Jefferson, TX

Avir At Jefferson

1-star overall rating with 2-star inspections with $16,498 in total fines with 14 recent health deficiencies

1307 Martin Luther King Dr, Jefferson, TX

(903) 665-3951

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

116

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Avir Health Group

Operator or chain grouping

Approved since

1994-01-01

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

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

0.43

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.58

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.52

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.53

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.01

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.85

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.24

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.46

CMS adjusted RN staffing hours

Adjusted total hours

3.77

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

38%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,559

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.77

Composite VBP score used to determine payment impact.

Payment multiplier

0.9893

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.54

Baseline 17.87% · Performance 21.18% · Measure score 0.54 · Achievement 0.54 · Improvement 0

Healthcare-associated infections

4.37

Baseline 8.05% · Performance 6.56% · Measure score 4.37 · Achievement 4.25 · Improvement 4.37

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

5.82

Baseline 4.69 hours · Performance 4.73 hours · Measure score 5.82 · Achievement 5.82 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.09%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 70 · Observed rate 7.14% · Lower 95% interval 6.66%
Discharge to community	41.07%	50.57% 9.5 pts worse	No Different than the National Rate · Eligible stays 48 · Observed rate 33.33% · Lower 95% interval 30.7%
Medicare spending per beneficiary	1.35	1.02 0.3 pts worse
Drug regimen review with follow-up	98.75%	95.27% 3.5 pts better	Numerator 79 · Denominator 80
Falls with major injury	2.5%	0.77% 1.7 pts worse	Numerator 2 · Denominator 80
Discharge self-care score	54.17%	53.69% 0.5 pts better	Numerator 26 · Denominator 48
Discharge mobility score	45.83%	50.94% 5.1 pts worse	Numerator 22 · Denominator 48
Pressure ulcers or injuries, new or worsened	8.75%	2.29% 6.5 pts worse	Numerator 7 · Denominator 80 · Adjusted rate 8.58%
Healthcare-associated infections requiring hospitalization	6.56%	7.12% 0.6 pts better	No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 3.86%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 114
Staff flu vaccination coverage	73.17%	42% 31.2 pts better	Numerator 90 · Denominator 123
Discharge function score	47.92%	56.45% 8.5 pts worse	Numerator 23 · Denominator 48
Transfer of health information to provider	96.55%	95.95% 0.6 pts better	Numerator 28 · Denominator 29
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	18.92%	25.2% 6.3 pts worse	Numerator 7 · Denominator 37

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · 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 98.7% · Q2 98.6% · Q3 100.0% · Q4 98.8% · 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	5.7%	3.3% 2.4 pts worse	3.3% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.4% · Q3 5.3% · Q4 5.8% · 4Q avg 5.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.5%	2.7% 1.2 pts better	11.4% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.5% · Q3 0.0% · Q4 1.3% · 4Q avg 1.5%
Percentage of long-stay residents who lose too much weight	9.2%	3.3% 5.9 pts worse	5.4% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.5% · Q3 12.1% · Q4 10.3% · 4Q avg 9.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.4%	18.9% 3.5 pts worse	19.6% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 18.9% · Q3 21.3% · Q4 23.9% · 4Q avg 22.4%
Percentage of long-stay residents who received an antipsychotic medication	11.6%	10.8% 0.8 pts worse	16.7% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 9.5% · Q3 12.5% · Q4 13.7% · 4Q avg 11.6% · 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	24.1%	15.4% 8.7 pts worse	16.3% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 36.6% · Q3 21.7% · Q4 13.1% · 4Q avg 24.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.1%	16.1% 9 pts worse	14.9% 10.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 30.6% · Q3 29.3% · Q4 17.2% · 4Q avg 25.1% · 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	1.0%	0.8% 0.2 pts worse	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.3% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.3%	15.0% 6.3 pts worse	19.8% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 36.3% · Q3 15.5% · Q4 13.1% · 4Q avg 21.3%
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 8.1% · Q2 6.7% · Q3 2.8% · Q4 4.0% · 4Q avg 5.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.7%	89.7% About the same	81.7% 8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 88.0% · Q3 92.3% · Q4 94.0% · 4Q avg 89.7%
Percentage of short-stay residents who had an outpatient emergency department visit	22.4%	12.0% 10.4 pts worse	12.0% 10.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 22.6% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.1%	1.5% 0.6 pts worse	1.6% 0.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.9% · Q4 3.1% · 4Q avg 2.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.4%	88.0% 1.4 pts better	79.7% 9.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.9%	25.9% 3 pts worse	23.9% 5 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 27.4% · Expected 22.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-03 · Fire 2025-12-03

14 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-09-19 · Fire 2024-09-19

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-08-16 · Fire 2023-08-16

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-09-19

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 2024-10-18

E · Potential for more than minimal harm 2024-09-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-10-18

E · Potential for more than minimal harm 2024-09-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-10-18

F · Potential for more than minimal harm 2023-08-16

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-09-15

E · Potential for more than minimal harm 2023-08-16

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2023-09-22

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-12-03

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 2025-12-07

E · Potential for more than minimal harm 2025-12-03

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 2025-12-07

E · Potential for more than minimal harm 2025-12-03

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 2025-12-07

E · Potential for more than minimal harm 2025-12-03

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 2025-12-07

E · Potential for more than minimal harm 2025-12-03

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-12-07

E · Potential for more than minimal harm 2025-12-03

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 2025-12-07

E · Potential for more than minimal harm 2025-12-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-07

D · Potential for more than minimal harm 2025-12-03

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-12-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-12-07

D · Potential for more than minimal harm 2025-12-03

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-12-07

D · Potential for more than minimal harm 2025-12-03

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 2025-12-07

D · Potential for more than minimal harm 2025-12-03

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-12-07

D · Potential for more than minimal harm 2025-12-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-12-07

D · Potential for more than minimal harm 2025-12-03

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-12-07

F · Potential for more than minimal harm 2024-09-19

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 2024-10-18

E · Potential for more than minimal harm 2024-09-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

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 2024-10-18

D · Potential for more than minimal harm 2024-09-19

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

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 2024-10-18

D · Potential for more than minimal harm 2024-09-19

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

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 2024-10-18

D · Potential for more than minimal harm 2024-09-19

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 2024-10-18

D · Potential for more than minimal harm 2024-09-19

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-19

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-07-31

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 2024-08-30

G · Actual harm 2024-04-23

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-04-30

E · Potential for more than minimal harm 2024-04-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-30

G · Actual harm 2023-09-20

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 2023-10-20

D · Potential for more than minimal harm 2023-09-20

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-10-20

F · Potential for more than minimal harm 2023-08-16

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 2023-09-12

E · Potential for more than minimal harm 2023-08-16

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-09-12