13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Waco, TX
2-star overall rating with 2-star inspections with $29,666 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
820 Jeffrey Dr, Waco, TX
(254) 772-9480
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
95
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1984-06-22
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
RN hours / resident day
0.16
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.29
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
3.09
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
12,173
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
1.55
Performance 57.35% · Measure score 1.55 · Achievement 1.55 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.17
Baseline 3.29 hours · Performance 3.41 hours · Measure score 1.17 · Achievement 1.17 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 13.16% · Lower 95% interval 6.64% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.6 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · 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 19 · 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 19 · 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 57 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 11 · Denominator 88 |
| 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 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.0 · Expected 1.7 · 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 | 3.5% |
3.3%
0.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 3.2% · Q4 4.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
2.7%
0.2 pts worse
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 1.8% · Q4 4.8% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
3.3%
1.1 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.8% · Q3 1.9% · Q4 1.7% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
18.9%
0.7 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 15.5% · Q3 17.9% · Q4 16.4% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
10.8%
11.6 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 23.8% · Q3 18.4% · Q4 21.4% · 4Q avg 22.4% · 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 | 24.0% |
15.4%
8.6 pts worse
|
16.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.3% · Q2 14.2% · Q3 15.0% · Q4 24.6% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
16.1%
1.5 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.9% · Q2 8.9% · Q3 9.6% · Q4 7.0% · 4Q avg 17.6% · 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 | 11.7% |
15.0%
3.3 pts better
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 13.2% · Q3 14.4% · Q4 10.9% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.7% · Q3 2.3% · Q4 1.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.7%
8.9 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
12.0%
6.8 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 20.8% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 12.5% |
1.5%
11 pts worse
|
1.6%
10.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.4% |
25.9%
14.5 pts worse
|
23.9%
16.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.4% · Observed 45.8% · Expected 27.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Resident Rights (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-10
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 2025-02-10
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-22
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-22
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-08
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-08
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-06
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-12-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-30
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-31
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-10
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 2025-02-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-10
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-10
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-02-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-10
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-02-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-10
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 2025-02-10
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-02-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-21
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 2024-07-21
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-24
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 2024-05-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-09
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-04-09
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-22
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 2024-02-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-22
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-22
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-02-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-20
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 2023-05-20
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 2022-12-10
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 2022-12-10
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 2022-12-10
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-10
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2022-12-10
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-12-10
Penalties and ownership
Fine · fine $21,645
Fine
Fine · fine $8,021
Fine
Payment Denial · denial start 2024-05-07 · 3 days
3 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Mortgage Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Mortgage Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Mortgage Interest · Organization
5% Or Greater Mortgage Interest · Organization
5% Or Greater Mortgage Interest · Organization
Nearby options
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