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35/100Avir at Rose Trail Inspection Report, Violations & Safety Grade (Tyler, Texas)
930 S Baxter, Tyler, Texas 75701
Phone: 9035972068
CMS Overall:1/5
Overview & Bed Count
Certified Beds
172
Avg Residents/Day
73.2
Ownership
Government - Hospital district
Provider Type
Medicare and Medicaid
County
Smith
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing2/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.48 | 0.44 | +0.04 |
| Total Nurse Hours per Resident per Day | 3.43 | 3.42 | +0.01 |
| CMS Staffing Rating | 2/5 | 1.9/5 | - |
| Nursing Staff Turnover | 60.0% | 50.8% | - |
Health Citation History
59 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-14 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | K – Immediate Jeopardy |
| 2026-08-14 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2026-06-26 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | D – Moderate Harm Potential |
| 2026-06-26 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-06-03 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E – Moderate Harm Potential |
| 2026-03-05 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2026-01-02 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | E – Moderate Harm Potential |
| 2025-12-04 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-12-04 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-12-04 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-12-04 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2025-12-04 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2025-12-04 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-12-04 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2025-11-18 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E – Moderate Harm Potential |
| 2025-11-18 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2025-10-02 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | K – Immediate Jeopardy |
| 2025-10-02 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | K – Immediate Jeopardy |
| 2025-10-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-10-02 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-10-02 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2025-08-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-08-15 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-03-25 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-03-25 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2025-03-25 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-09-25 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2024-09-25 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2024-09-25 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2024-09-25 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2024-09-25 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-08-25 | Administration Deficiencies | Provide timely, quality laboratory services/tests to meet the needs of residents. | D – Moderate Harm Potential |
| 2024-07-10 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | D – Moderate Harm Potential |
| 2024-05-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2024-05-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-04-03 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-04-03 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-03-18 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-03-18 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2024-03-18 | Resident Rights Deficiencies | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | D – Moderate Harm Potential |
| 2024-01-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-12-18 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2023-12-18 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2023-12-18 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-11-02 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | E – Moderate Harm Potential |
| 2023-11-02 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2023-11-02 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
Showing 50 of 59 citations.
Fire Safety Citation History
4 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-04 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-12-04 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2024-09-25 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2024-09-25 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
Total Penalties & Fines
$483,785
Total Fine Amount (CMS)
6
Number of Fines
6
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-08-14 | Fine | $75,860 | - |
| 2025-08-15 | Fine | $12,038 | - |
| 2025-08-15 | Fine | $105,739 | - |
| 2024-05-17 | Fine | $15,074 | - |
| 2024-03-18 | Fine | $230,484 | - |
| 2023-12-18 | Fine | $44,590 | - |
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Tyler area at no cost.
Find Safe, Vetted Facilities Near Tyler
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.