Cycle 1
Health 2024-09-26 · Fire 2024-09-26
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hillsboro, TX
Avir at Hillsboro
1-star overall rating with 2-star inspections with $106,740 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
411 Old Brandon Rd, Hillsboro, TX
(254) 582-8416
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1992-11-20
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
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.06
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
0.98
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
71%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,943
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.17
Baseline 17.84% · Performance 20.89% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Healthcare-associated infections
1.57
Baseline 6.92% · Performance 7.36% · Measure score 1.57 · Achievement 1.57 · Improvement 0
Total nurse turnover
1.05
Baseline 62.67% · Performance 59.38% · Measure score 1.05 · Achievement 1.05 · Improvement 0.37
Adjusted total nurse staffing
0
Baseline 2.79 hours · Performance 2.51 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.82% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 15.19% · Lower 95% interval 8.14% |
| Discharge to community | 44.92% |
50.57%
5.6 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 38.78% · Lower 95% interval 30.27% |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 55 |
| Falls with major injury | 3.64% |
0.77%
2.9 pts worse
|
Numerator 2 · Denominator 55 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 26 · Denominator 40 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 24 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 55 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.36% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 7.5% · Lower 95% interval 4.24% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 45 |
| Staff flu vaccination coverage | 26.39% |
42%
15.6 pts worse
|
Numerator 19 · Denominator 72 |
| Discharge function score | 65% |
56.45%
8.5 pts better
|
Numerator 26 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · 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 | 96.0% |
97.9%
1.9 pts worse
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.3%
3.2 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.6% · Q3 7.2% · Q4 5.9% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 19.3% |
18.9%
0.4 pts worse
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 18.8% · Q3 19.0% · Q4 18.0% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
10.8%
0.7 pts worse
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.9% · Q3 10.4% · Q4 19.0% · 4Q avg 11.5% · 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 | 11.7% |
15.4%
3.7 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 7.8% · Q3 15.0% · Q4 16.0% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
16.1%
4.2 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.1% · Q3 16.7% · Q4 10.9% · 4Q avg 11.9% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 3.7% |
15.0%
11.3 pts better
|
19.8%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 3.9% · Q4 8.0% · 4Q avg 3.7% |
| 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 5.1% · Q3 1.7% · Q4 1.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
12.0%
6.7 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.2% |
88.0%
13.8 pts worse
|
79.7%
5.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
25.9%
8.8 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 14.0% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-16 · Fire 2023-08-16
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-02
E · Potential for more than minimal harm
2024-09-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-26
F · Potential for more than minimal harm
2023-08-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-27
F · Potential for more than minimal harm
2023-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-27
F · Potential for more than minimal harm
2023-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-27
F · Potential for more than minimal harm
2023-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-29
F · Potential for more than minimal harm
2023-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-27
E · Potential for more than minimal harm
2023-08-16
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 2024-04-27
E · Potential for more than minimal harm
2023-08-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-27
E · Potential for more than minimal harm
2023-08-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-27
D · Potential for more than minimal harm
2022-05-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-09
H · Actual harm
2025-03-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-03-17
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 2025-03-19
D · Potential for more than minimal harm
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-26
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 2024-09-28
E · Potential for more than minimal harm
2024-09-26
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 2024-09-28
E · Potential for more than minimal harm
2024-09-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-28
E · Potential for more than minimal harm
2024-09-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-28
E · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-28
E · Potential for more than minimal harm
2024-09-26
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-09-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-09-26
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-26
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-09-28
J · Immediate jeopardy
2024-04-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-20
J · Immediate jeopardy
2024-04-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-20
J · Immediate jeopardy
2024-04-19
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 2024-04-20
D · Potential for more than minimal harm
2024-04-19
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 2024-04-20
E · Potential for more than minimal harm
2023-10-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-18
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 2023-09-20
E · Potential for more than minimal harm
2023-08-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-08-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-16
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 2023-08-18
D · Potential for more than minimal harm
2023-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-18
D · Potential for more than minimal harm
2022-05-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-26
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 2022-06-20
D · Potential for more than minimal harm
2022-05-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-20
Penalties and ownership
What sits behind the stars
$98,719
2025-03-17
Fine
Fine · fine $98,719
Fine
$8,021
2024-04-19
Fine
Fine · fine $8,021
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
411 Old Brandon Road Opco, LLC
Operational/Managerial Control · Organization
411 Old Brandon Road Property Owner, LLC
5% Or Greater Security Interest · Organization
Earhart, James
Operational/Managerial Control · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Welltower Nnn Group, LLC
5% Or Greater Security Interest · Organization
Welltower Op LLC
5% Or Greater Security Interest · Organization
Wright, Laban
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Town Hall Estates
Hillsboro, TX
1-star overall rating with 1-star inspections with $83,494 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Avir at Itasca
Itasca, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Whitney Nursing And Rehabilitation Center
Whitney, TX
1-star overall rating with 2-star inspections with $45,435 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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