Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Comfort during CMS and state inspections, most recent first.
Failure to include activity preferences in person-centered care plans affected 3 residents with documented interests and varying cognitive status, including one with bipolar disorder, one with hemiplegia/hemiparesis after CVA, and one with Alzheimer’s disease. Although the residents’ activity preferences were recorded in activity reviews, the care plan reports did not reflect those preferences, and interviews showed the Activities Director did not routinely attend care plan conferences while the DON handled care plan creation and shared preferences with staff outside the care plan process.
Inconsistent Activity Program and Frequent Cancellations: The facility failed to provide an ongoing activity program with daily organized options for 3 residents, including a resident with bipolar disorder, a resident with hemiplegia/hemiparesis after CVA, and a resident with Alzheimer's disease. The calendar showed self-directed activities every weekend, while residents and a CNA reported that scheduled events such as the coffee social were often cancelled or not actually held, leaving little more than TV or independent packets for engagement. The AD said 2 to 3 activities were cancelled each week and that weekend activities were self-directed due to a conflict, while the Admin acknowledged the weekend schedule did not meet facility standards and noted prior complaints about lack of activities.
The facility did not provide RN coverage for at least 8 consecutive hours per day, 7 days a week, on 19 separate days, as confirmed by staffing records and interviews. The absence of an RN was due to the loss of a weekend nurse, with LVNs covering shifts and the DON available by phone.
A CNA transferred a resident with significant neurological and muscular conditions using a mechanical lift without the required assistance of a second staff member, contrary to the resident's care plan and facility policy, which both specified the need for two-person assistance during such transfers.
On one occasion, the facility did not have any CNAs available for about five hours during an afternoon/evening shift, leaving only licensed nurses to provide care. As a result, a resident had to transfer herself without assistance, another was put to bed much later than usual, and a resident's brief was changed by her roommate due to unanswered call lights. Staff interviews and time records confirmed the lack of CNA coverage, which was below the facility's own minimum staffing requirements.
A resident with hemiplegia, hemiparesis, cerebral infarction, and dementia had a care plan that incorrectly listed a one-person transfer, despite staff and records indicating a two-person mechanical lift was required. Staff often relied on verbal communication or cheat sheets rather than the care plan, and the DON confirmed the care plan was outdated and needed revision.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, over 20 days from January to June 2024. The absence of RN coverage was confirmed through staffing data and timesheets. The DON worked primarily Monday through Friday and was available by phone, but the facility lacked a weekend RN supervisor until June 2024. The facility's policy required RN services for at least 8 consecutive hours daily, which was not met during the specified period.
A resident with moderate cognitive impairment and requiring substantial assistance was found with the call light out of reach on two occasions. The resident expressed difficulty in locating the call light, and staff confirmed it was not accessible. The facility's policy requires call lights to be within easy reach, which was not followed.
The facility failed to ensure staff wore hair restraints in the kitchen, risking food contamination. A CNA was seen washing hands without a hair net, and the DM was observed without a hair net or beard restraint near food prep areas. Both acknowledged the importance of hair restraints to prevent contamination, aligning with facility policy and the U.S. Food Code.
The facility did not make the most recent survey results readily accessible to residents and visitors, as required. Despite a sign indicating their location, the survey results were not found in the lobby or common areas. The HRC initially could not locate the binder, which was later found behind the nurses' station. The Administrator noted that the plastic pocket for the results had fallen off the wall, causing the inaccessibility.
The facility failed to update and post daily nurse staffing information for four consecutive days, leading to outdated postings. Observations showed the most recent posting was dated several days prior, and interviews revealed confusion among staff about who was responsible for updating the information. The facility's policy requires staffing levels to be updated each shift and posted publicly, which was not followed.
Failure to Include Activity Preferences in Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that addressed the psychosocial needs and activity preferences of 3 of 3 residents reviewed for care planning. Resident #1, a female with bipolar disorder and intact cognition (BIMS 15), had documented preferences for arts and crafts, coloring, and gardening, and was described as being very involved in activities and creative with the Activities Director, but the care plan report did not include person-centered care planning related to those preferences. Resident #2, a male with hemiplegia and hemiparesis following cerebral infarction and intact cognition (BIMS 15), had a documented preference that he loved all activities, but his care plan report also did not reflect person-centered care planning related to activities preferences. Resident #3, a female with Alzheimer’s disease and moderately impaired cognition (BIMS 12), had documented preferences for creating unique crafts/art, bingo, social gatherings, manicures/makeup, family visits, music, movies, most activities, outings, and visiting with friends and family, but her care plan report did not reveal person-centered care planning related to those preferences. Interviews with the LSW, AD, Admin, and DON showed that the Activities Director did not attend routine care plan conferences, the facility was in the process of changing the conference process to include the Activities Department, and the DON stated that resident preferences were reviewed during conferences but were not included specifically in the care plans.
