Cycle 1
Health 2024-11-21 · Fire 2024-11-21
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Pasadena, TX
Avir at Pasadena
4-star overall rating with 3-star inspections with $30,361 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4300 Vista Rd, Pasadena, TX
(713) 946-6787
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1996-09-11
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
0.44
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,991
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
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
0.59
Performance 7.66% · Measure score 0.59 · Achievement 0.59 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.85
Performance 31.58% · Measure score 7.85 · Achievement 7.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.62 hours · Performance 3.07 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 6.77% |
| Discharge to community | 49.98% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 45% · Lower 95% interval 35.32% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 90.32% |
95.27%
5 pts worse
|
Numerator 28 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 1 · Denominator 31 · Adjusted rate 2.14% |
| Healthcare-associated infections requiring hospitalization | 7.66% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 33.62% |
42%
8.4 pts worse
|
Numerator 39 · Denominator 116 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · 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 | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.3 · 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 | 98.0% |
97.9%
0.1 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 2.1% · Q4 2.0% · 4Q avg 2.6% · 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 | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.4% · Q4 1.2% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
18.9%
4.2 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 23.2% · Q3 24.7% · Q4 27.7% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
10.8%
7.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.2% · Q3 2.8% · Q4 2.9% · 4Q avg 3.7% · 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 | 9.0% |
15.4%
6.4 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.5% · Q3 2.8% · Q4 14.8% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
16.1%
3.3 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.1% · Q3 10.1% · Q4 26.3% · 4Q avg 12.8% · 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 | 8.6% |
15.0%
6.4 pts better
|
19.8%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.5% · Q3 5.4% · Q4 12.2% · 4Q avg 8.6% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 1.1% · Q4 4.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.7%
9.5 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.4% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
12.0%
6.5 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 6.7% · Expected 13.5% · Used in QM five-star |
| 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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
88.0%
1.3 pts worse
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
25.9%
4.2 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 33.3% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-29 · Fire 2022-06-29
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-23
E · Potential for more than minimal harm
2024-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-23
E · Potential for more than minimal harm
2024-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-17
F · Potential for more than minimal harm
2023-10-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-10-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-10-13
D · Potential for more than minimal harm
2022-06-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-29
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-21
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 2024-01-02
F · Potential for more than minimal harm
2024-11-21
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 2024-11-22
E · Potential for more than minimal harm
2024-11-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-08
E · Potential for more than minimal harm
2023-10-12
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 2023-11-03
D · Potential for more than minimal harm
2023-10-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-10-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-10-16
J · Immediate jeopardy
2023-09-01
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 2023-09-12
J · Immediate jeopardy
2023-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-12
J · Immediate jeopardy
2023-09-01
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 2023-09-12
D · Potential for more than minimal harm
2023-09-01
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-09-12
E · Potential for more than minimal harm
2022-06-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-05
Penalties and ownership
What sits behind the stars
$8,021
2024-11-21
Fine
Fine · fine $8,021
Fine
$22,340
2023-09-01
Fine
Fine · fine $22,340
Fine
Ownership
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Gopalakrishnan, Thandavarajan
Operational/Managerial Control · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Weathers, Kimberly
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Focused Care At Pasadena
Pasadena, TX
1-star overall rating with 2-star inspections with $131,012 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Pasadena Post Acute
Pasadena, TX
3-star overall rating with 3-star inspections with $27,254 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Hca Houston Healthcare Southeast
Pasadena, TX
0-star overall rating with 0-star inspections with 9 fire-safety deficiencies in the latest cycle
Jump out