Cycle 1
Health 2025-06-05 · Fire 2025-06-05
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Pilot Point, TX
Avir at Pilot Point
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
208 N Prairie St, Pilot Point, TX
(940) 686-5507
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
57
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
2001-12-26
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
0.46
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.38
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.79
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.49
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
78%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,439
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0038
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.62
Baseline 22.27% · Performance 18.01% · Measure score 7.62 · Achievement 7.38 · Improvement 7.62
Healthcare-associated infections
3.59
Baseline 8.13% · Performance 6.85% · Measure score 3.59 · Achievement 3.30 · Improvement 3.59
Total nurse turnover
7.42
Baseline 52.50% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 6.43
Adjusted total nurse staffing
1.27
Baseline 2.66 hours · Performance 3.21 hours · Measure score 1.27 · Achievement 0 · Improvement 1.27
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 12.96% · Lower 95% interval 7.7% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 90.48% |
95.27%
4.8 pts worse
|
Numerator 57 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 59.46% |
53.69%
5.8 pts better
|
Numerator 22 · Denominator 37 |
| Discharge mobility score | 48.65% |
50.94%
2.3 pts worse
|
Numerator 18 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 3.17% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 63 · Adjusted rate 2.33% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 91 |
| Staff flu vaccination coverage | 39.36% |
42%
2.6 pts worse
|
Numerator 37 · Denominator 94 |
| Discharge function score | 72.97% |
56.45%
16.5 pts better
|
Numerator 27 · Denominator 37 |
| Transfer of health information to provider | 95.24% |
95.95%
0.7 pts worse
|
Numerator 20 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.67% |
25.2%
18.5 pts worse
|
Numerator 2 · Denominator 30 |
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 | 3.4 |
2.1
1.3 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.1%
2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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 | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 3.7% · Q4 3.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
3.3%
2.2 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.2% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.7% |
18.9%
19.8 pts worse
|
19.6%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 43.1% · Q3 34.0% · Q4 36.0% · 4Q avg 38.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
10.8%
1.2 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.1% · Q3 13.5% · Q4 8.8% · 4Q avg 9.6% · 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 | 12.2% |
15.4%
3.2 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 4.6% · Q3 7.5% · Q4 24.2% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
16.1%
6.1 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.2% · Q3 10.4% · Q4 8.5% · 4Q avg 10.0% · 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 | 12.0% |
15.0%
3 pts better
|
19.8%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 14.0% · Q3 14.3% · Q4 9.7% · 4Q avg 12.0% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
89.7%
2.3 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 85.7% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
12.0%
0.6 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 12.5% · Expected 12.2% · 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
25.9%
4.8 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 26.6% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-02 · Fire 2024-05-02
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-05
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 2025-07-18
F · Potential for more than minimal harm
2025-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-18
F · Potential for more than minimal harm
2025-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-18
F · Potential for more than minimal harm
2025-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-18
F · Potential for more than minimal harm
2023-03-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-03-10
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 2023-04-21
C · Minimal harm
2023-03-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-07
E · Potential for more than minimal harm
2025-06-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-06-05
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 2025-06-06
E · Potential for more than minimal harm
2025-06-05
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 2025-06-06
D · Potential for more than minimal harm
2025-06-05
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 2025-06-06
D · Potential for more than minimal harm
2025-06-05
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 2025-06-06
D · Potential for more than minimal harm
2025-06-05
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 2025-06-06
D · Potential for more than minimal harm
2025-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2024-05-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-06
D · Potential for more than minimal harm
2023-03-10
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 2023-03-11
D · Potential for more than minimal harm
2023-03-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-11
D · Potential for more than minimal harm
2023-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-11
Penalties and ownership
What sits behind the stars
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
208 N Prairie Street Opco, LLC
Operational/Managerial Control · Organization
208 N Prairie Street Property Owner, LLC
5% Or Greater Security Interest · Organization
Freund, Nochum
Operational/Managerial Control · Individual
Thompson, Johnny
Corporate Officer · Individual
Tibbels, Jason
Operational/Managerial Control · Individual
Travitsky, Aaron
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
Nearby options
Other facilities in reach
#1
Cedar Ridge Rehabilitation And Healthcare Center
Pilot Point, TX
3-star overall rating with 3-star inspections with $13,628 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Settlers Ridge Care Center
Celina, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Cottonwood Nursing And Rehabilitation
Denton, TX
2-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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