Inconsistent Activity Program and Frequent Cancellations
Penalty
Summary
The facility failed to ensure residents received an ongoing program of activities that supported their choices and psychosocial well-being, including facility-sponsored group activities, individual activities, and independent activities. The deficiency involved 3 of 3 residents reviewed for activities: a female resident with bipolar disorder and intact cognition, a male resident with hemiplegia and hemiparesis following cerebral infarction and intact cognition, and a female resident with Alzheimer's disease and moderately impaired cognition. The facility’s May 2026 activities calendar listed self-directed activities on every Saturday and Sunday, totaling 10 days, rather than organized daily activities. Resident interviews and staff statements showed that scheduled activities were frequently cancelled or not actually held. One resident said the coffee social and most weekday activities were often not hosted by the facility, and that the weekend self-directed activities meant there was nothing scheduled except television, which had been occurring for several months and made her feel terrible. Another resident said he was satisfied overall but wished there were weekend activities. A CNA stated there was no coffee social or other organized activity occurring at the time of interview, that the calendar did not reflect which activities were actually hosted, and that residents frequently reported boredom due to lack of activities. The AD stated she was unsure whether the coffee social occurred because she had arrived late and had not arranged for anyone else to host it. She also stated that approximately 2 to 3 scheduled activities were cancelled each week and that weekend activities were scheduled as self-directed because of a conflict with a resident regarding weekend activity type. She said she prepared activity packets for interested residents and used an activity cart with snacks and independent activities as backup. The Admin stated she was aware that every weekend in May 2026 was scheduled as self-directed, that this did not meet facility standards, and that the AD had been on a performance improvement plan since January 2026 due to complaints from residents and staff about lack of activities, poor communication, and inconsistent efforts to engage residents in activities.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as required. Review of Payroll-Based Journal (PBJ) staffing data and facility time sheets revealed that there was no RN coverage on a total of 19 days, including multiple Saturdays and Sundays over several months. The absence of RN coverage was confirmed for specific dates through both PBJ data and facility time sheets. The deficiency was further substantiated by interviews with the Administrator and the Director of Nursing (DON), who acknowledged the lack of RN coverage on weekends due to the loss of their Sunday nurse. The Administrator reported that efforts were being made to hire a new weekend RN and that a new nurse had recently started training. Despite the absence of an RN, the Administrator and DON stated that licensed vocational nurses (LVNs) were present and that the DON was available by phone 24/7. Facility policy reviewed indicated a requirement to comply with RN staffing regulations, but the documented staffing records showed noncompliance on the identified dates.
Mechanical Lift Transfer Performed by Single CNA
Penalty
Summary
A certified nursing assistant (CNA) transferred a male resident with a history of Wernicke's encephalopathy, generalized muscle weakness, muscle wasting, and a prior transient ischemic attack, using a mechanical lift without the required assistance of a second staff member. The resident's care plan and annual MDS assessment specified the need for a two-person physical assist for bed mobility and transfers, and facility policy mandated two staff for mechanical lift transfers. The CNA admitted to performing the transfer alone because no other staff were visible in the hallway and did not request assistance. Observation confirmed the resident was in his wheelchair with the mechanical lift sling still underneath him, and both the CNA and the resident stated the transfer was completed by one staff member. The resident reported feeling safe and noted that staff typically used two people for such transfers. The CNA had previously been trained and passed competency for two-person mechanical lift transfers. The facility's policy, effective at the time, required two staff for all mechanical lift transfers to ensure resident and staff safety.
Failure to Provide Sufficient Nursing Staff on Evening Shift
Penalty
Summary
The facility failed to provide a sufficient number of nursing personnel on a 24-hour basis to meet the needs of all residents, as required by resident care plans, for one out of four days reviewed. On the afternoon and evening shift of 04/07/25, there were no certified nursing assistants (CNAs) available for approximately five hours, from 5PM to 10PM. This was confirmed by staff interviews and punch detail reports, which showed all scheduled CNAs had clocked out by 5:06PM, leaving only licensed nurses to provide care for the remainder of the shift. During this period, residents experienced delays in care. One resident reported that her call light was not answered when she needed assistance transferring from her wheelchair to bed, resulting in her transferring herself without staff supervision. Another resident, who typically went to bed at 7PM, was not assisted to bed until 10 or 11PM. Additionally, a resident's roommate had to change her brief because her call light was not answered and staff did not respond to her needs. Interviews with staff confirmed that nurses had to perform all CNA duties, including answering call lights, feeding, and providing incontinence care, in addition to their regular nursing responsibilities. The facility's own assessment tool indicated that a minimum of two CNAs were needed for the afternoon shift, and the facility's policy required that licensed nurses and CNAs be available 24 hours a day to provide direct resident care. However, on the day in question, there was a failure to ensure adequate CNA coverage, resulting in unmet care needs and delays in assistance for multiple residents.
