Houston, TX

Avir at Orem

4-star overall rating with 4-star inspections with $34,418 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

3730 W. Orem Drive, Houston, TX

(832) 799-6484

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

95

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Avir Health Group

Operator or chain grouping

Approved since

2012-06-07

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

0.42

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.87

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.64

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.28

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.32

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.34

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.34

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

46%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,815

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

Performance score

28.70

Composite VBP score used to determine payment impact.

Payment multiplier

0.9851

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

5.09

Baseline 10.40% · Performance 7.38% · Measure score 5.09 · Achievement 1.52 · Improvement 5.09

Total nurse turnover

0

Performance 68.08% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

3.52

Baseline 4.04 hours · Performance 4.08 hours · Measure score 3.52 · Achievement 3.52 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.2%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 6.77%
Discharge to community	43.93%	50.57% 6.6 pts worse	No Different than the National Rate · Eligible stays 34 · Observed rate 29.41% · Lower 95% interval 27.96%
Medicare spending per beneficiary	1.56	1.02 0.5 pts worse
Drug regimen review with follow-up	63.64%	95.27% 31.6 pts worse	Numerator 14 · Denominator 22
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 22
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	4.55%	2.29% 2.3 pts worse	Numerator 1 · Denominator 22 · Adjusted rate 2.68%
Healthcare-associated infections requiring hospitalization	7.38%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 4.34%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 140
Staff flu vaccination coverage	32.46%	42% 9.5 pts worse	Numerator 37 · Denominator 114
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 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	97.1% 2.6 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7%
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	1.4%	3.3% 1.9 pts better	3.3% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 1.1% · Q4 0.0% · 4Q avg 1.4% · 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	7.1%	3.3% 3.8 pts worse	5.4% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 9.8% · Q3 4.8% · Q4 3.8% · 4Q avg 7.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.8%	18.9% 6.9 pts worse	19.6% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 27.1% · Q3 26.2% · Q4 23.8% · 4Q avg 25.8%
Percentage of long-stay residents who received an antipsychotic medication	12.1%	10.8% 1.3 pts worse	16.7% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.0% · Q3 14.7% · Q4 12.7% · 4Q avg 12.1% · 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	37.0%	15.4% 21.6 pts worse	16.3% 20.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 59.5% · Q3 31.1% · Q4 30.4% · 4Q avg 37.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.2%	16.1% 15.1 pts worse	14.9% 16.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 35.1% · Q3 32.4% · Q4 25.7% · 4Q avg 31.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.9%	0.5% 1.4 pts worse	1.0% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	0.8% 0.1 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.4%	15.0% 7.4 pts worse	19.8% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 26.3% · Q3 23.2% · Q4 21.5% · 4Q avg 22.4%
Percentage of long-stay residents with pressure ulcers	7.1%	4.2% 2.9 pts worse	5.1% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.5% · Q3 5.7% · Q4 7.9% · 4Q avg 7.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	89.7% 9.8 pts better	81.7% 17.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5%
Percentage of short-stay residents who had an outpatient emergency department visit	3.0%	12.0% 9 pts better	12.0% 9 pts better	Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 4.5% · Expected 16.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 5.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.5%	88.0% 8.5 pts better	79.7% 16.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.1%	25.9% 1.8 pts better	23.9% 0.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 36.4% · Expected 35.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-04 · Fire 2025-04-04

2 health deficiencies

Top issue: Infection Control (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-02-17 · Fire 2024-02-17

11 health deficiencies

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

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2022-12-15 · Fire 2022-12-15

7 health deficiencies

Top issue: Resident Rights (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-09

F · Potential for more than minimal harm 2025-04-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-04

E · Potential for more than minimal harm 2025-04-04

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-04-24

E · Potential for more than minimal harm 2025-04-04

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-04-02

F · Potential for more than minimal harm 2024-02-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-15

F · Potential for more than minimal harm 2024-02-17

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-03-15

F · Potential for more than minimal harm 2024-02-17

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-15

F · Potential for more than minimal harm 2024-02-17

K900 · Miscellaneous Deficiencies

Fire Safety

Meet Health Care Facilities Code mechanical requirements.

Corrected 2024-03-15

E · Potential for more than minimal harm 2024-02-17

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-03-15

C · Minimal harm 2024-02-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-03-15

C · Minimal harm 2024-02-17

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-03-15

F · Potential for more than minimal harm 2022-12-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-12-22

F · Potential for more than minimal harm 2022-12-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-12-22

E · Potential for more than minimal harm 2022-12-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-12-22

E · Potential for more than minimal harm 2022-12-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-12-22

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-04-04

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-04-28

E · Potential for more than minimal harm 2025-04-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-28

D · Potential for more than minimal harm 2025-02-27

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 2025-03-31

D · Potential for more than minimal harm 2025-02-27

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 2025-03-31

D · Potential for more than minimal harm 2025-01-02

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 2025-01-27

D · Potential for more than minimal harm 2025-01-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-11-21

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 2025-01-06

D · Potential for more than minimal harm 2024-04-05

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 2024-05-07

J · Immediate jeopardy 2024-02-17

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-03-08

E · Potential for more than minimal harm 2024-02-17

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 2024-03-08

D · Potential for more than minimal harm 2024-02-17

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-17

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-17

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 2024-03-08

E · Potential for more than minimal harm 2022-12-15

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 2023-01-04