Avir at Converse
7700 MESQUITE PASS, CONVERSE, TX 78109 · CCN 675452
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 100
- Avg residents/day
- 47.3
- Phone
- 2106500551
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 | 2025-04-04 | 20 | 9.1 | 9.5 | +10.9 worse |
| 2 | 2024-02-25 | 20 | 9.4 | 9.8 | +10.6 worse |
| 3 | 2023-01-10 | 3 | 8.1 | 9.3 | -5.1 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 2 |
| Resident assessment and care planning | 5 |
| Nursing and physician services | 1 |
| Resident rights | 2 |
| Nutrition and dietary | 1 |
| Pharmacy service | 3 |
| Administration | 5 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.61 | 69.8% |
| RN staffing (reported) | 0.22 | 87.5% |
| Total nurse staffing (adjusted) | 2.87 | — |
Fines & penalties
- Total fines
- $64,590
- Number of fines
- 3
- Number of penalties
- 4
- Payment denials
- 1
Inspection citations (43)4 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.2025-09-04 · Health · corrected 2025-09-07
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2025-04-04 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.2025-04-04 · Health · corrected 2025-04-08
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2025-04-04 · Health · corrected 2025-04-08
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.2025-04-04 · Health · corrected 2025-04-08
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.2025-04-04 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-04-04 · Health · corrected 2025-04-10
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-04-04 · Health · corrected 2025-04-07
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.2025-04-04 · Health · corrected 2025-04-07
Potential for more than minimal harm
- DF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2025-04-04 · Health · corrected 2025-04-10
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-04-04 · Health · corrected 2025-04-10
Potential for more than minimal harm
- EF0940Develop, implement, and/or maintain an effective training program for all new and existing staff members.2025-04-04 · Health · corrected 2025-04-22
Potential for more than minimal harm
- EF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2025-04-04 · Health · corrected 2025-04-22
Potential for more than minimal harm
- EF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2025-04-04 · Health · corrected 2025-04-22
Potential for more than minimal harm
- EF0946Provide training in compliance and ethics.2025-04-04 · Health · corrected 2025-04-22
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-04-04 · Health · corrected 2025-04-22
Potential for more than minimal harm
- EF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-04-04 · Health · corrected 2025-04-22
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2025-03-28 · Health · corrected 2025-04-30
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-03-28 · Health · corrected 2025-04-30
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.2025-03-23 · Health · corrected 2025-04-23
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.2024-09-06 · Health · corrected 2024-10-01
Potential for more than minimal harm
- JF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2024-07-27 · Health · corrected 2024-07-28
Immediate jeopardy
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-05-22 · Health · corrected 2024-05-24
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2024-04-09 · Health · corrected 2024-04-10
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2024-04-09 · Health · corrected 2024-04-10
Potential for more than minimal harm
- JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-04-09 · Health · corrected 2024-04-10
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.2024-04-09 · Health · corrected 2024-04-10
Potential for more than minimal harm
- JF0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.2024-02-25 · Health · corrected 2024-03-22
Immediate jeopardy
- DF0584Honor 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.2024-02-25 · Health · corrected 2024-03-25
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-02-25 · Health · corrected 2024-03-22
Potential for more than minimal harm
- DF0641Ensure each resident receives an accurate assessment.2024-02-25 · Health · corrected 2024-03-25
Potential for more than minimal harm
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2024-02-25 · Health · corrected 2024-03-25
Potential for more than minimal harm
- EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-02-25 · Health · corrected 2024-03-25
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-02-25 · Health · corrected 2024-03-22
Potential for more than minimal harm
- JF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2024-02-25 · Health · corrected 2024-03-22
Immediate jeopardy
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-25 · Health · corrected 2024-03-22
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-02-25 · Health · corrected 2024-03-22
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.2024-02-25 · Health · corrected 2024-03-22
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-02-25 · Health · corrected 2024-03-22
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-02-25 · Health · corrected 2024-03-22
Potential for more than minimal harm
- DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2023-08-18 · Health · corrected 2023-09-08
Potential for more than minimal harm
- DF0640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.2023-01-10 · Health · corrected 2023-01-11
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.2023-01-10 · Health · corrected 2023-02-10
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| CONVERSE SENIOR CARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-09-01 |
| MCCULLOCH COUNTY HOSPITAL DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-09-01 |
| COOK, JACK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-09-01 |
| GIVENS, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-01-01 |
| JONES, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2020-09-01 |
| KESTERSON, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-01-01 |
| COOK, CATHERINE | Individual | CORPORATE DIRECTOR | — | 2024-03-01 |
| COOK, JACK | Individual | CORPORATE DIRECTOR | — | 2024-03-01 |
| DERRICK, MICHELE | Individual | CORPORATE DIRECTOR | — | 2020-09-01 |
| JONES, TIMOTHY | Individual | CORPORATE DIRECTOR | — | 2015-03-01 |
| KELTZ, TERRY | Individual | CORPORATE DIRECTOR | — | 2020-09-01 |
| RODDIE, KIRK | Individual | CORPORATE DIRECTOR | — | 2020-01-01 |
| SCHAFFNER, MICHAEL | Individual | CORPORATE DIRECTOR | — | 2020-09-01 |
Other facilities in CONVERSE
| 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.