Failure to Update Care Plan for Resident Transfer Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, including hemiplegia, hemiparesis, cerebral infarction, and dementia. The resident's care plan inaccurately documented that only one person was required for transfers, despite multiple records and staff interviews confirming that the resident required a two-person mechanical lift transfer. The care plan had not been updated to reflect the resident's actual transfer needs, even though the resident's quarterly MDS assessment indicated substantial/maximal assistance was necessary. Interviews with CNAs and LVNs revealed that staff were aware of the need for a two-person mechanical lift transfer, but this information was often communicated verbally rather than through the care plan. Some staff relied on cheat sheets or verbal reports instead of reading the care plan, while others stated they would refer to the care plan if unsure about a resident's needs. The Director of Nursing acknowledged that the care plan was outdated and needed to be revised to prevent inappropriate transfers, as per facility policy requiring ongoing assessment and timely updates to care plans.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, over a period of 20 days from January to June 2024. This deficiency was identified through interviews and record reviews, including the CMS PBJ staffing data report and facility timesheets, which confirmed the absence of RN coverage on specific dates. The Director of Nursing (DON) stated that she worked a minimum of 40 hours a week, primarily Monday through Friday, and was available by phone for emergencies. However, the facility lacked a weekend RN supervisor until June 2024. Interviews with the Human Resources Coordinator (HRC) and the Administrator revealed that the facility had previously employed other RNs whose timesheets were inaccessible. The Administrator acknowledged the absence of an RN on duty but noted that nurses had immediate access to the DON, clinical resource nurse, physician's group, and emergency services. Despite these measures, the facility's policy required RN services for at least 8 consecutive hours daily, which was not met during the specified period.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to call for help as needed. The resident, who had moderate cognitive impairment and required substantial assistance for various activities, was observed on two occasions with the call light out of reach. On the first occasion, the call light was found on the floor at the foot of the bed, and the resident expressed a desire for help to turn the light on, indicating she was unaware of its location. A Licensed Vocational Nurse (LVN) confirmed that the call light was not within reach and acknowledged that it was everyone's responsibility to ensure it was accessible. On a subsequent observation, the resident was again found with the call light out of reach, placed on the other side of a privacy curtain. The Director of Nursing (DON), while administering medications, noticed the call light's inaccessibility and placed it on the resident's lap, emphasizing the importance of having it within reach. The facility's policy on answering call lights, which mandates that call lights be within easy reach when residents are in bed or confined to a chair, was not adhered to in these instances.
Failure to Use Hair Restraints in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that staff wore appropriate hair restraints in the kitchen. During an initial tour of the kitchen, a CNA was observed entering the kitchen and washing hands without wearing a hair net. The CNA acknowledged the oversight, explaining that she had just come in from taking out the trash and needed to wash her hands. She admitted that a hair net should always be worn in the kitchen to prevent contamination. Further observations revealed that the Dietary Manager (DM) was not wearing a hair net or beard restraint while standing near the stove and prep table. The DM later acknowledged the importance of wearing hair restraints to prevent hair from contaminating food, as hair can carry bacteria. The facility's policy and the U.S. Food Code require food employees to wear hair restraints to prevent hair from contacting food and food-contact surfaces. The ADM confirmed that staff should wear hair restraints every time they enter the kitchen to avoid infection control issues.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the results of the most recent survey readily accessible to residents, family members, and legal representatives. On two separate days, surveyors observed that the survey results were not available in the lobby, common area, or on the nurses' station desk, despite a sign indicating their location. Interviews with staff revealed that the survey results binder was misplaced behind the nurses' station with other binders, and the Human Resources Coordinator (HRC) was initially unable to locate it. During a resident council group meeting, some residents mentioned that the survey binder was usually available near the front desk. However, the Administrator later explained that the plastic pocket meant to hold the survey results had fallen off the wall, and the issue had not been addressed, leading to the inaccessibility of the survey results. The facility's policy requires that survey results be maintained in an accessible location, but this was not adhered to during the survey period.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for four consecutive days during the survey period. Specifically, the daily staff postings were not updated on 7/4/24, 7/5/24, 7/6/24, and 7/7/24. Observations on 7/7/24 revealed that the staffing information displayed was outdated, with the most recent posting dated 7/3/24. Interviews with staff, including an LVN and the Director of Nursing (DON), indicated confusion regarding the responsibility for updating the staffing information. The LVN was unsure who was responsible, while the DON stated that any nursing staff member could update the postings. Further interviews revealed inconsistencies in understanding the responsibility for posting the staffing data. The Administrator confirmed that the DON was responsible for ensuring the daily staffing sheet was posted. However, the DON mentioned that she prepared the sheets and expected any nurse on duty to update them. The facility's policy, revised in July 2021, requires staffing levels to be updated each shift and posted in a public area, which was not adhered to during the specified days.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Comfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Hills Health And Rehabilitation Center | 13.5 mi | ★★★★★ | 7 | 0 |
| Avir At Kerrville | 14.3 mi | ★★★★★ | 21 | 0 |
| Arbor View Nursing & Rehabilitation | 14.6 mi | ★★★★★ | 3 | 1 |
| Town And Country Nursing And Rehabilitation Center | 15.8 mi | ★★★★★ | 5 | 0 |
| Care Choice Of Boerne | 16 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.