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Complaint Investigation

Avir At Comfort

May 27, 2026 · Comfort, TX · 615 Faltin Ave
Citations 2
CMS Rating 5/5
Beds 76
Provider ID 675871
Healthcare Facility
Avir At Comfort
Comfort, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Avir at Comfort in COMFORT, TX — inspection on May 27, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies

unsure if residents' preferences for activities were reviewed during these conferences.

She was

overall well-being and healing. In an interview on 5/27/2026 at 2:54 PM, the Admin said the facility

department.

She said the current process was the care conferences were attended only by the LSW and DON, and all care areas were reviewed.

She said the staff were aware of residents' activities preferences because the census was small and the staff had become familiar with the residents over time. In an interview on 5/27/2026 at 3:45 PM, the DON said she was responsible for creating resident's care plans.

She said residents' preferences and needs were reviewed during care plan conferences, but the facility was instituting a new process that would include the Activities Director at all care plan conferences.

She said the care plans did not include specific preferences, but she made the preferences known to staff during routine, weekly staff meetings.

Record review of the facility policy Care Plans, Comprehensive Person-Centered dated 2001, revised March 2022 reflected the following: .7.

The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

675871 05/27/2026

Avir at Comfort 615 Faltin Ave Comfort, TX 78013

facility was displeased with her decision to include self-directed activity on the calendar for the

interview with the Admin. on 5/27/2026 at 2:54 PM, she said was aware the scheduled activity for

seen the schedule when the calendar was posted by the AD.

She said this activity did not meet the standards of the facility, but she did not discuss the deficiency with the AD due to ongoing performance issues.

She said 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, and the AD had resigned effective June 2026.

Record review of the facility policy titled Activity Programs dated June 2018 reflected the following: .

  • Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute
  • to the planning, preparation, conducting, cleanup and critique of the programs .

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COMFORT, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Comfort or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.

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