Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Heritage during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction, dysphagia, and gastrostomy status was designated NPO and required enteral nutrition via G-tube, but the care plan was not updated to reflect this status. The plan continued to include interventions for oral intake, such as offering alternate meals and encouraging fluids, despite the resident's NPO order. Staff interviews confirmed the care plan was not revised after a change in condition, and facility policy lacked guidance on ensuring care plan accuracy.
A resident with a gastrostomy and indwelling catheter did not have Enhanced Barrier Precautions (EBP) properly implemented, as required by their care plan. Staff provided care without donning gowns, EBP signage was missing, and there was no physician's order for EBP in the record. Interviews revealed staff were unaware of the correct EBP process, and the ADON was not aware of the missing order or signage.
A resident's room was found to have a damaged bathroom door, a malfunctioning toilet, and an unsecured sprinkler system access panel. These deficiencies were not reported through the facility's work order system, and the resident occupying the room was unable to be interviewed. The facility's preventative maintenance policy was not followed as required.
Care plans for three residents with dysphagia and physician orders for thickened liquids were not updated to reflect these dietary modifications after comprehensive assessments. The MDS nurse did not review physician orders, resulting in care plans that did not include the required thickened liquid orders, as confirmed by staff interviews and facility policy review.
Surveyors identified multiple deficiencies in kitchen food storage and sanitation, including crumbs and paper wrapping in the fryer, sand-like particles on the dish washing machine, undated packages of corn beef and potatoes in the refrigerator, and unsealed, undated boxes of corn dogs and hamburger patties. The Dietary Manager confirmed these issues and their potential for contamination.
A resident with documented bipolar and schizoaffective disorders was not referred for a required Level I PASARR screen after diagnosis. The MDS coordinator, responsible for PASARR referrals, was unaware of the resident's mental illness due to not reviewing all active diagnoses, resulting in the omission of the screening process as required by facility policy.
Dietary staff prepared pureed foods for a meal without using measuring devices or following recipes, resulting in pureed bread, spinach, and macaroni and cheese that were too thick and sticky, making them difficult to swallow. The required recipes and protocols were not present during preparation, and both the Dietary Manager and Administrator confirmed the improper consistency during testing.
Two CNAs failed to change gloves or perform hand hygiene after touching contaminated surfaces and before providing incontinent care to a resident with complex medical needs and on enhanced barrier precautions. Both staff had received infection control training and passed competency checks, but did not follow facility policy requiring hand hygiene before direct care.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with multiple wounds and complex medical conditions. Despite facility policy and staff expectations requiring hand hygiene between glove changes, the nurse changed gloves multiple times without sanitizing or washing hands, as directly observed by surveyors. Interviews with staff confirmed the expectation for proper hand hygiene, and facility policies supported this requirement.
A resident with multiple pressure ulcers did not receive wound care in accordance with physician orders and professional standards. An LVN failed to clean the inside of wounds before applying dressings, used a wet-to-dry dressing instead of the ordered hydrofera blue on one wound, and did not secure the dressings. Interviews with clinical leadership confirmed these actions did not meet expected standards or facility policy.
A resident with multiple wounds and complex medical conditions received wound care treatments that were not documented in the TAR or LNAR as required by facility policy. Although a nurse performed the treatments, the absence of documentation in the medical records indicated a failure to maintain complete and accurate records in accordance with professional standards.
A resident with severe cognitive impairment was referred for wound care and received a debridement without prior notification to the responsible party. The facility failed to inform the responsible party and hospice of the procedure, despite the resident's inability to consent. Interviews revealed that the responsible party and hospice should have been notified, and the facility's policy emphasized involving the family in care decisions.
A resident was found with eye drops and a nasal spray on her bedside table without a specific written order to self-administer these medications. Despite having no cognitive impairment, the facility's records did not include an order for self-administration, and previous assessments had not confirmed her ability to do so safely. Interviews revealed staff were unaware of the policy on self-administration, and the facility's policy requiring an interdisciplinary team evaluation and a physician's order was not followed.
A medication aide failed to ensure a resident took her medications as required by facility policy, leaving a medication cup with seven medications at the bedside. The resident, with a history of respiratory failure, depression, and paraplegia, was not observed taking her medications, contrary to the facility's policy. The DON confirmed that staff must observe residents taking medications to prevent missed doses.
