SeniorHomeViolations
B+
84/100

Avir at Comfort Inspection Report, Violations & Safety Grade (COMFORT, Texas)

615 Faltin St., COMFORT, Texas 78013

Phone: 8309953757

CMS Overall:4/5

Overview & Bed Count

Certified Beds
76
Avg Residents/Day
32.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Kendall
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health4/5
Staffing3/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityTexas AvgDifference
RN Hours per Resident per Day0.570.44+0.13
Total Nurse Hours per Resident per Day3.293.42-0.12
CMS Staffing Rating3/51.9/5-
Nursing Staff Turnover56.3%50.8%-

Health Citation History

36 health citations on record

DateCategoryDescriptionSeverity
2026-05-27Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E – Moderate Harm Potential
2026-05-27Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.E – Moderate Harm Potential
2025-08-22Nursing and Physician Services DeficienciesHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.F – Moderate Harm Potential
2025-08-22Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2025-04-18Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.F – Moderate Harm Potential
2025-04-18Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2024-07-10Nursing and Physician Services DeficienciesHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.E – Moderate Harm Potential
2024-07-10Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.D – Moderate Harm Potential
2024-07-10Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.D – Moderate Harm Potential
2024-07-10Resident Rights DeficienciesAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.C – Minimal Harm Potential
2024-07-10Nursing and Physician Services DeficienciesPost nurse staffing information every day.C – Minimal Harm Potential
2024-03-01Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2024-03-01Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2023-06-08Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-06-08Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.E – Moderate Harm Potential
2023-06-08Administration DeficienciesDevelop, implement, and/or maintain an effective training program for all new and existing staff members.E – Moderate Harm Potential
2023-06-08Administration DeficienciesDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.E – Moderate Harm Potential
2023-06-08Resident Rights DeficienciesEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.E – Moderate Harm Potential
2023-06-08Freedom from Abuse, Neglect, and Exploitation DeficienciesGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.E – Moderate Harm Potential
2023-06-08Infection Control DeficienciesInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.E – Moderate Harm Potential
2023-06-08Administration DeficienciesProvide training in compliance and ethics.E – Moderate Harm Potential
2023-06-08Nursing and Physician Services DeficienciesEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.E – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.D – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesAssess the resident when there is a significant change in conditionD – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.D – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesEnsure a qualified health professional conducts resident assessments.D – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2023-06-08Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2023-06-08Nursing and Physician Services DeficienciesHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.D – Moderate Harm Potential
2023-06-08Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2023-06-08Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2023-06-08Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2023-06-08Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2023-06-08Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential

Fire Safety Citation History

4 fire safety citations on record

DateCategoryDescriptionSeverity
2025-08-22Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.F – Moderate Harm Potential
2025-08-22Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.F – Moderate Harm Potential
2025-08-22Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.E – Moderate Harm Potential
2024-07-10Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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