23 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tyler, TX
1-star overall rating with 1-star inspections with Special Focus status with $539,122 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
930 S Baxter, Tyler, TX
(903) 597-2068
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
Beds
172
Certified beds
Average residents
79
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1977-01-01
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
RN hours / resident day
0.32
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.93
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
0.97
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
86%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
13,457
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.35% · Performance 22.88% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.5
Baseline 9.46% · Performance 8.57% · Measure score 1.5 · Achievement 0 · Improvement 1.5
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.79 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 16.33% · Lower 95% interval 7.9% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 87.88% |
95.27%
7.4 pts worse
|
Numerator 58 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 24 · Denominator 32 |
| Discharge mobility score | 65.63% |
50.94%
14.7 pts better
|
Numerator 21 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 9.09% |
2.29%
6.8 pts worse
|
Numerator 6 · Denominator 66 · Adjusted rate 7.19% |
| Healthcare-associated infections requiring hospitalization | 8.57% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 17.24% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 114 |
| Staff flu vaccination coverage | 13.64% |
42%
28.4 pts worse
|
Numerator 15 · Denominator 110 |
| Discharge function score | 71.88% |
56.45%
15.4 pts better
|
Numerator 23 · Denominator 32 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| 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 | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 36 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.4 |
2.1
2.3 pts worse
|
1.9
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 5.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.6 |
2.1
2.5 pts worse
|
1.8
2.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.6 · Observed 5.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
97.1%
5.3 pts worse
|
93.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 89.4% · Q3 95.6% · Q4 98.5% · 4Q avg 91.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.8% |
97.9%
6.1 pts worse
|
95.5%
3.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.4% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
2.7%
0.3 pts worse
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.5% · Q3 1.7% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
3.3%
1.2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 5.2% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.1% |
18.9%
13.2 pts worse
|
19.6%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 34.9% · Q3 30.6% · Q4 28.8% · 4Q avg 32.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
10.8%
7.8 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 20.8% · Q3 18.8% · Q4 17.0% · 4Q avg 18.6% · 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 | 8.0% |
15.4%
7.4 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 12.2% · Q3 8.0% · Q4 7.6% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
16.1%
5.4 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 17.2% · Q3 12.1% · Q4 3.6% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 14.7% |
15.0%
0.3 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 20.6% · Q3 13.8% · Q4 11.0% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 14.5% |
4.2%
10.3 pts worse
|
5.1%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 13.7% · Q3 15.7% · Q4 14.4% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.1% |
89.7%
32.6 pts worse
|
81.7%
24.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 45.2% · Q3 65.8% · Q4 80.0% · 4Q avg 57.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
12.0%
4.9 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 20.6% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.5%
2.4 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 7.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.3% |
88.0%
33.7 pts worse
|
79.7%
25.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
25.9%
0.4 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 25.4% · Expected 23.1% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
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 2025-12-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-08
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-27
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-27
Inspection history
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-05
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-05
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-12-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-05
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-11-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-04
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-04
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 2025-10-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-27
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-27
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-25
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-07-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-18
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-22
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 2024-04-22
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-04-02
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-02
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-04-02
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-19
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 2023-12-19
Health
Provide or obtain dental services for each resident.
Corrected 2023-11-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-23
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 2023-09-23
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 2023-09-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-21
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-21
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-21
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 2023-08-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-21
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-21
Health
Post nurse staffing information every day.
Corrected 2023-08-21
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-08-05
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-05
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-04-05
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-05
Health
Have policies on smoking.
Corrected 2023-04-05
Penalties and ownership
Fine · fine $18,520
Fine
Fine · fine $161,475
Fine
Fine · fine $230,484
Fine
Fine · fine $44,590
Fine
Fine · fine $49,470
Fine
Fine · fine $14,518
Fine
Fine · fine $20,065
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Organization
Nearby options
Tyler, TX
2-star overall rating with 2-star inspections with abuse icon flag with $61,847 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Tyler, TX
1-star overall rating with 1-star inspections with abuse icon flag with $272,779 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Tyler, TX
2-star overall rating with 3-star inspections with $51,034 in total fines with 1 recent health deficiencies
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