A resident receiving hospice respite services underwent a surgical wound debridement without the hospice agency's prior authorization or the responsible party's consent. The facility failed to notify the hospice agency and the resident's responsible party, leading to uncoordinated care. The resident had severe cognitive impairment and was admitted with multiple diagnoses, including dementia and depression.
Staff failed to follow infection control protocols for two residents requiring special precautions. In one case, a CNA fed a resident on contact isolation without wearing a gown or gloves, despite posted signage and available PPE. In another case, a CNA provided incontinence care and then handled a clean brief with soiled gloves, without changing gloves or sanitizing hands. Both incidents were observed by other staff and acknowledged as breaches of infection control policy.
Failure to Update Care Plan for NPO Resident Receiving Enteral Nutrition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's current medical needs. Specifically, a male resident with diagnoses including cerebral infarction, dysphagia, and gastrostomy status was admitted and assessed as requiring enteral nutrition via a G-tube and was designated as NPO (nothing by mouth) due to swallowing difficulties. Despite this, the resident's care plan included interventions for encouraging oral intake, such as offering alternate meals or supplements if less than 50% of food was consumed and encouraging or assisting with oral fluid intake. These interventions were not appropriate for a resident with NPO status and were not updated following a recent hospitalization and change in condition. Observations confirmed the resident was receiving enteral nutrition via a feeding pump, and interviews with facility staff, including the MDS Nurse and DON, revealed that the care plan had not been revised to remove oral intake interventions after the resident was made NPO. The staff acknowledged the oversight and the importance of ensuring care plans reflect current orders and resident needs. Review of facility policy did not provide specific guidance on ensuring the accuracy of care plan content.
Failure to Implement Enhanced Barrier Precautions for Resident with Infection Risks
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with significant infection risks, including a gastrostomy and an indwelling urinary catheter. The resident's care plan indicated the need for Enhanced Barrier Precautions (EBP), but there was no physician's order for EBP in the medical record, and EBP signage was not present at the entrance or inside the resident's room. During observation, a nurse provided direct care to the resident using gloves but did not don a gown as required by EBP protocols. The nurse left the facility before a follow-up interview could be conducted. Interviews with staff revealed a lack of awareness and understanding regarding the implementation of EBP for the resident. The primary nurse was unsure if EBP was required and could not locate the necessary signage or physician's order. The Assistant Director of Nursing, responsible for the infection prevention program, was unaware that the EBP order was missing and could not explain the absence of signage. The facility's policy required targeted gown and glove use and the posting of precaution signs, but these measures were not followed for the resident in question.
Failure to Maintain Safe and Functional Resident Room Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of four resident rooms reviewed for environmental concerns. Specifically, in the identified room, there was a hole measuring approximately 3 inches by 2 inches in the bathroom door, a toilet that continuously ran water and would not flush, and an unsecured sprinkler system access panel on the bathroom wall measuring about 1.5 feet by 1.5 feet. These issues were directly observed during a walkthrough with the Administrator and Maintenance Director. Interviews revealed that the room was occupied by a single resident who was unable to be interviewed. The Maintenance Director stated that repairs are typically reported through the TELS work order system, but no work order had been received for this room. He also mentioned that resident rooms are checked weekly as needed for repairs. The facility's policy on physical environment, dated 01/2023, indicates a preventative maintenance program is in place to ensure all essential equipment is in safe operating condition.
Failure to Update Care Plans for Thickened Liquids
Penalty
Summary
The facility failed to review and revise care plans for three residents after their comprehensive assessments, specifically neglecting to update the care plans to reflect physician orders for thickened liquids. For each of the three residents, medical records indicated diagnoses including dysphagia and orders for thickened liquids, as documented in their quarterly MDS assessments and monthly physician orders. However, the care plans for these residents were not updated to include these dietary modifications. Interviews with facility staff confirmed that the MDS nurse had not updated the care plans due to not reviewing the residents' physician orders. The DON also acknowledged that the care plans should have been updated to reflect the thickened liquids orders. Facility policy requires care plans to be reviewed and updated at least quarterly and with significant changes in condition, but this was not done for the affected residents.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, preparation, and sanitation. Crumbs and paper food wrapping were found inside the fryer, and sand-like particles were present on top of the dish washing machine, particularly at the opening. The Dietary Manager confirmed both the presence of these contaminants and acknowledged their potential to contaminate food and clean dishes. Additionally, three packages of corn beef and a box of raw potatoes were found undated in the refrigerator, and the Dietary Manager stated these items had recently been placed there. Further observations revealed that a box of corn dogs and a box of hamburger patties were stored in unsealed and undated packaging in the refrigerator and freezer, respectively. The Dietary Manager confirmed that these unsealed foods were subject to contamination and, in the case of the hamburger patties, also to freezer burn. Review of the facility's Kitchen Sanitation policy indicated that all Nutrition and Foodservice employees are required to maintain clean, sanitary kitchen facilities to prevent food-borne illness, but these standards were not met during the survey.
