. CNA G failed to wear required PPE when entering Resident #41's room on 04/08/2025. 2. HSK H failed to wear required PPE when entering Resident #41's room on 04/09/2025. 3. CNA I failed to wear required PPE when entering Resident #41's room on 04/10/2025. This failure could place resident's risk for cross contamination and the spread of infection. Findings included: Review of Resident #41's admission Record revealed she was an [AGE] year-old female originally admitted to the facility 03/14/2023 with a most recent admission date of 12/07/2024 with a diagnosis of recurrent enterocolitis due to clostridium difficile (infection of the colon…

  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 before2025-04-10 · 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 review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 13 residents (Resident #20 and 41) reviewed for care plans. There was no care plan addressing Resident #20's use of a gait belt across his wheelchair. There was no care plan addressing Resident #41's isolation status. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: Review of Resident #20's admission Record, dated 4/9/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fracture of thoracic vertebra with routine healing (upper back). Review of Resident #20's initial 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · 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 was possible for 1 of 3 residents (Resident #20) reviewed for accidents and hazards: The facility failed to ensure Resident #20 was thoroughly educated about the risks associated with strapping himself into his wheelchair with a gait belt (device typically used by aides as a transfer aide for more dependent resident to prevent falls). This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Review of Resident #20's admission Record, dated 4/9/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fracture of thoracic vertebra with routine healing (upper back). Review of Resident #20's initial MDS Assessment, dated 3/9/25 revealed: He had a mental status of 11 of 15 (indicating moderate cognitive impairment). He had range of motion…

  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 before2024-05-02 · 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 review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure that Resident #4 had a care plan in place for his use of diuretic medication. 2. The facility failed to ensure that Resident #5 had a care plan in place for her use of diuretic medication. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #4's admission Record dated 5/2/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included end stage renal disease with dependence on renal dialysis, congestive heart failure, and benign prostatic…

  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 · E2024-03-01 · tag F0552 — pattern
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 20 residents (Resident #34, Resident # 47, Resident#260) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #34 prior to administering Zoloft, an antidepressant used to treat depression. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #47 prior to administering Zoloft, an antidepressant used to treat obsessive compulsive disorder. The facility also failed to obtain informed consent…

  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 · Dcited before2024-03-01 · 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 provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (hall 100 medication cart) of 2 medication carts inspected for medication storage. The hall 100 medication cart had expired medications and wound care supplies. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation on 2/27/24 at 2:20 PM of Hall 100 medication cart with LVN B revealed: 1- 86 gram tube of antimicrobial wound gel, expired 12/8/2022. 8- 3 milliliter vials of sodium chloride inhalation solution expired 7/8/2022. 1-5X9inch Xeroform Petrolatum dressing, expired 2/2023. During an interview on 2/27/24 at 2:20 PM LVN B stated it was her cart and she was responsible for checking her cart for expired medications. LVN B stated expired medications may not have benefits for residents and therefore should not be used. During an interview on 2/27/24 at 4:00…

  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.

Fines & penalties

$135,553 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $16,350 — penalty dated 2026-06-01
• $16,448 — penalty dated 2024-03-01
• $102,755 — penalty dated 2023-12-27
• Medicare payment denial — starting 2024-01-26 for 1 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 16 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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