Cycle 1
Health 2024-12-31 · Fire 2024-12-31
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Waco, TX
Avir at Waco
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
9101 Panther Way, Waco, TX
(254) 537-9200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-09-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.28
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,129
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.99% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.97
Baseline 5.70% · Performance 6.35% · Measure score 4.97 · Achievement 4.97 · Improvement 0
Total nurse turnover
0
Performance 72.97% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.53
Baseline 3.96 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 10.29% · Lower 95% interval 7.13% |
| Discharge to community | 37.58% |
50.57%
13 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 27.78% · Lower 95% interval 24.36% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 3 · Denominator 36 · Adjusted rate 7.25% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 36.43% |
42%
5.6 pts worse
|
Numerator 47 · Denominator 129 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 2 · Denominator 23 |
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 2.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · 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 | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.6% · Q4 1.7% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.5% |
18.9%
15.6 pts worse
|
19.6%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 37.0% · Q3 37.1% · Q4 28.8% · 4Q avg 34.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
10.8%
4.3 pts worse
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 12.8% · Q3 12.8% · Q4 15.2% · 4Q avg 15.1% · 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 | 11.3% |
15.4%
4.1 pts better
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.6% · Q4 23.6% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
16.1%
5.9 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 10.2% · Q3 10.5% · Q4 13.2% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
0.8%
1.2 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 4.7% · Q4 1.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
15.0%
4.9 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 9.5% · Q3 7.2% · Q4 12.5% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.2%
2.5 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 1.5% · Q4 2.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
12.0%
6.8 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 18.4% · Expected 10.9% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 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 | 94.4% |
88.0%
6.4 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
25.9%
0.9 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 22.4% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
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
2024-12-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-31
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 2025-02-10
D · Potential for more than minimal harm
2024-12-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-12-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-30
D · Potential for more than minimal harm
2024-12-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-31
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-03-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-31
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 2025-01-20
E · Potential for more than minimal harm
2024-12-31
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-31
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 2025-01-20
D · Potential for more than minimal harm
2024-12-31
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 2025-01-20
D · Potential for more than minimal harm
2024-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-07-16
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 2024-08-08
F · Potential for more than minimal harm
2023-11-02
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
E · Potential for more than minimal harm
2023-11-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-11-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-11-02
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 2023-11-03
D · Potential for more than minimal harm
2023-11-02
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 2023-11-03
C · Minimal harm
2023-11-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-03
E · Potential for more than minimal harm
2022-08-18
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 2022-09-08
E · Potential for more than minimal harm
2022-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-08-18
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 2022-09-08
D · Potential for more than minimal harm
2022-08-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-08
Penalties and ownership
What sits behind the stars
Ownership
Cook, Catherine
5% Or Greater Direct Ownership Interest · Individual
Cook, Jack
5% Or Greater Direct Ownership Interest · Individual
Cook, Jack
Operational/Managerial Control · Individual
Derrick, Michele
Corporate Director · Individual
Johnson, Benjamin
Operational/Managerial Control · Individual
Jones, Timothy
Corporate Director · Individual
Keltz, Terry
Corporate Director · Individual
Mcculloch County Hospital District
5% Or Greater Indirect Ownership Interest · Organization
Mcculloch County Hospital District
Operational/Managerial Control · Organization
Royal East Senior Care LLC
5% Or Greater Direct Ownership Interest · Organization
Royal East Senior Care LLC
Operational/Managerial Control · Organization
Schaffner, Michael
Corporate Director · Individual
Schwedock, Nicholas
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Wesley Woods Health & Rehabilitation
Waco, TX
2-star overall rating with 2-star inspections with $17,550 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Hewitt Nursing And Rehabilitation
Hewitt, TX
1-star overall rating with 2-star inspections with $33,539 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
St. Anthony's Care Center
Waco, TX
4-star overall rating with 4-star inspections with $3,276 in total fines with 6 recent health deficiencies
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