Avir at Western Hills

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.

58.3% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 120 beds and averages 84.9 residents a day — about 71% occupied, or roughly 35 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.76 hrs/resident/day on weekends vs 3.33 on weekdays — 17% thinner on weekends. RN hours go from 0.55 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 75% is well above 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 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.

32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-11-20 · 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 assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for supervision:The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility across the street in the parking lot of the convenience store on Saturday, 11/12/25 at 7:45 AM. The facility had a plan in place to monitor the front door, but the lock was not working to prevent Resident #1's elopement. The noncompliance was identified as PNC. The IJ began on 11-12-2025 and ended on 11-14-2025. The facility had corrected the noncompliance before the survey began.The findings included:Record review of Resident #1s chart reflected he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of acute respiratory failure with hypercapnia, unspecified dementia, unspecified severity, with other behavioral…

  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
• Immediate jeopardy · Jcited before2025-07-02 · 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 received adequate supervision to prevent accidents for 1 of 1 resident (Resident #2) reviewed for elopement.On 06/11/2025 Resident #2 eloped from the facility; On 06/25/2025 a Record Review of the Facility Incident report was completed. According to the Report, it was estimated that Resident #2 left the facility between 5:30PM and 6:00PM, was found on the grounds of a nearby apartment complex, and taken to the ER with an admission time around 7:10PM. The noncompliance was identified as PNC . The Immediate Jeopardy began on 6/11/25 and ended on 6/12/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of physical injury.Findings include: Review of Resident #2’s face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis of secondary malignant neoplasm of the brain (cancer cells that have spread to the brain…

  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 before2025-01-22 · 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 interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 (Resident #8) of 15 residents reviewed for accidents and hazards. The facility failed to ensure CNA G performed appropriate incontinent care on Resident #8 when she asked her to hold onto the bed, which subsequently led to Resident #8 losing grip of the bed, falling to the ground, and sustaining a skin tear to her right forearm and bump to the left side of her forehead. This deficient practice could place residents at risk of injuries. Findings include: Review of Resident #8's admission record, dated 01/22/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 had diagnoses including unspecified Parkinsonism (a general term for a group of neurological disorders that affect movement), unspecified fall, unspecified pain, age-related physical debility (a symptom of frailty, which is a syndrome…

  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 · D2026-06-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  During Observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; for 1 of 6 residents (Resident #1) reviewed for quality of care.-The facility failed to ensure the ADON did not leave Resident #1 without providing incontinent care, when the resident had an BM on 06/11/2026 at 2:35 pm.This failure could result in skin breakdown, infection, and a significant decline in Resident #1's health.Findings included:Record review of Resident #1's face sheet revealed she is a forty-three-year-old woman with a diagnosis of cerebral palsy, aphasia, dysphagia, muscle weakness, muscle wasting and atrophy, epilepsy, and quadriplegia.Record review of Resident #1's care plan revealed she is dependent on staff etc. for meeting emotional, intellectual, physical, and social needs r/t Disease process (cerebral palsy), Immobility, Physical Limitations. Resident #1 is at high risk for falls related to Cerebral Palsy, muscle…

  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 · D2026-05-27 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  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 was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 2 residents (Resident # 1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with dignity and respect when her foley bag was uncovered and exposed, and was 1/4 full of urine. This failure could place residents at risk of lack of comfortability and respect, as well as a decline in self-worth. Findings include: Record review of Resident #1's face sheet, dated 05/27/26, reflected a [AGE] year-old female who was admitted to the facility 12/30/24. Resident #1 had diagnoses which included cerebral palsy (abnormal brain development), obstructive (blockage) and reflux (travels wrong way) uropathy (disease of urinary tract), unspecified, retention of urine, unspecified and presence…

  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 · E2025-12-29 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 confidential residents interviewed for grievances. The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance. Findings included: Review of the November and December 2025 grievance logs revealed 5 grievances in November, all which had documented follow up dates and resolutions noted. 7 grievances were documented in December which had follow up dates and resolutions noted. In confidential interviews on 12/29/2025 with residents who had filed grievances with the facility revealed none of them had received written findings of their grievances. Some stated that they never received verbal investigation findings and were not aware if staff they had complained about had received education, or disciplinary action. The confidential residents all recalled being spoken to by…

