Cycle 1
Health 2024-10-31 · Fire 2024-10-31
7 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Lancaster, TX
Avir At Lancaster
2-star overall rating with 2-star inspections with abuse icon flag with $39,757 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1241 Westridge Ave, Lancaster, TX
(972) 227-5110
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1999-10-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing
LPN hours / resident day
0.69
Licensed practical nurse staffing
Aide hours / resident day
1.76
Nurse aide staffing
Weekend hours
2.89
Weekend nurse staffing
RN turnover
64%
Annual RN turnover
Total nurse turnover
68%
Annual nurse turnover
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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
97.9%
0.3 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
2.7%
1.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.4% |
18.9%
18.5 pts worse
|
19.6%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 29.6% |
10.8%
18.8 pts worse
|
16.7%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.4% |
15.4%
1 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
16.1%
4.2 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
0.8%
0.7 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.7% |
15.0%
5.3 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.2%
1.3 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
89.7%
4.1 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.0% |
88.0%
33 pts worse
|
79.7%
24.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-07-20 · Fire 2022-07-20
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-10-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-31
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 2024-12-13
E · Potential for more than minimal harm
2024-10-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-13
F · Potential for more than minimal harm
2023-09-20
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 2023-10-20
E · Potential for more than minimal harm
2023-09-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-20
E · Potential for more than minimal harm
2022-07-20
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 2022-09-28
E · Potential for more than minimal harm
2022-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-28
C · Minimal harm
2022-07-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-24
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Not marked corrected
D · Potential for more than minimal harm
2025-11-05
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-11-06
J · Immediate jeopardy
2025-06-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-20
E · Potential for more than minimal harm
2024-10-31
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-31
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 2024-11-15
E · Potential for more than minimal harm
2024-10-31
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 2024-11-15
E · Potential for more than minimal harm
2024-10-31
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-15
J · Immediate jeopardy
2024-09-18
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 2024-08-19
E · Potential for more than minimal harm
2024-09-18
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 2024-09-19
E · Potential for more than minimal harm
2024-09-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-09-18
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 2024-09-19
F · Potential for more than minimal harm
2023-09-20
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 2023-10-07
D · Potential for more than minimal harm
2023-09-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-20
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 2023-10-07
D · Potential for more than minimal harm
2023-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-07
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 2023-10-07
E · Potential for more than minimal harm
2022-07-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-20
E · Potential for more than minimal harm
2022-07-20
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-08-20
E · Potential for more than minimal harm
2022-07-20
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 2022-08-20
D · Potential for more than minimal harm
2022-07-20
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 2022-08-20
D · Potential for more than minimal harm
2022-07-20
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-08-20
Penalties and ownership
What sits behind the stars
$26,130
2025-06-19
Fine
Fine · fine $26,130
Fine
$13,627
2024-09-18
Fine
Fine · fine $13,627
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Hooper, Grady
Corporate Officer · Individual
Leonard, Joshua
Operational/Managerial Control · Individual
Slp Lancaster LLC
Operational/Managerial Control · Organization
Wm 41 Flatonia Re LLC
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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Lancaster Nursing & Rehabilitation
Lancaster, TX
1-star overall rating with 1-star inspections with $55,760 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Millbrook Healthcare and Rehabilitation Center
Lancaster, TX
2-star overall rating with 3-star inspections with $13,565 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Windsor Gardens
Lancaster, TX
3-star overall rating with 3-star inspections with $13,877 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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