Cycle 1
Health 2025-08-13 · Fire 2025-08-13
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Palestine, TX
Avir at Town Creek
1-star overall rating with 1-star inspections with $76,268 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1816 Tile Factory Rd, Palestine, TX
(903) 729-2261
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1985-07-19
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
0.68
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.55
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.23
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
5.21
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,395
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 68.97% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.50
Baseline 2.97 hours · Performance 3.79 hours · Measure score 2.50 · Achievement 2.50 · Improvement 2.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 43.14% |
8.2%
34.9 pts better
|
Numerator 22 · Denominator 51 |
| Staff flu vaccination coverage | 7.79% |
42%
34.2 pts worse
|
Numerator 6 · Denominator 77 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · 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 | 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 | 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 | 7.7% |
3.3%
4.4 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 5.7% · Q3 6.2% · Q4 3.2% · 4Q avg 7.7% · 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 | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.0% |
18.9%
14.1 pts worse
|
19.6%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 34.5% · Q3 32.0% · Q4 29.2% · 4Q avg 33.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.0% |
10.8%
2.8 pts better
|
16.7%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · 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 | 24.6% |
15.4%
9.2 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 38.5% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.7% |
16.1%
15.6 pts worse
|
14.9%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 35.7% · Q3 33.3% · Q4 54.5% · 4Q avg 31.7% · 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 | 11.9% |
15.0%
3.1 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 8.3% · Q3 15.0% · Q4 12.5% · 4Q avg 11.9% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
4.2%
3.4 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-03-25 · Fire 2025-03-25
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2024-10-01 · Fire 2024-10-01
19 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-13
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 2025-08-15
D · Potential for more than minimal harm
2025-08-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-22
C · Minimal harm
2025-08-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
D · Potential for more than minimal harm
2025-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-22
C · Minimal harm
2025-03-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
E · Potential for more than minimal harm
2024-10-01
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 2024-11-20
E · Potential for more than minimal harm
2024-10-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-20
C · Minimal harm
2024-10-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
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 2025-09-02
E · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-08-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-08-13
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 2025-09-02
D · Potential for more than minimal harm
2025-08-13
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 2025-09-02
D · Potential for more than minimal harm
2025-08-13
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-09-02
E · Potential for more than minimal harm
2025-03-25
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 2025-03-28
D · Potential for more than minimal harm
2025-03-25
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-03-28
H · Actual harm
2025-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-27
H · Actual harm
2025-02-03
F917 · Environmental Deficiencies
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-10-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-10-01
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 2024-10-31
F · Potential for more than minimal harm
2024-10-01
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 2024-10-31
D · Potential for more than minimal harm
2024-10-01
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 2024-10-31
D · Potential for more than minimal harm
2024-10-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
D · Potential for more than minimal harm
2023-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-10-26
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.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-26
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 2023-10-27
D · Potential for more than minimal harm
2023-10-26
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 2023-10-27
J · Immediate jeopardy
2023-08-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-08-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-10
K · Immediate jeopardy
2023-06-28
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.
Corrected 2023-08-10
K · Immediate jeopardy
2023-06-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-10
K · Immediate jeopardy
2023-06-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-29
J · Immediate jeopardy
2023-06-28
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 2023-06-29
E · Potential for more than minimal harm
2023-06-28
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-06-28
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 2023-06-29
D · Potential for more than minimal harm
2023-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-29
Penalties and ownership
What sits behind the stars
$17,345
2025-02-03
Fine
Fine · fine $17,345
Fine
$31,720
2024-04-05
Fine
Fine · fine $31,720
Fine
$27,203
2023-06-28
Fine
Fine · fine $27,203
Fine
$0
2023-06-28
Payment Denial
Payment Denial · denial start 2023-07-28 · 13 days
13 day denial
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Carlisle Taylor Whitworth 2020 Irrevocable Trust
5% Or Greater Mortgage Interest · Organization
Gary Scott Whitworth 2019 Irrevocable Trust
5% Or Greater Mortgage Interest · Organization
Leonard, Joshua
Operational/Managerial Control · Individual
Lqcp Management, LLC
5% Or Greater Mortgage Interest · Organization
Murrell, Edward
Corporate Director · Individual
Slp Palestine LLC
Operational/Managerial Control · Organization
Wm 41 Palestine Re, LLC
5% Or Greater Mortgage Interest · Organization
Wm-Lqc Mm, LLC
5% Or Greater Mortgage Interest · Organization
Wt Holdings, LP
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Legacy At Town Creek
Palestine, TX
2-star overall rating with 2-star inspections with $300,185 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Trucare Living Centers
Palestine, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Greenbrier Nursing & Rehabilitation Center Of Pale
Palestine, TX
4-star overall rating with 5-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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