Avir at Rose Trail
930 S Baxter · Tyler, TX · 75701 · 9035972068
172 certified beds Government - Hospital district Chain: Avir Health Group
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $181,195 in fines in the last 24 months.
- 3 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
5 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$181,195 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.90 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
67% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 2.90 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.34 | 0.55–0.75 |
| Weekend hours / resident-day | 2.46 | ≈ weekday level |
| Nursing turnover / year | 67% | median 45% |
| Fines (3-yr window) | 6 · $520,257 |
Inspection citations (60 in the current record)
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Potential for harm · D March 5, 2026 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected March 16, 2026 · Pharmacy Service
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Potential for harm · E January 2, 2026 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected January 3, 2026 · Resident Rights
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Potential for harm · D December 4, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 5, 2025 · Resident Rights
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Potential for harm · D December 4, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected December 5, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 4, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected December 8, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 4, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 4, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 5, 2025 · Quality of Life and Care
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Potential for harm · D December 4, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 5, 2025 · Pharmacy Service
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Potential for harm · D December 4, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected December 5, 2025 · Pharmacy Service
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Potential for harm · D December 4, 2025
Ensure that residents are free from significant medication errors.
Corrected December 5, 2025 · Pharmacy Service
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Potential for harm · E December 4, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 5, 2025 · Nutrition and Dietary
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Potential for harm · E December 4, 2025
Provide and implement an infection prevention and control program.
Corrected December 11, 2025 · Infection Control
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Potential for harm · E November 18, 2025 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected November 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · E November 18, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 19, 2025 · Resident Assessment and Care Planning
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Immediate jeopardy · K October 2, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected October 4, 2025 · Quality of Life and Care
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Immediate jeopardy · K October 2, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected October 4, 2025 · Infection Control
-
Potential for harm · D October 2, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 4, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 2, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 4, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 2, 2025 · found via complaint
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 October 4, 2025 · Quality of Life and Care
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Immediate jeopardy · J August 15, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 12, 2025 · Quality of Life and Care
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Potential for harm · D August 15, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected August 18, 2025 · Quality of Life and Care
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Potential for harm · D March 25, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 25, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 28, 2025 · Quality of Life and Care
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Potential for harm · D March 25, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 28, 2025 · Infection Control
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Potential for harm · E September 25, 2024
Ensure each resident receives an accurate assessment.
Corrected September 27, 2024 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 15, 2025 | Fine | $18,520 |
| August 15, 2025 | Fine | $162,675 |
| March 18, 2024 | Fine | $230,484 |
| December 18, 2023 | Fine | $44,590 |
| August 4, 2023 | Fine | $49,470 |
| June 29, 2023 | Fine | $14,518 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 455429 · certified since January 1, 1977. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.