Cycle 1
Health 2024-10-10 · Fire 2024-10-10
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Itasca, TX
Avir at Itasca
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
409 S Files St, Itasca, TX
(254) 687-2383
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1997-08-04
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
0.71
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.07
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,141
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.54
Baseline 69.39% · Performance 42.50% · Measure score 5.54 · Achievement 5.18 · Improvement 5.54
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 2.55 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 31 |
| Staff flu vaccination coverage | 53.45% |
42%
11.5 pts better
|
Numerator 31 · Denominator 58 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
97.1%
1.9 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| 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 | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 2.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
2.7%
1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
3.3%
0.4 pts worse
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 2.6% · Q4 7.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
18.9%
8.9 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.7% · Q3 15.0% · Q4 10.5% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
10.8%
6 pts worse
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 17.4% · Q3 18.2% · Q4 20.8% · 4Q avg 16.8% · 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 | 6.3% |
15.4%
9.1 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 0.0% · Q3 8.5% · Q4 0.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
16.1%
7.4 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 11.6% · Q3 28.2% · Q4 28.9% · 4Q avg 23.5% · 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 | 0.0% |
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 | 10.0% |
15.0%
5 pts better
|
19.8%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 5.8% · Q3 4.1% · Q4 20.0% · 4Q avg 10.0% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.2%
1.1 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 5.4% · Q3 9.0% · Q4 4.9% · 4Q avg 5.3% · 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 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
12.0%
7.8 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.5% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
25.9%
16.8 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.1% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
6 health deficiencies
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-22
C · Minimal harm
2024-10-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
B · Minimal harm
2024-10-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
D · Potential for more than minimal harm
2023-08-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-01
C · Minimal harm
2023-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-01
D · Potential for more than minimal harm
2022-06-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-10
D · Potential for more than minimal harm
2022-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-10
D · Potential for more than minimal harm
2022-06-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-26
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 2024-12-12
D · Potential for more than minimal harm
2024-10-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
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 2024-10-31
D · Potential for more than minimal harm
2024-10-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-07-18
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 2024-07-19
F · Potential for more than minimal harm
2023-08-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-08-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-25
B · Minimal harm
2023-08-24
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-08-25
F · Potential for more than minimal harm
2022-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-09
E · Potential for more than minimal harm
2022-06-09
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 2022-07-09
D · Potential for more than minimal harm
2022-06-09
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 2022-07-09
D · Potential for more than minimal harm
2022-06-09
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 2022-07-09
B · Minimal harm
2022-06-09
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-07-09
Penalties and ownership
What sits behind the stars
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
409 S Files Street Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
409 S Files Street Opco, LLC
Operational/Managerial Control · Organization
409 S Files Street 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
Grandview Nursing And Rehabilitation Center
Grandview, TX
3-star overall rating with 2-star inspections with $21,125 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Avir at Hillsboro
Hillsboro, TX
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
#3
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
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