Failure to Coordinate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with newly evident or possible severe mental disorder. Specifically, a male resident with diagnoses of bipolar disorder and schizoaffective disorder was not referred for a Level I PASARR screen after being diagnosed with a mental disorder. Record reviews showed that the resident had active diagnoses of psychiatric mood disorder, bipolar disorder, and schizoaffective disorder, and was receiving medication for hallucinations and paranoia. Despite these documented mental health conditions, there was no evidence that the required PASARR screening was completed. Interviews with facility staff revealed that the MDS coordinator, who was responsible for referring and screening residents for Level I PASARR, was unaware of the resident's mental illness due to not having reviewed all residents' active diagnoses. The DON confirmed that the MDS coordinator should have referred the resident for evaluation in accordance with facility policy. Facility policy required PASARR screening for all individuals with mental illness, but this process was not followed for the resident in question.
Failure to Prepare Pureed Foods to Required Consistency and Recipe Standards
Penalty
Summary
The facility failed to prepare pureed foods according to required consistency and recipe standards for residents on pureed diets during a lunch meal. Dietary staff prepared pureed bread and spinach by adding chicken broth and thickener without using measuring devices, relying instead on visual assessment of consistency. Recipes for the pureed items were not present during preparation, and the staff did not follow the specified measurements outlined in the corporate recipe for pureed bread. Observations showed that the pureed macaroni and cheese and bread were not at the required pudding or mashed potato consistency, instead being thick, sticky, and difficult to move in the mouth. During testing, both the Dietary Manager and the Administrator noted that the pureed items were too thick and could be difficult for residents to swallow or remove from the roof of their mouths. Record review confirmed that the facility's policy required residents to receive diets as ordered by their physicians, including pureed diets, but the policy or protocol for pureeing food was not provided at the time of the survey. This failure to follow proper preparation methods and recipes for pureed foods was observed for one meal and could affect residents requiring pureed diets.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control protocols while providing incontinent care to a resident with multiple medical conditions, including schizophrenia, PTSD, type 2 diabetes, gastrostomy status, hypertension, and Parkinson's disease. The resident required total assistance with activities of daily living and was always incontinent of bowel and bladder. During care, one CNA touched the bed remote and another touched the privacy curtain with gloved hands, both of which are considered contaminated surfaces. Neither CNA changed gloves or performed hand hygiene before proceeding with direct care for the resident, who was on enhanced barrier precautions due to gastrostomy status. Interviews with the CNAs revealed they were aware that the bed remote and privacy curtain were considered dirty and acknowledged they should have changed gloves and sanitized their hands, but did not realize this was required before starting care. Both CNAs had received infection control training and passed competency checks on hand hygiene. The Director of Nursing confirmed that staff are expected to change gloves and sanitize hands prior to providing care to prevent cross-contamination and infection, and that infection control training and skills checks are conducted at least annually. Facility policy also requires hand hygiene before and after direct resident contact and when moving from contaminated to clean procedures.
Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound care for one resident. The resident in question had significant medical conditions, including quadriplegia, morbid obesity, type 2 diabetes, neurogenic bowel, and was always incontinent of bowel. The resident also had multiple wounds, including pressure ulcers and surgical wounds, requiring regular wound care and dressing changes as per physician orders and care plan interventions. On three observed occasions, an LVN performed wound care for the resident and failed to follow proper infection control protocols. Specifically, the LVN removed contaminated dressings, changed gloves multiple times, and performed wound cleansing and dressing application without performing hand hygiene between glove changes. The LVN stated she believed hand hygiene was only necessary after patient care or when hands were visibly soiled, and was unaware of the facility's specific policy regarding hand hygiene between glove changes. Interviews with the treatment nurse, ADNS, DNS, and the administrator confirmed that facility policy and expectations required hand hygiene to be performed between glove changes, either by washing with soap and water or using hand sanitizer, unless hands were visibly soiled. Review of the facility's policies on wound care and hand hygiene further supported these requirements, stating that hand hygiene is the primary means to prevent the spread of infection and must be performed between glove changes. The failure to follow these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection control program.
