Home › Texas › Bexar County › Avir at Converse
Avir at Converse
7700 Mesquite Pass, Converse, TX 78109 · CMS Certification Number (CCN) 675452
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 49 in the last 3 inspection cycles (4 immediate jeopardy, 0 actual harm, 24 from complaints)
- Fire safety citations
- 16
- Fines (last 3 years)
- 2 fines, total $43,845
- Payment denials
- 1
- Most recent standard inspection
- June 4, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★☆☆☆☆ 1 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | June 4, 2026 | 10 | 7 | 3 |
| Cycle 2 | April 4, 2025 | 36 | 16 | 21 |
CMS weighted health inspection score: 118.5 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
49 health citations across 12 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 4, 2026: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/24/2026 |
| D | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/08/2026 |
| D | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/25/2026 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/16/2026 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/08/2026 |
| E | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/24/2026 |
| D | F-0584 | 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. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/05/2026 |
March 6, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/09/2026 |
February 5, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/06/2026 |
September 4, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/07/2025 |
April 4, 2025: 16 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/22/2025 |
| E | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/22/2025 |
| E | F-0946 | Provide training in compliance and ethics. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/22/2025 |
| E | F-0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/22/2025 |
| E | F-0941 | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/22/2025 |
| E | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/22/2025 |
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/10/2025 |
| D | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/10/2025 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/07/2025 |
| E | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/07/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/10/2025 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/10/2025 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/08/2025 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/08/2025 |
| D | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/08/2025 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/10/2025 |
March 28, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/30/2025 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/30/2025 |
March 23, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/23/2025 |
September 6, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/01/2024 |
July 27, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/28/2024 |
May 22, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/24/2024 |
April 9, 2024: 4 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0761 | 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. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/10/2024 |
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/10/2024 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/10/2024 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/10/2024 |
February 25, 2024: 13 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| J | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/25/2024 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/25/2024 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/25/2024 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0584 | 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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/25/2024 |
| J | F-0578 | 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. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
16 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 06/04/2026 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/19/2026 |
| 06/04/2026 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/22/2026 |
| 06/04/2026 | E | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies | Deficient, Provider has date of correction Corrected 06/10/2026 |
| 04/04/2025 | D | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 04/08/2025 |
| 04/04/2025 | E | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 04/30/2025 |
| 04/04/2025 | E | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 04/24/2025 |
| 04/04/2025 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/04/2025 |
| 04/04/2025 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/14/2025 |
| 04/04/2025 | E | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2025 |
| 04/04/2025 | D | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/03/2025 |
| 04/04/2025 | D | K-0281 | Install proper backup exit lighting. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2025 |
| 04/04/2025 | E | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies | Deficient, Provider has date of correction Corrected 04/30/2025 |
| 04/04/2025 | E | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/09/2025 |
| 04/04/2025 | F | E-0031 | Provide emergency officials' contact information. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 04/04/2025 |
| 02/25/2024 | F | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/25/2024 |
| 02/25/2024 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/15/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| July 27, 2024 | Fine | $23,845 | — |
| February 25, 2024 | Fine | $20,000 | — |
| February 25, 2024 | Payment Denial | — | Starting March 26, 2024, 15 days |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.29 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.98 | Not published | Not published |
| Nurse aide hours per resident per day | 1.73 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.5 | Not published | Not published |
| RN hours per resident per day, weekends | 0.26 | Not published | Not published |
| Total nursing staff turnover (%) | 67.2 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 80 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Mcculloch County Hospital District
- Ownership type
- For profit - Limited Liability company
- Chain
- Avir Health Group (118 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 100
- Average residents per day
- 55.4
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- February 24, 1995
- County/parish
- Bexar
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
8 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| JONES, TIMOTHY | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JONES, TIMOTHY | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GIVENS, LAURA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JONES, TIMOTHY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KESTERSON, LISA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GIVENS, LAURA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JONES, TIMOTHY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KESTERSON, LISA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Avir at Converse. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.