Cycle 1
Health 2025-08-29 · Fire 2025-08-29
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
El Paso, TX
Avir At Patriot
1-star overall rating with 2-star inspections with $38,235 in total fines with 18 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
11490 Gateway North Blvd., El Paso, TX
(915) 317-1758
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
136
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
2019-08-30
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
0.15
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.68
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.89
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.43
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
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.14
CMS adjusted RN staffing hours
Adjusted total hours
2.58
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,480
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.36
Baseline 19.89% · Performance 20.80% · Measure score 1.36 · Achievement 1.36 · Improvement 0
Healthcare-associated infections
4.50
Baseline 9.30% · Performance 7.15% · Measure score 4.50 · Achievement 2.29 · Improvement 4.50
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
1.21
Baseline 2.47 hours · Performance 3.03 hours · Measure score 1.21 · Achievement 0 · Improvement 1.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 9.71% · Lower 95% interval 7.06% |
| Discharge to community | 41.48% |
50.57%
9.1 pts worse
|
Worse than the National Rate · Eligible stays 92 · Observed rate 32.61% · Lower 95% interval 30.07% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 97.35% |
95.27%
2.1 pts better
|
Numerator 110 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 42.5% |
53.69%
11.2 pts worse
|
Numerator 17 · Denominator 40 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 16 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 112 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 71 · Observed rate 7.04% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 127 · Denominator 127 |
| Staff flu vaccination coverage | 47.55% |
42%
5.5 pts better
|
Numerator 126 · Denominator 265 |
| Discharge function score | 45% |
56.45%
11.5 pts worse
|
Numerator 18 · Denominator 40 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 49 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| 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 | 97.1% |
97.9%
0.8 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.3%
1.3 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.4% · Q3 4.3% · Q4 3.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
2.7%
1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 2.3% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
3.3%
0.2 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.9% · Q3 1.3% · Q4 3.7% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
18.9%
5 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 22.5% · Q3 20.2% · Q4 28.4% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
10.8%
1.2 pts worse
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.3% · Q3 12.1% · Q4 6.8% · 4Q avg 12.0% · 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 | 6.3% |
15.4%
9.1 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 7.1% · Q4 12.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
16.1%
5.8 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 16.7% · Q3 7.6% · Q4 7.4% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.5%
0.7 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.3% |
15.0%
7.7 pts better
|
19.8%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.7% · Q3 4.6% · Q4 15.4% · 4Q avg 7.3% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.2%
1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.4% · Q3 4.0% · Q4 3.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.7%
9.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.4% · Q3 98.8% · Q4 99.3% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
12.0%
0.1 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 13.6% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.1% · Q3 1.7% · Q4 2.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
88.0%
8.2 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
25.9%
5.7 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 24.3% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
28 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-05-24 · Fire 2023-05-24
24 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-08-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-08-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-08-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-08-29
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 2025-12-30
E · Potential for more than minimal harm
2025-08-29
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-12-30
F · Potential for more than minimal harm
2024-07-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-20
F · Potential for more than minimal harm
2024-07-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-07-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-25
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 2025-11-26
D · Potential for more than minimal harm
2025-11-25
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 2025-11-26
D · Potential for more than minimal harm
2025-11-25
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 2025-11-26
E · Potential for more than minimal harm
2025-08-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-08-29
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 2025-08-30
E · Potential for more than minimal harm
2025-08-29
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 2025-08-30
E · Potential for more than minimal harm
2025-08-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
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 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F761 · Pharmacy Service Deficiencies
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 2025-08-30
D · Potential for more than minimal harm
2025-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-08-08
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 2025-08-09
D · Potential for more than minimal harm
2025-04-22
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 2025-04-23
J · Immediate jeopardy
2025-03-25
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 2025-02-27
D · Potential for more than minimal harm
2025-03-25
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 2025-03-26
D · Potential for more than minimal harm
2025-03-25
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 2025-03-26
E · Potential for more than minimal harm
2024-12-12
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 2024-12-13
E · Potential for more than minimal harm
2024-12-12
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-12-12
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 2024-12-13
D · Potential for more than minimal harm
2024-10-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-08-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-08-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-08-05
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 2024-08-06
D · Potential for more than minimal harm
2024-08-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-08-05
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 2024-08-06
E · Potential for more than minimal harm
2024-07-19
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 2024-07-20
E · Potential for more than minimal harm
2024-07-19
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 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-07-19
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 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F693 · Quality of Life and Care Deficiencies
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 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-07-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-20
B · Minimal harm
2024-07-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-07-20
J · Immediate jeopardy
2024-07-10
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 2024-04-22
E · Potential for more than minimal harm
2024-04-23
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 2024-05-14
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 2024-05-14
D · Potential for more than minimal harm
2024-04-23
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 2024-05-14
D · Potential for more than minimal harm
2024-04-23
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 2024-05-14
D · Potential for more than minimal harm
2024-04-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-23
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-03-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-12-22
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 2024-01-02
E · Potential for more than minimal harm
2023-12-22
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 2024-01-05
E · Potential for more than minimal harm
2023-12-22
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 2024-01-05
E · Potential for more than minimal harm
2023-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-12-22
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-17
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 2023-11-24
D · Potential for more than minimal harm
2023-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-13
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 2023-10-26
E · Potential for more than minimal harm
2023-10-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-09-26
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 2023-10-06
D · Potential for more than minimal harm
2023-09-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-06
C · Minimal harm
2023-09-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-06
G · Actual harm
2023-05-24
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 2023-06-21
E · Potential for more than minimal harm
2023-05-24
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 2023-06-22
E · Potential for more than minimal harm
2023-05-24
F693 · Quality of Life and Care Deficiencies
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 2023-06-23
E · Potential for more than minimal harm
2023-05-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-24
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 2023-06-16
D · Potential for more than minimal harm
2023-05-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-05-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-05-24
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 2023-06-22
D · Potential for more than minimal harm
2023-05-24
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 2023-06-23
Penalties and ownership
What sits behind the stars
$10,509
2025-03-25
Fine
Fine · fine $10,509
Fine
$15,808
2024-07-10
Fine
Fine · fine $15,808
Fine
$11,918
2023-05-24
Fine
Fine · fine $11,918
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
11490 Gateway North Boulevard Opco, LLC
Operational/Managerial Control · Organization
11490 Gateway North Boulevard Property Owner, LLC
5% Or Greater Security Interest · Organization
Freund, Nochum
Operational/Managerial Control · Individual
Thompson, Johnny
Corporate Officer · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Varghese, Linda
Operational/Managerial Control · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Welltower Nnn Group, LLC
5% Or Greater Security Interest · Organization
Welltower Op LLC
5% Or Greater Security Interest · Organization
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