Failure to Provide Pressure Ulcer Care per Professional Standards and Physician Orders
Penalty
Summary
A resident with multiple medical conditions, including quadriplegia, morbid obesity, and type 2 diabetes, was readmitted to the facility with existing pressure ulcers. The resident's care plan and physician orders specified wound care protocols, including cleansing wounds with wound cleanser and applying specific dressings such as hydrofera blue for the right glute and wet-to-dry dressings for the left ischium if the wound vac was dislodged or malfunctioned. The facility's wound care policy and competency checklist also required wound cleansing and securing dressings as part of standard practice. On the observed date, an LVN performed wound care on the resident's left ischium and right glute. The LVN did not clean the inside of the wounds prior to applying dressings, only cleaning the peri-wound areas. Additionally, the LVN applied a wet-to-dry dressing to both wounds, contrary to the physician's order for the right glute, which required a hydrofera blue dressing. The LVN also failed to secure the dressings after application, leaving them unfastened. The LVN stated she followed instructions from the DNS and checked the orders, but misapplied the treatment and did not follow the facility's wound care policy or the specific physician orders. Interviews with the treatment nurse, ADNS, DNS, and NP confirmed that the expected standard of care was not met. All agreed that wounds should be cleansed prior to dressing application, dressings should be secured, and orders should be followed precisely. The facility's policy and competency checklist further supported these expectations, indicating that the LVN's actions were inconsistent with both professional standards and facility protocols.
Failure to Document Wound Care Treatments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with professional standards and were complete and accurately documented for one resident. Specifically, on two occasions, wound care treatments provided to a resident with quadriplegia, morbid obesity, type 2 diabetes, neurogenic bowel, and multiple wounds were not documented in the Treatment Administration Record (TAR) or Licensed Nurse Administration Record (LNAR) as required by facility policy. The resident's care plan included interventions for fragile skin and actual wounds, with physician orders for specific wound care treatments. However, review of the April TAR and LNAR revealed blanks for the required wound care treatments on the specified date, and there was no documentation in the progress notes for those treatments. Observation confirmed that a nurse performed the required wound care treatments, but interviews with nursing staff and administration revealed that documentation was expected to be completed immediately after treatment. The nurse involved stated she had documented the treatments, but the records did not reflect this. Facility policy required documentation of wound care in the TAR, and the absence of such documentation indicated non-compliance with professional standards and facility policy.
Failure to Inform Responsible Party of Treatment Options
Penalty
Summary
The facility failed to ensure that a resident's responsible party was informed in advance of the risks and benefits of proposed care, treatment alternatives, or treatment options. This deficiency was identified for a resident who was referred to a Wound Care Physician for an evaluation and subsequently received a wound debridement without prior notification to the responsible party. The resident, who was admitted for hospice respite services, had severe cognitive impairment and was unable to consent to the procedure herself. The resident's medical records indicated that she had an unstageable wound on her coccyx, which was covered in necrotic tissue. A surgical excisional debridement was performed to remove the necrotic tissue and establish the margins of viable tissue. The facility's records showed that the treatment options, risks, and benefits were explained to the resident, who indicated agreement to proceed. However, the responsible party was not informed of the procedure until several days later, and it was unclear if the hospice was ever notified. Interviews with the facility's physician, the wound care physician, and the Director of Nursing (DON) revealed that the responsible party and hospice should have been notified and consent obtained before the procedure. The DON stated that the previous wound LVN, who was responsible for contacting hospice and notifying the responsible party, had not worked at the facility since January 2025. The facility's policy on end-of-life care emphasized the importance of involving the resident and family in developing the plan of care, which was not adhered to in this case.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined whether a resident could safely self-administer medications. This deficiency was identified for one resident who was observed with eye drops and a nasal spray on her bedside table without a specific written order to self-administer these medications. The resident, who had a BIMS score indicating no cognitive impairment, was using the eye drops multiple times a day for dry eyes and self-administered the nasal spray once a day. However, the facility's records did not include an order for the resident to self-administer these medications, and previous assessments had not confirmed her ability to do so safely. Interviews with facility staff revealed a lack of awareness regarding the policy on self-administration of medications. The medication aide responsible for the resident was unaware of any residents allowed