Avir at Converse: Medical Record Errors Risk Resident Care - TX
The resident, identified in inspection records only as Resident #28, is a man with bipolar disorder, dementia, and diabetes whose face sheet, dated February 17, 2026, contained no mention of pain. His history and physical, dated April 23, 2025, documented the diagnosis. His care plan, last updated in December 2022, listed pain as a focus area. His June 2026 physician orders included Morphine Sulfate 30 mg, one tablet twice a day. None of that made it onto the face sheet that summarizes his conditions for the people caring for him each day.
When a federal inspector interviewed him on June 2, 2026, he said he had been in pain for years because of an old injury sustained during military service.
The MDS nurse, interviewed the following morning, said she was the one responsible for entering diagnoses onto face sheets. She acknowledged that Resident #28's pain diagnosis had not been entered. She said the omission could have affected staff awareness of his condition and the provision of appropriate care and services. She also said she had not yet audited residents' diagnoses against their corresponding histories and physicals, which was why the information was not correlating.
That audit had not happened. The discrepancy between what his records actually showed and what his face sheet said had gone undetected.
The assistant director of nursing, interviewed later that same morning, said he had been in his role for two months and had not yet audited prior admissions for face sheet accuracy. He said omitting a pain diagnosis from the face sheet could cause confusion for providers and might result in the resident not receiving appropriate care. He described the MDS nurse as responsible for the task, with himself conducting random monitoring.
Random monitoring that had not caught this.
Resident #28 was assessed in May 2026 with a cognitive score indicating intact cognition, meaning he is aware of his circumstances and capable of communicating his needs. He told the inspector directly that he has had pain for years. The documentation trail confirming that pain, and the medication prescribed to treat it, existed across multiple records inside the same facility. The face sheet, the document designed to give any staff member a fast and accurate picture of who a resident is and what he needs, reflected none of it.
The inspection, completed June 4, 2026, cited the facility for failing to maintain accurate medical records, with the finding affecting one of four residents whose records were reviewed. Inspectors classified the level of harm as minimal harm or potential for actual harm.
The facility's own charting and documentation policy, dated 2001, states that documentation in the medical record will be objective, complete, and accurate.
A man taking a Schedule II opioid twice a day for a documented, longstanding injury, and the piece of paper meant to tell his caregivers who he is had no record of why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Converse from 2026-06-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 17, 2026 · Our methodology
Avir at Converse in CONVERSE, TX was cited for violations during a health inspection on June 4, 2026.
His history and physical, dated April 23, 2025, documented the diagnosis.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.