Avir at Converse

7700 MESQUITE PASS
CONVERSE, TX, 78109
2106500551
CCN: 675452
1
Overall
2
Health
1
Staffing
3
Quality
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
SCHAFFNER, MICHAELCORPORATE DIRECTORNOT APPLICABLE
COOK, CATHERINECORPORATE DIRECTORNOT APPLICABLE
COOK, JACKCORPORATE DIRECTORNOT APPLICABLE
DERRICK, MICHELECORPORATE DIRECTORNOT APPLICABLE
JONES, TIMOTHYCORPORATE DIRECTORNOT APPLICABLE
KELTZ, TERRYCORPORATE DIRECTORNOT APPLICABLE
RODDIE, KIRKCORPORATE DIRECTORNOT APPLICABLE
MCCULLOCH COUNTY HOSPITAL DISTRICTOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
COOK, JACKOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
GIVENS, LAURAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
JONES, TIMOTHYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
KESTERSON, LISAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
CONVERSE SENIOR CARE LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (3)
DateTypeAmount
2024-07-27Fine$24K
2024-02-25Fine$25K
2024-02-25Payment Denial15 days
Health Deficiencies (43)
2025-09-04 · Health
D
F761 · Pharmacy Service Deficiencies
Ensure 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
E
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
E
F947 · Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
E
F946 · Administration Deficiencies
Provide training in compliance and ethics.
E
F944 · Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
E
F941 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
E
F940 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F813 · Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
E
F761 · Pharmacy Service Deficiencies
Ensure 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
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2025-03-28 · Health
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2025-03-23 · Health
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2024-09-06 · Health
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
2024-07-27 · Health
J
F678 · Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
2024-05-22 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2024-04-09 · Health
D
F761 · Pharmacy Service Deficiencies
Ensure 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.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2024-02-25 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
J
F678 · Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F584 · Resident Rights Deficiencies
Honor 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.
J
F578 · Resident Rights Deficiencies
Honor 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.
2023-08-18 · Health
D
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
2023-01-10 · Health
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
2.61
3.68
RN Hrs/Resident/Day
0.22
0.54
LPN Hrs/Resident/Day
0.93
0.81
CNA Hrs/Resident/Day
1.46
2.33
PT Hrs/Resident/Day
0.00
0.12
Data as of 2026-03-01