F59

Avir at Converse

Grade F 59/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
1/5
Health Insp.
2/5
Quality
3/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

100

Ownership

For profit - Limited Liability company

Total Fines

$64,590

Last Survey

N/A

7700 MESQUITE PASS, CONVERSE, TX 78109
2106500551

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.24h
LPN
1.03h
CNA
1.60h
Total
2.87h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

CONVERSE SENIOR CARE LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Sep 2020

MCCULLOCH COUNTY HOSPITAL DISTRICT

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Sep 2020

COOK, JACK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2020

GIVENS, LAURA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2024

JONES, TIMOTHY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2020

KESTERSON, LISA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2024

COOK, CATHERINE

IndividualCORPORATE DIRECTORSince Mar 2024

COOK, JACK

IndividualCORPORATE DIRECTORSince Mar 2024

DERRICK, MICHELE

IndividualCORPORATE DIRECTORSince Sep 2020

JONES, TIMOTHY

IndividualCORPORATE DIRECTORSince Mar 2015

KELTZ, TERRY

IndividualCORPORATE DIRECTORSince Sep 2020

RODDIE, KIRK

IndividualCORPORATE DIRECTORSince Jan 2020

SCHAFFNER, MICHAEL

IndividualCORPORATE DIRECTORSince Sep 2020

Penalties & Fines (4)

$64,590total fines
DateTypeDescriptionAmount
Jul 27, 2024Fine$23,845
Feb 25, 2024Fine$15,440
Feb 25, 2024Fine$25,305
Feb 25, 2024Payment Denial

Health Inspection Deficiencies (43)

September 4, 2025Health1 deficiency
0761DMinimal harm, Isolated

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

Corrected Sep 7, 2025
April 4, 2025Health16 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Apr 10, 2025
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 8, 2025
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 8, 2025
0656DMinimal harm, Isolated

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

Corrected Apr 8, 2025
0690DMinimal harm, Isolated

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

Corrected Apr 10, 2025
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 10, 2025
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Apr 7, 2025
0761EMinimal harm, Pattern

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

Corrected Apr 7, 2025
0813DMinimal harm, Isolated

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Corrected Apr 10, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 10, 2025
0940EMinimal harm, Pattern

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies

Corrected Apr 22, 2025
0941EMinimal harm, Pattern

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Administration Deficiencies

Corrected Apr 22, 2025
0944EMinimal harm, Pattern

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies

Corrected Apr 22, 2025
0946EMinimal harm, Pattern

Provide training in compliance and ethics.

Administration Deficiencies

Corrected Apr 22, 2025
0947EMinimal harm, Pattern

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

Corrected Apr 22, 2025
0949EMinimal harm, Pattern

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies

Corrected Apr 22, 2025
March 28, 2025Health2 deficiencies
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Apr 30, 2025
0842EMinimal harm, Pattern

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

Corrected Apr 30, 2025
March 23, 2025Health1 deficiency
0656DMinimal harm, Isolated

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

Corrected Apr 23, 2025
September 6, 2024Health1 deficiency
0690DMinimal harm, Isolated

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

Corrected Oct 1, 2024
July 27, 2024Health1 deficiency1 severe
0678JImmediate jeopardy, Isolated

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

Corrected Jul 28, 2024
May 22, 2024Health1 deficiency
0842DMinimal harm, Isolated

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

Corrected May 24, 2024
April 9, 2024Health4 deficiencies1 severe
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Apr 10, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 10, 2024
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 10, 2024
0761DMinimal harm, Isolated

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

Corrected Apr 10, 2024
February 25, 2024Health13 deficiencies2 severe
0578JImmediate jeopardy, Isolated

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

Corrected Mar 22, 2024
0678JImmediate jeopardy, Isolated

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

Corrected Mar 22, 2024
0584DMinimal harm, Isolated

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

Corrected Mar 25, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 22, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 25, 2024
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 25, 2024
0656EMinimal harm, Pattern

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

Corrected Mar 25, 2024
0657DMinimal harm, Isolated

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

Corrected Mar 22, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 22, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Mar 22, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 22, 2024
0842DMinimal harm, Isolated

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

Corrected Mar 22, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 22, 2024
August 18, 2023Health1 deficiency
0636DMinimal harm, Isolated

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 8, 2023
January 10, 2023Health2 deficiencies
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jan 11, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 10, 2023

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Frequently Asked Questions

What is the CareGrader rating for Avir at Converse?

Avir at Converse in CONVERSE, Texas has a CareGrader grade of F (Poor), with a composite score of 59 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Avir at Converse?

Avir at Converse has an overall CMS star rating of 1 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Avir at Converse have?

Avir at Converse has 43 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has Avir at Converse been fined?

Yes. Avir at Converse has $64,590 in total fines from CMS enforcement actions across 4 penalties.

How many beds does Avir at Converse have?

Avir at Converse has 100 certified beds with approximately 47 current residents (47% occupancy). The facility is located at 7700 MESQUITE PASS, CONVERSE, Texas 78109. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.