Tyler, TX

Avir At Petal Hill

2-star overall rating with 2-star inspections with abuse icon flag with $61,847 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

900 S Baxter Ave, Tyler, TX

(903) 597-8192

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Avir Health Group

Operator or chain grouping

Approved since

1984-04-18

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

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

0.99

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.90

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.32

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.42

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

0.16

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

0.49

CMS adjusted RN staffing hours

Adjusted total hours

3.85

CMS adjusted total nurse staffing hours

Case-mix index

1.18

Higher values indicate more complex resident acuity

RN turnover

100%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

78%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,121

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

Performance score

8.17

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.56% · Performance 21.48% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.40

Baseline 8.75% · Performance 8.04% · Measure score 1.40 · Achievement 0 · Improvement 1.40

Total nurse turnover

Baseline 63.04% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.87

Baseline 3.74 hours · Performance 3.61 hours · Measure score 1.87 · Achievement 1.87 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.16%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 59 · Observed rate 8.47% · Lower 95% interval 6.76%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.34	1.02 0.3 pts worse
Drug regimen review with follow-up	88.1%	95.27% 7.2 pts worse	Numerator 37 · Denominator 42
Falls with major injury	2.38%	0.77% 1.6 pts worse	Numerator 1 · Denominator 42
Discharge self-care score	52.38%	53.69% 1.3 pts worse	Numerator 11 · Denominator 21
Discharge mobility score	33.33%	50.94% 17.6 pts worse	Numerator 7 · Denominator 21
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 42 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.04%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 12.5% · Lower 95% interval 4.81%
Staff COVID-19 vaccination coverage	9.52%	8.2% 1.3 pts better	Numerator 6 · Denominator 63
Staff flu vaccination coverage	6.32%	42% 35.7 pts worse	Numerator 6 · Denominator 95
Discharge function score	47.62%	56.45% 8.8 pts worse	Numerator 10 · Denominator 21
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	19.05%	25.2% 6.1 pts worse	Numerator 4 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.6 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.5	2.1 1.4 pts worse	1.8 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.2 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	76.3%	97.1% 20.8 pts worse	93.4% 17.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 73.9% · Q3 62.3% · Q4 78.7% · 4Q avg 76.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	89.6%	97.9% 8.3 pts worse	95.5% 5.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 89.6%
Percentage of long-stay residents experiencing one or more falls with major injury	5.2%	3.3% 1.9 pts worse	3.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.3% · Q3 5.8% · Q4 9.3% · 4Q avg 5.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.7%	2.7% About the same	11.4% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7%
Percentage of long-stay residents who lose too much weight	2.4%	3.3% 0.9 pts better	5.4% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.5% · Q3 0.0% · Q4 3.0% · 4Q avg 2.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.5%	18.9% 1.6 pts worse	19.6% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 19.0% · Q3 22.7% · Q4 22.9% · 4Q avg 20.5%
Percentage of long-stay residents who received an antipsychotic medication	15.4%	10.8% 4.6 pts worse	16.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.2% · Q3 17.0% · Q4 14.6% · 4Q avg 15.4% · 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	17.4%	15.4% 2 pts worse	16.3% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 3.5% · Q3 17.0% · Q4 21.1% · 4Q avg 17.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	29.8%	16.1% 13.7 pts worse	14.9% 14.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 41.4% · Q2 8.6% · Q3 16.7% · Q4 49.3% · 4Q avg 29.8% · 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	0.4%	0.8% 0.4 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.3%	15.0% 6.3 pts worse	19.8% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 21.9% · Q3 21.4% · Q4 19.6% · 4Q avg 21.3%
Percentage of long-stay residents with pressure ulcers	2.6%	4.2% 1.6 pts better	5.1% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 2.0% · Q4 3.7% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	44.3%	89.7% 45.4 pts worse	81.7% 37.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 33.3% · Q3 11.1% · Q4 54.2% · 4Q avg 44.3%
Percentage of short-stay residents who had an outpatient emergency department visit	18.6%	12.0% 6.6 pts worse	12.0% 6.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 21.6% · Expected 13.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.1%	1.5% 1.6 pts worse	1.6% 1.5 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	35.0%	88.0% 53 pts worse	79.7% 44.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 35.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.1%	25.9% 8.2 pts worse	23.9% 10.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.1% · Observed 33.3% · Expected 23.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-11 · Fire 2024-12-11

7 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

8 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2023-11-08 · Fire 2023-11-08

14 health deficiencies

Top issue: Environmental (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-09-21 · Fire 2022-09-21

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-11

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-12-31

F · Potential for more than minimal harm 2024-12-11

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-12-31

F · Potential for more than minimal harm 2024-12-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-12-15

E · Potential for more than minimal harm 2024-12-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-15

E · Potential for more than minimal harm 2024-12-11

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-12-15

E · Potential for more than minimal harm 2024-12-11

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-12-15

D · Potential for more than minimal harm 2024-12-11

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 2024-12-15

D · Potential for more than minimal harm 2024-12-11

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 2024-12-15

E · Potential for more than minimal harm 2022-09-21

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2022-10-13

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-05

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 2025-12-06

J · Immediate jeopardy 2025-11-11

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.

Not marked corrected

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

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 2025-03-28

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

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 2025-02-28

E · Potential for more than minimal harm 2024-12-11

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 2024-12-15

E · Potential for more than minimal harm 2024-12-11

F850 · Administration Deficiencies

Health

Hire a qualified full-time social worker in a facility with more than 120 beds.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-11

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 2025-01-15

D · Potential for more than minimal harm 2024-12-11

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 2024-12-15

D · Potential for more than minimal harm 2024-12-11

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 2024-12-15

E · Potential for more than minimal harm 2024-04-18