AVIR AT MADISONVILLE
600 BACON STREET, MADISONVILLE, TX 77864 · CCN 676475
Ratings
- Overall
- ★★☆☆☆ 2
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Partnership
- Certified beds
- 90
- Avg residents/day
- 61.3
- Phone
- 9363489097
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-04-10 | 18 | 9.1 | 9.5 | +8.9 worse |
| 2 | 2024-02-29 | 8 | 9.4 | 9.8 | -1.4 better |
| 3 | 2023-01-02 | 26 | 8.1 | 9.3 | +17.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 4 |
| Resident assessment and care planning | 1 |
| Resident rights | 4 |
| Nutrition and dietary | 3 |
| Pharmacy service | 3 |
| Infection control | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.94 | 53.2% |
| RN staffing (reported) | 0.47 | — |
| Total nurse staffing (adjusted) | 3.51 | — |
Fines & penalties
- Total fines
- $8,827
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- GULF COAST LTC PARTNERS
- Facilities in chain
- 20
- Chain avg overall
- 2.40 / 5
Inspection citations (52)3 immediate jeopardy
- DF0761Ensure 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.2026-01-27 · Health · corrected 2026-01-30
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2026-01-27 · Health · corrected 2026-01-30
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2025-05-20 · Health · corrected 2025-05-21
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2025-05-20 · Health · corrected 2025-05-21
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0584Honor 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.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0761Ensure 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.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- DF0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.2025-04-10 · Health · corrected 2025-04-11
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-10-03 · Health · corrected 2024-08-24
Immediate jeopardy
- EF0760Ensure that residents are free from significant medication errors.2024-05-10 · Health · corrected 2024-06-07
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-04-25 · Health · corrected 2024-05-09
Potential for more than minimal harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-02-29 · Health · corrected 2024-03-18
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-29 · Health · corrected 2024-03-18
Potential for more than minimal harm
- DF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2024-02-29 · Health · corrected 2024-03-18
Potential for more than minimal harm
- DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-02-29 · Health · corrected 2024-03-18
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-02-29 · Health · corrected 2024-03-18
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-11-14 · Health · corrected 2023-12-11
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2023-11-14 · Health · corrected 2023-12-11
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-11-14 · Health · corrected 2023-12-11
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-11-14 · Health · corrected 2023-12-11
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-25 · Health · corrected 2023-11-17
Potential for more than minimal harm
- EF0584Honor 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.2023-09-14 · Health · corrected 2023-10-08
Potential for more than minimal harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-09-14 · Health · corrected 2023-10-08
Potential for more than minimal harm
- EF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2023-09-14 · Health · corrected 2023-10-08
Potential for more than minimal harm
- EF0836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.2023-09-14 · Health · corrected 2023-10-08
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-03-10 · Health · corrected 2023-04-20
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-03-10 · Health · corrected 2023-04-30
Potential for more than minimal harm
- EF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2023-03-10 · Health · corrected 2023-04-20
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-03-10 · Health · corrected 2023-04-30
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- KF0584Honor 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.2023-01-02 · Health · corrected 2023-02-05
Immediate jeopardy
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- EF0742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- EF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
- KF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2023-01-02 · Health · corrected 2023-02-05
Immediate jeopardy
- EF0880Provide and implement an infection prevention and control program.2023-01-02 · Health · corrected 2023-02-05
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| WEST WHARTON COUNTY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2023-12-14 |
| MADISONVILLETX LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-14 |
| JIAN, PETER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-14 |
| MISTRETTA, CASSANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-14 |
| PARKER, KAREN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-08-22 |
| PFEIFER, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2023-12-14 |
| THOMPSON, JOHNNY | Individual | CORPORATE OFFICER | — | 2023-12-14 |
Other facilities in MADISONVILLE
| Name | Overall | Beds |
|---|
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.