Cycle 1
Health 2025-12-11 · Fire 2025-12-11
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Gainesville, TX
Gainesville Convalescent Center
2-star overall rating with 1-star inspections with abuse icon flag with $127,532 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1900 O'Neal St, Gainesville, TX
(940) 665-2826
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
52
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1992-07-23
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.13
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.59
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.74
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
70%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
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 88.09% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 5.91 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 7.6% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.64 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 13 · 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 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 25 |
| Staff flu vaccination coverage | 89.8% |
42%
47.8 pts better
|
Numerator 44 · Denominator 49 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.1%
1.8 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.8% · 4Q avg 98.9% |
| 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 | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 2.2% · Q4 2.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
2.7%
4 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 2.7% · Q3 4.5% · Q4 8.7% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
3.3%
2.1 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
18.9%
12.5 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 27.9% · Q3 32.6% · Q4 41.9% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
10.8%
0.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 13.8% · Q3 7.4% · Q4 11.1% · 4Q avg 10.5% · 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 | 10.3% |
15.4%
5.1 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 8.3% · Q3 19.3% · Q4 7.9% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
16.1%
0.7 pts worse
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 11.9% · Q3 18.6% · Q4 16.7% · 4Q avg 16.8% · 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 | 0.0% |
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 | 6.6% |
15.0%
8.4 pts better
|
19.8%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 3.8% · Q3 5.8% · Q4 9.7% · 4Q avg 6.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.2%
0.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 3.4% · Q4 6.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
89.7%
8.3 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 95.2% · 4Q avg 98.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-13 · Fire 2024-09-13
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
13 health deficiencies
Top issue: Environmental (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-24
F · Potential for more than minimal harm
2025-12-11
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2026-01-24
F · Potential for more than minimal harm
2025-12-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-24
E · Potential for more than minimal harm
2025-12-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-24
E · Potential for more than minimal harm
2025-12-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-24
C · Minimal harm
2025-12-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
F · Potential for more than minimal harm
2024-09-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-09-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-09-13
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-09-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-09-13
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-13
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-09-13
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 2024-10-24
E · Potential for more than minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-09-13
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 2024-10-24
E · Potential for more than minimal harm
2024-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-13
C · Minimal harm
2024-09-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-14
F · Potential for more than minimal harm
2023-07-20
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 2023-08-25
F · Potential for more than minimal harm
2023-07-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-20
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 2023-08-25
F · Potential for more than minimal harm
2023-07-20
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-07-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-25
C · Minimal harm
2023-07-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
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 2026-01-10
E · Potential for more than minimal harm
2025-12-11
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-10
E · Potential for more than minimal harm
2025-12-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-10
E · Potential for more than minimal harm
2025-12-11
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 2026-01-10
D · Potential for more than minimal harm
2025-12-11
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 2026-01-10
D · Potential for more than minimal harm
2025-12-11
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 2026-01-10
D · Potential for more than minimal harm
2025-12-11
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2026-01-10
D · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-10
J · Immediate jeopardy
2025-06-06
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 2025-06-07
J · Immediate jeopardy
2025-06-06
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 2025-06-07
D · Potential for more than minimal harm
2025-06-06
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 2025-06-07
D · Potential for more than minimal harm
2025-06-06
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 2025-06-07
F · Potential for more than minimal harm
2024-09-13
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 2024-09-19
E · Potential for more than minimal harm
2024-09-13
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 2024-09-17
E · Potential for more than minimal harm
2024-09-13
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 2024-09-18
E · Potential for more than minimal harm
2024-09-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-09-13
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 2024-09-17
D · Potential for more than minimal harm
2024-09-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-09-13
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 2024-09-18
D · Potential for more than minimal harm
2024-09-13
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 2024-09-18
D · Potential for more than minimal harm
2024-09-13
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 2024-09-18
D · Potential for more than minimal harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-09-13
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 2024-09-18
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-27
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-30
K · Immediate jeopardy
2024-07-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-23
K · Immediate jeopardy
2024-07-22
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-07-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-07-22
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 2024-07-26
D · Potential for more than minimal harm
2024-07-22
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 2024-07-26
D · Potential for more than minimal harm
2024-07-22
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 2024-07-26
D · Potential for more than minimal harm
2024-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-26
E · Potential for more than minimal harm
2023-12-16
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 2023-12-19
D · Potential for more than minimal harm
2023-12-16
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 2023-12-19
F · Potential for more than minimal harm
2023-07-20
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-07-20
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 2023-08-18
F · Potential for more than minimal harm
2023-07-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-20
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 2023-08-18
E · Potential for more than minimal harm
2023-07-20
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 2023-08-18
E · Potential for more than minimal harm
2023-07-20
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 2023-08-18
E · Potential for more than minimal harm
2023-07-20
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-20
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 2023-08-18
E · Potential for more than minimal harm
2023-07-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-18
Penalties and ownership
What sits behind the stars
$81,305
2025-06-06
Fine
Fine · fine $81,305
Fine
$46,227
2024-07-22
Fine
Fine · fine $46,227
Fine
Ownership
County Of Throckmorton
5% Or Greater Direct Ownership Interest · Organization
1900 O'neal Street Opco, LLC
Operational/Managerial Control · Organization
1900 O'neal Street Property Owner, LLC
5% Or Greater Security Interest · Organization
Freund, Nochum
Operational/Managerial Control · Individual
Gober, Kirby
Corporate Director · Individual
Travitsky, Aaron
Operational/Managerial Control · Individual
Watson, Nathan
Operational/Managerial Control · Individual
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#3
River Valley Health & Rehabilitation Center
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3-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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