Your report for Avir at Pasadena
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove 69% of peers1,167 rated homes · average 2.8★
- Harris CountyAbove 69% of peers94 rated homes · average 2.8★
- United StatesAbove 61% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point3★+0.2 vs TX avg
- StaffingCan add or remove a star4★+1.9 vs TX avg
- Quality measuresCan add or remove a star5★+1.2 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 46% of peersTX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 88% of peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 68% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.55hrsAbove 75% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.44hrsAbove 64% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better28%Top 4%TX avg51%RN turnover14%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$30,361Above only 41% of peersTX avg$55,368Fines · denials2 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJun 2022 – Nov 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Nov 21, 2024Cycle 1worst J · immediate jeopardy$8,021
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 8, 2024
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Dec 20, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 22, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jan 2, 2024
Oct 12, 2023Cycle 2worst E · no actual harm
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Oct 16, 2023
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 13, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 3, 2023
Sep 1, 2023Cycle 3worst J · immediate jeopardy$22,340
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Sep 12, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsJ · isolatedCorrected Sep 12, 2023
- F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Sep 12, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesJ · isolatedCorrected Sep 12, 2023
Jun 29, 2022Cycle 3worst E · no actual harm
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Aug 5, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.55hrs
- Registered nursesRN hours only0.44hrs
- Licensed practical nursesLPN hours0.60hrs
- Nurse aidesCNA hours2.51hrs
- Weekend nursingAll staff on Saturdays and Sundays3.14hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better28%Top 4%TX avg 51%
- RN turnoverRegistered nurses only14%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy131 certified beds · ~99 residents a day75%Above 66% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $30,361In fines
- 2Fines
- 0Payment denials
- $55,368TX avg in fines
Actions on record
- Nov 21, 2024Civil money penalty$8,021
- Sep 1, 2023Civil money penalty$22,340
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Avir Health Group79 facilities in the chain2.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 675625 · 4300 VISTA RD, PASADENA, TX, 77504.
- Percentiles compare this facility with every rated nursing home in Texas and Harris County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
