Cycle 1
Health 2025-06-13 · Fire 2025-06-13
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Temple, TX
Avir at Weston
1-star overall rating with 1-star inspections with $235,757 in total fines with 9 recent health deficiencies
2505 S 37Th St, Temple, TX
(254) 298-7300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1999-06-29
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
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.10
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
1.22
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
91%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,618
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.94% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.57
Baseline 5.54% · Performance 6.47% · Measure score 4.57 · Achievement 4.57 · Improvement 0
Total nurse turnover
0
Baseline 75.90% · Performance 74.71% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.70 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.97% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 12.79% · Lower 95% interval 7.97% |
| Discharge to community | 44.72% |
50.57%
5.9 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 33.85% · Lower 95% interval 33.48% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 76.19% |
95.27%
19.1 pts worse
|
Numerator 32 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 41.94% |
53.69%
11.8 pts worse
|
Numerator 13 · Denominator 31 |
| Discharge mobility score | 45.16% |
50.94%
5.8 pts worse
|
Numerator 14 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 2 · Denominator 42 · Adjusted rate 4.32% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 5.08% |
8.2%
3.1 pts worse
|
Numerator 3 · Denominator 59 |
| Staff flu vaccination coverage | 79.12% |
42%
37.1 pts better
|
Numerator 72 · Denominator 91 |
| Discharge function score | 51.61% |
56.45%
4.8 pts worse
|
Numerator 16 · Denominator 31 |
| 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 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 96.1% |
97.9%
1.8 pts worse
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 4.7% · Q4 4.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
2.7%
4.1 pts worse
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 5.5% · Q3 2.0% · Q4 2.0% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
3.3%
0.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.7% · Q3 5.5% · Q4 1.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
18.9%
2 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 15.0% · Q3 12.5% · Q4 13.0% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
10.8%
1.3 pts worse
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 11.1% · Q3 9.5% · Q4 8.1% · 4Q avg 12.1% · 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 | 27.8% |
15.4%
12.4 pts worse
|
16.3%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q4 13.5% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
16.1%
3.8 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 25.0% · Q3 8.5% · Q4 4.3% · 4Q avg 12.3% · 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 | 24.2% |
15.0%
9.2 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 25.6% · Q3 15.3% · Q4 29.9% · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.2%
1.7 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.2% · Q3 7.2% · Q4 7.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
89.7%
5.6 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 92.5% · Q3 94.1% · Q4 100.0% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
12.0%
0.2 pts worse
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.8% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
88.0%
7.7 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.6% |
25.9%
9.7 pts worse
|
23.9%
11.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.6% · Observed 38.5% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
15 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-03-02
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 2023-06-08
E · Potential for more than minimal harm
2023-03-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-03-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Not marked corrected
J · Immediate jeopardy
2025-07-23
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 2025-07-24
J · Immediate jeopardy
2025-06-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-06-13
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 2025-06-14
E · Potential for more than minimal harm
2025-06-13
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 2025-06-14
D · Potential for more than minimal harm
2025-06-13
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 2025-06-14
G · Actual harm
2025-05-12
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 2025-05-28
D · Potential for more than minimal harm
2025-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-10
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 2025-04-20
D · Potential for more than minimal harm
2025-02-14
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 2025-02-15
K · Immediate jeopardy
2025-02-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-15
K · Immediate jeopardy
2025-02-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-15
E · Potential for more than minimal harm
2025-02-12
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 2025-02-15
E · Potential for more than minimal harm
2025-02-12
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 2025-02-15
E · Potential for more than minimal harm
2025-02-12
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 2025-02-15
E · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-02-12
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 2025-02-15
E · Potential for more than minimal harm
2024-12-17
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 2025-01-10
D · Potential for more than minimal harm
2024-12-17
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 2025-01-10
E · Potential for more than minimal harm
2024-04-12
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 2024-05-07
E · Potential for more than minimal harm
2024-04-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-04-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-07
C · Minimal harm
2024-04-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-07
D · Potential for more than minimal harm
2024-03-22
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 2024-04-05
H · Actual harm
2023-11-28
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 2023-11-29
D · Potential for more than minimal harm
2023-11-21
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 2023-11-22
D · Potential for more than minimal harm
2023-09-05
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 2023-09-30
J · Immediate jeopardy
2023-06-14
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 2023-06-15
J · Immediate jeopardy
2023-06-14
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 2023-06-15
Penalties and ownership
What sits behind the stars
$19,685
2025-06-13
Fine
Fine · fine $19,685
Fine
$133,382
2025-02-12
Fine
Fine · fine $133,382
Fine
$1,099
2023-11-21
Fine
Fine · fine $1,099
Fine
$81,591
2023-06-14
Fine
Fine · fine $81,591
Fine
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Chudleigh, Geoff
Operational/Managerial Control · Individual
Chumley, Richard
Corporate Officer · Individual
Nearby options
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#2
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1-star overall rating with 2-star inspections with $31,752 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Avir at Temple West
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1-star overall rating with 1-star inspections with abuse icon flag with $7,257 in total fines with 4 recent health deficiencies
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