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Avir at Jeffrey Place Inspection Report, Violations & Safety Grade (Waco, Texas)

820 Jeffrey Dr, Waco, Texas 76710

Phone: 2547729480

CMS Overall:2/5

Overview & Bed Count

Certified Beds
95
Avg Residents/Day
70.6
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Mc Lennan
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall2/5
Health3/5
Staffing1/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityTexas AvgDifference
RN Hours per Resident per Day0.190.44-0.26
Total Nurse Hours per Resident per Day3.443.42+0.03
CMS Staffing Rating1/51.9/5-
Nursing Staff Turnover61.3%50.8%-

Health Citation History

33 health citations on record

DateCategoryDescriptionSeverity
2026-04-09Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2026-04-09Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2026-04-09Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2025-07-29Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E – Moderate Harm Potential
2025-07-11Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J – Immediate Jeopardy
2025-07-11Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2025-02-06Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-02-06Resident Rights DeficienciesHonor 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.E – Moderate Harm Potential
2025-02-06Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2025-02-06Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.D – Moderate Harm Potential
2025-02-06Resident Rights DeficienciesHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.D – Moderate Harm Potential
2025-02-06Resident Assessment and Care Planning DeficienciesDevelop 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
2025-02-06Quality of Life and Care DeficienciesEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.D – Moderate Harm Potential
2025-02-06Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2025-02-06Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2025-02-06Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2025-01-22Resident Rights DeficienciesPrepare residents for a safe transfer or discharge from the nursing home.D – Moderate Harm Potential
2024-07-19Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.E – Moderate Harm Potential
2024-07-19Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2024-06-27Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D – Moderate Harm Potential
2024-06-27Resident Assessment and Care Planning DeficienciesDevelop 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
2024-05-07Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2024-05-07Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2024-04-08Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J – Immediate Jeopardy
2024-04-08Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2024-04-08Resident Rights DeficienciesPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.D – Moderate Harm Potential
2024-01-24Resident Rights DeficienciesHonor the resident's right to organize and participate in resident/family groups in the facility.E – Moderate Harm Potential
2024-01-24Resident Rights DeficienciesHonor 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.E – Moderate Harm Potential
2024-01-24Resident Assessment and Care Planning DeficienciesDevelop 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
2024-01-24Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.E – Moderate Harm Potential
2024-01-24Nutrition and Dietary DeficienciesHave a policy regarding use and storage of foods brought to residents by family and other visitors.E – Moderate Harm Potential
2024-01-24Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2023-10-17Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.E – Moderate Harm Potential

Fire Safety Citation History

12 fire safety citations on record

DateCategoryDescriptionSeverity
2026-04-09Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.C – Minimal Harm Potential
2025-02-06Emergency Preparedness DeficienciesDevelop and maintain an Emergency Preparedness Program (EP).F – Moderate Harm Potential
2025-02-06Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.F – Moderate Harm Potential
2025-02-06Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.C – Minimal Harm Potential
2024-01-24Smoke DeficienciesProvide properly protected cooking facilities.F – Moderate Harm Potential
2024-01-24Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.F – Moderate Harm Potential
2024-01-24Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2024-01-24Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2024-01-24Smoke DeficienciesInstall an approved automatic sprinkler system.D – Moderate Harm Potential
2024-01-24Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.D – Moderate Harm Potential
2024-01-24Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.D – Moderate Harm Potential
2024-01-24Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.C – Minimal Harm Potential

Total Penalties & Fines

$22,382
Total Fine Amount (CMS)
2
Number of Fines
3
Total Penalties
DateTypeFine AmountPayment Denial
2025-07-11Fine$14,361-
2024-04-08Fine$8,021-
2024-04-08Payment Denial-3 days starting 2024-05-07

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