Cycle 1
Health 2025-03-20 · Fire 2025-03-20
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
Avir at Houston
2-star overall rating with 1-star inspections with $216,791 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2310 S Eldridge Parkway, Houston, TX
(281) 558-3900
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
2005-10-05
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
0.65
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
0.18
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
1.55
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
1.29
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
1.53
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,516
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.27
Baseline 21.86% · Performance 21.00% · Measure score 1.27 · Achievement 0.93 · Improvement 1.27
Healthcare-associated infections
3.40
Baseline 6.64% · Performance 6.82% · Measure score 3.40 · Achievement 3.40 · Improvement 0
Total nurse turnover
2.17
Performance 54.81% · Measure score 2.17 · Achievement 2.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.75
Baseline 3.95 hours · Performance 4.14 hours · Measure score 3.75 · Achievement 3.75 · Improvement 0.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 227 · Observed rate 11.01% · Lower 95% interval 8.64% |
| Discharge to community | 59.69% |
50.57%
9.1 pts better
|
Better than the National Rate · Eligible stays 239 · Observed rate 51.05% · Lower 95% interval 54.01% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.34% |
95.27%
1.1 pts better
|
Numerator 79 · Denominator 82 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 82 |
| Discharge self-care score | 45.28% |
53.69%
8.4 pts worse
|
Numerator 24 · Denominator 53 |
| Discharge mobility score | 50.94% |
50.94%
About the same
|
Numerator 27 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 82 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 7.19% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 143 |
| Staff flu vaccination coverage | 17.74% |
42%
24.3 pts worse
|
Numerator 22 · Denominator 124 |
| Discharge function score | 58.49% |
56.45%
2 pts better
|
Numerator 31 · Denominator 53 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 58.33% |
25.2%
33.1 pts better
|
Numerator 21 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 90.9% |
97.9%
7 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.4% · Q3 1.9% · Q4 1.8% · 4Q avg 2.2% · 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 | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
18.9%
2.9 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 17.9% · Q3 14.6% · Q4 16.0% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
10.8%
5.2 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 13.0% · Q4 4.0% · 4Q avg 5.6% · 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 | 17.9% |
15.4%
2.5 pts worse
|
16.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.7% |
16.1%
12.4 pts better
|
14.9%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.2% · Q3 5.3% · Q4 2.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
0.5%
2.6 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.9% · Q3 5.6% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.3% |
15.0%
7.7 pts better
|
19.8%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 16.2% · Q4 5.0% · 4Q avg 7.3% |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
4.2%
4.8 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.4% · Q3 15.1% · Q4 9.1% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.7%
10.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.7% · Q3 99.7% · Q4 99.7% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
12.0%
3 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.8% |
88.0%
10.2 pts worse
|
79.7%
1.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
25.9%
3.2 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 23.5% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-20 · Fire 2024-02-20
4 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-20
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-20
F · Potential for more than minimal harm
2024-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-02-20
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-02-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-19
E · Potential for more than minimal harm
2023-01-05
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-02-05
D · Potential for more than minimal harm
2023-01-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-05
Inspection history
Recent health citations
K · Immediate jeopardy
2025-12-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-12-02
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-11-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-12-06
D · Potential for more than minimal harm
2025-11-19
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 2025-12-06
E · Potential for more than minimal harm
2025-03-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
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 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-20
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 2025-04-20
D · Potential for more than minimal harm
2025-03-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-07
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 2025-03-28
E · Potential for more than minimal harm
2025-03-07
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-07
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 2025-03-28
J · Immediate jeopardy
2024-02-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-23
J · Immediate jeopardy
2024-02-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-23
E · Potential for more than minimal harm
2024-02-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-03-23
E · Potential for more than minimal harm
2024-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-23
D · Potential for more than minimal harm
2023-12-07
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 2023-12-27
K · Immediate jeopardy
2023-11-08
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 2023-11-22
K · Immediate jeopardy
2023-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-09-19
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 2023-10-16
D · Potential for more than minimal harm
2023-01-05
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-02-05
Penalties and ownership
What sits behind the stars
$188,050
2025-11-19
Fine
Fine · fine $188,050
Fine
$10,845
2024-02-20
Fine
Fine · fine $10,845
Fine
$0
2024-02-20
Payment Denial
Payment Denial · denial start 2024-03-20 · 3 days
3 day denial
$17,896
2023-11-08
Fine
Fine · fine $17,896
Fine
Ownership
Freund, Nochum
Corporate Officer · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Nearby options
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#2
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4-star overall rating with 3-star inspections with $45,741 in total fines with 2 recent health deficiencies
#3
Park Manor Of Westchase
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1-star overall rating with 1-star inspections with $109,932 in total fines with 10 recent health deficiencies
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