to self-administer medications and did not know the facility's policy on the matter. The Director of Nursing confirmed that residents must be assessed for safe self-administration and have an order to do so, which was not initially in place for the resident in question. The facility's policy requires an interdisciplinary team evaluation and a physician's order for residents to self-administer medications, which was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate administration of medications for one resident, leading to a deficiency in medication administration. On the morning of March 18, 2025, a medication aide (MA A) was responsible for administering medications to a resident. However, the resident was later observed with a medication cup containing seven medications on her bedside table, indicating that the medications were not taken as intended. The resident confirmed that the medications were given to her by a male medication aide and that she placed the medication cup on the overbed table while other staff members performed a mechanical lift transfer. The medication aide left the room before the resident finished taking her medications, contrary to the facility's policy that requires staff to observe residents taking all medications before leaving the room. The resident involved was a female with a history of acute or chronic respiratory failure, depression, and paraplegia, and had a BIMS score of 15, indicating no cognitive impairment. Despite this, her comprehensive care plan noted impaired cognitive function or thought process. The facility's Director of Nursing (DON) confirmed that the policy for medication administration mandates that no medications should be left at the bedside and that staff must observe residents taking their medications. The failure to adhere to this policy could result in residents missing medications and not receiving the necessary therapeutic benefits.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care with the hospice agency for a resident receiving hospice services. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including cerebral atherosclerosis, dementia, and depression, was admitted for hospice respite services. During her stay, she underwent a surgical wound debridement without the hospice agency being notified or giving prior authorization, as required by the hospice's interdisciplinary plan of care. The resident had an unstageable wound on her coccyx, which was evaluated and treated by a wound care physician without the knowledge or consent of the hospice agency or the resident's responsible party. The facility's physician did not recall referring the resident to the wound care physician and stated that the hospice team should have been the referring entity. The wound care physician also noted that there was no documentation indicating the resident was on hospice, which would have prompted further consultation before proceeding with the debridement. Interviews with the hospice director, facility physician, and wound care physician revealed that the facility failed to notify the hospice agency and the resident's responsible party about the evaluation and procedure. The Director of Nursing (DON) indicated that the previous wound LVN, who was responsible for such referrals, should have contacted hospice for approval. The facility's policy on end-of-life care emphasizes the importance of obtaining physician orders and involving the resident and family in the care plan, which was not adhered to in this case.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents identified as requiring such measures. In the first instance, a cognitively intact female resident with quadriplegia, urinary tract infection, and hematuria was placed on contact isolation due to a vancomycin-resistant infection. Despite clear signage and a fully stocked PPE cart outside the resident's room, a CNA who was new to the facility entered the room and fed the resident without wearing the required gown and gloves. The CNA stated she was distracted by the timing of the meal tray and did not notice the isolation precautions, although she acknowledged understanding the importance of PPE use for infection control. In the second instance, a male resident with paraplegia, muscle wasting, neurogenic bowel, and an indwelling urinary catheter required regular incontinence care. During observed care, a CNA cleaned the resident's bowel movement but then touched a new, clean brief with the same soiled gloves, failing to change gloves or sanitize hands between tasks. The CNA admitted to forgetting to change gloves due to nervousness, despite having received in-service training on infection control practices. Both incidents were observed and confirmed by other staff members, including a medication aide and an LVN, who recognized these actions as breaches of infection control policy. Facility policy requires staff to follow procedures to prevent cross-contamination, including proper hand hygiene and glove changes after providing personal care. The failures observed could contribute to the development and transmission of communicable diseases within the facility.
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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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windcrest Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 12 | 0 |
| Crestway Nursing & Rehabilitation | 1.9 mi | ★★★★★ | 2 | 0 |
| The Army Residence Community Health Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Avir At Converse | 2.8 mi | ★★★★★ | 13 | 0 |
| Northeast Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 10 | 1 |
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