Cycle 1
Health 2024-12-04 · Fire 2024-12-04
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Athens, TX
Avir at Athens
2-star overall rating with 3-star inspections with $243,325 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
150 Gibson Rd, Athens, TX
(903) 677-5864
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
74
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Summit Ltc
Operator or chain grouping
Approved since
1989-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 3 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
65%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,557
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.78
Performance 21.07% · Measure score 0.78 · Achievement 0.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 7.87% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 33.33% · Performance 64.91% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.72
Baseline 2.86 hours · Performance 3.22 hours · Measure score 0.72 · Achievement 0 · Improvement 0.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 12.94% · Lower 95% interval 8.05% |
| Discharge to community | 59.46% |
50.57%
8.9 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 60.42% · Lower 95% interval 46.36% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 12 · Denominator 24 |
| Discharge mobility score | 16.67% |
50.94%
34.3 pts worse
|
Numerator 4 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 2 · Denominator 36 · Adjusted rate 4.65% |
| Healthcare-associated infections requiring hospitalization | 7.87% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 4.68% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 22.62% |
42%
19.4 pts worse
|
Numerator 19 · Denominator 84 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 10 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.1%
2.5 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
3.3%
1.9 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.8% · Q4 1.9% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
18.9%
5.1 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.2% · Q3 8.9% · Q4 9.3% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
10.8%
9.1 pts worse
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 22.2% · Q3 19.1% · Q4 17.8% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.9% |
15.4%
1.5 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 21.3% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.5% |
16.1%
5.4 pts worse
|
14.9%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 22.0% · Q3 3.7% · Q4 34.6% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.1% |
15.0%
3.9 pts better
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 11.1% · Q3 8.1% · Q4 7.6% · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.2%
1.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 2.6% · Q4 3.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
89.7%
4.8 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 94.3% · Q3 95.1% · Q4 98.0% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.9% |
12.0%
7.9 pts worse
|
12.0%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 21.9% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 3.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
88.0%
4.5 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
25.9%
5.9 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 31.2% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
12 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-09-13 · Fire 2022-09-13
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-04
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-12-06
E · Potential for more than minimal harm
2023-10-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-17
F · Potential for more than minimal harm
2022-09-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-12-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-12-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-06
J · Immediate jeopardy
2024-11-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-19
J · Immediate jeopardy
2024-11-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-19
J · Immediate jeopardy
2024-11-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-03
K · Immediate jeopardy
2023-10-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-10-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-27
C · Minimal harm
2023-10-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-08-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-22
Penalties and ownership
What sits behind the stars
$8,400
2024-11-26
Fine
Fine · fine $8,400
Fine
$8,400
2024-11-26
Fine
Fine · fine $8,400
Fine
$12,844
2024-11-26
Fine
Fine · fine $12,844
Fine
$213,681
2023-10-25
Fine
Fine · fine $213,681
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
150 Gibson Rd Opco, LLC
Operational/Managerial Control · Organization
Batson, Justin
Operational/Managerial Control · Individual
Edwards, Jonathan
Operational/Managerial Control · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Officer · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
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