Cycle 1
Health 2025-03-21 · Fire 2025-03-21
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Bandera, TX
Avir At Bandera
3-star overall rating with 2-star inspections with $100,293 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
222 Fm 1077, Bandera, TX
(830) 796-4077
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
2009-09-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.48
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.60
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.65
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.43
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
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
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,229
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.06% · Performance 22.02% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.93
Baseline 7.16% · Performance 6.96% · Measure score 2.93 · Achievement 2.93 · Improvement 0.44
Total nurse turnover
0
Performance 63.23% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.39 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.69% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 12.33% · Lower 95% interval 7.67% |
| Discharge to community | 52.51% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 50% · Lower 95% interval 38.74% |
| 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 54 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 70.27% |
53.69%
16.6 pts better
|
Numerator 26 · Denominator 37 |
| Discharge mobility score | 62.16% |
50.94%
11.2 pts better
|
Numerator 23 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 5.06% |
8.2%
3.1 pts worse
|
Numerator 4 · Denominator 79 |
| Staff flu vaccination coverage | 16.9% |
42%
25.1 pts worse
|
Numerator 84 · Denominator 497 |
| Discharge function score | 72.97% |
56.45%
16.5 pts better
|
Numerator 27 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.1
1.1 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 5.6% |
3.3%
2.3 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.9% · Q3 3.8% · Q4 8.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
2.7%
3.3 pts worse
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.2% · Q3 5.5% · Q4 9.1% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
3.3%
2.9 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
18.9%
0.3 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 20.6% · Q3 16.2% · Q4 19.7% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
10.8%
7.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.7% · Q3 5.5% · Q4 2.0% · 4Q avg 3.7% · 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 | 8.2% |
15.4%
7.2 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.7% · Q3 9.0% · Q4 13.5% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
16.1%
7.4 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.1% · Q3 10.8% · Q4 15.3% · 4Q avg 8.7% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.9% |
15.0%
1.1 pts better
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 12.9% · Q3 17.6% · Q4 15.4% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.2%
2.6 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 2.8% · Q4 2.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
89.7%
8.1 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 97.3% · Q3 97.3% · Q4 98.6% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
12.0%
5.3 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 16.2% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.2% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
88.0%
7.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
25.9%
6.9 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 16.2% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-27 · Fire 2024-01-27
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-21
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-01-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-28
F · Potential for more than minimal harm
2024-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-28
E · Potential for more than minimal harm
2024-01-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-29
D · Potential for more than minimal harm
2024-01-27
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 2024-01-28
D · Potential for more than minimal harm
2024-01-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-16
F · Potential for more than minimal harm
2022-11-10
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-11-10
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2022-11-11
Inspection history
Recent health citations
K · Immediate jeopardy
2025-04-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-04-05
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 2025-04-06
E · Potential for more than minimal harm
2025-03-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-22
E · Potential for more than minimal harm
2025-03-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-03-22
E · Potential for more than minimal harm
2025-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-03-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-02-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-21
J · Immediate jeopardy
2024-06-20
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 2024-06-05
F · Potential for more than minimal harm
2024-01-27
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-01-28
F · Potential for more than minimal harm
2024-01-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-28
E · Potential for more than minimal harm
2024-01-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-28
E · Potential for more than minimal harm
2022-11-10
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-11-22
E · Potential for more than minimal harm
2022-11-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-10
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 2022-11-22
D · Potential for more than minimal harm
2022-11-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-22
Penalties and ownership
What sits behind the stars
$86,444
2025-03-21
Fine
Fine · fine $86,444
Fine
$13,849
2024-06-20
Fine
Fine · fine $13,849
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Campbell, Leslie
Operational/Managerial Control · Individual
Castillo, Lynnea
Operational/Managerial Control · Individual
Clayton, Jonathon
Operational/Managerial Control · Individual
Dominguez, Mariah
Operational/Managerial Control · Individual
Frias, Rhonda
Operational/Managerial Control · Individual
Heritage Tc Bandera LLC
Operational/Managerial Control · Organization
Hooper, Grady
Corporate Officer · Individual
Sehlke, Bryon
Operational/Managerial Control · Individual
Zurovec, Darrell
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cedar Creek Nursing And Rehabilitation Center
Bandera, TX
3-star overall rating with 3-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Avir at Comfort
Comfort, TX
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Kendall House Wellness & Rehabilitation
Boerne, TX
3-star overall rating with 3-star inspections with $88,390 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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