  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 before2025-12-29 · tag F0806 — failed to honor food preferences — pattern
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  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 food that accommodates residents' allergies, intolerances, and preferences for 1 (Resident #1) of 5 residents reviewed for food preferences and allergies. The facility failed on 10/20/25, 10/22/25, 11/17/25, 12/8/25, and 12/27/25 to serve Resident #1 meals that excluded foods she was allergic to or foods that aligned with her religious beliefs. This failure placed residents at risk of food-related medical emergencies and did not honor their religious preferences. Findings included: Review of Resident #1's quarterly MDS dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: anemia (deficiency of red blood cells), neurogenic bladder (a condition where neurological conditions affect bladder function, leading to issues with bladder control), anxiety (feelings of worry, nervousness or unease), bipolar disorder (mental disorder characterized by wide mood swings), schizophrenia (mental…

  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 · Ecited before2025-05-08 · 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, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: Food items were not labeled and/or dated. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 5/06/2025 at 7:50 am in the refrigerator reflected the following: o Sliced ham in a container with water in it dated 4-28-2025 with no discard date. o Sliced bread in a serving pan with no date. o 2-boiled eggs in a zip lock bag dated 4-25-2025 with no discard date. o 2-side serving bowls with appeared to be pureed chicken dated 4-30-2025 with no discard date. o A container of what appeared to be grits with no date and was still warmed. Observation on 5/06/2025 at 8:15 am in the pantry reflected the following: o An open bag of potato chips not wrapped up with no discard date. o An open bag of grits not wrapped up with no discard date. Interview on 05/08/25…

  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 before2025-05-08 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  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 provide food that accommodates residents' allergies, intolerance's, and preferences for 2 of 3 residents (Resident #13 and Resident #46) reviewed for food allergies. The facility failed to honor Resident #13 and Resident #46's food preference of an alternative meal according to their meal ticket. This failure could place the residents at risk of not having their preference honored and a diminished quality of life. Findings included: Review of Resident # 13's face sheet, dated, 05/08/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses which included need for assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), anemia in chronic kidney disease (a common complication where the body has a deficiency of red blood cells or hemoglobin, which can lead to a reduced ability to carry oxygen…

  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 before2025-05-08 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection 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 1 of 3 residents (Resident #73) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN A provided gastric tube feeding for Resident #73. This failure could place residents at-risk for spread of infection. Findings included: Record review of Resident #73's face sheet dated 07/10/2024 revealed she was a [AGE] year-old woman, with an initial admission date of 07/10/2024, with re-admission on [DATE] and with diagnoses of Nontraumatic Intracerebral Hemorrhage, Unspecified (bleeding within the brain tissue that is not caused by head trauma). Record review of Resident #73's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-30 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 ensure the right to be free from misappropriation of resident property for one of three residents (Resident #1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's oxycodone HCl Oral Tablet 5 MG, 16 tablets (an oxycodone pain reliever) received through hospice and reported missing on 04/18/2025. The noncompliance was identified as PNC. The non-compliance began on 04/10/2025 and ended on 04/28/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings included: Review of Resident #1's face sheet printed 04/30/2025 reflected a [AGE] year-old female admitted to the facility 12/04/2023. Her diagnoses included pain unspecified, chronic kidney disease stage 5, and other osteoporosis with current pathological fracture 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2025-01-22 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 each resident had the right to be free from misappropriation of property for 6 of 10 residents ( Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, and Resident #15) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #10's Oxycodone (a schedule II controlled opioid medication used to treat moderate to severe pain) taking taken during the days of 10/17/24 through 10/21/24, and Residents #11, #12, #13, #14 and #15's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain) taken on unknown dates. This failure placed residents at risk for not receiving prescribed medications for pain relief. Findings included: 1. Review of Resident #10's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, stage 5 (kidney failure), congestive heart failure (heart…

  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
• Potential for harm · Ecited before2025-01-22 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 7 of 9 (Resident #10, #11, #12, #13, #14, #15, and #16) residents reviewed. A. The facility failed to ensure Resident #16 received Rifaximin (an antibiotic used to prevent hepatic encephalopathy). Ten doses of the medication were missed during the 34 days stay at the facility. B. The facility failed to prevent the misappropriation of Resident #10's Oxycodone (a schedule II controlled opioid medication used to treat moderate to severe pain) taken during the days of 10/17/24 through 10/21/24, and Residents #11, #12, #13, #14 and #15's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain) taken on unknown dates. This deficient practice could place residents at risk for adverse effects by not receiving the therapeutic effects…

  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

$16,562 in federal fines across 2 penalties.

• $8,281 — penalty dated 2025-11-20
• $8,281 — penalty dated 2025-07-02

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 14 rows in the source record cover these 13 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