Avir At Converse
Avir at Converse in CONVERSE, TX — inspection on June 4, 2026.
Found 7 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
The facility failed to ensure Resident #53 sink faucet was functional and did not spray water onto the floor.
This deficient practice could prevent residents from using the sink in the restroom and could cause avoidable accidents.
The findings were:Review of Resident #53's face sheet, dated 6/2/26, revealed she was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (joint damage), post-traumatic stress disorder ( is a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) recurrent.
Review of Resident #53's quarterly MDS assessment, dated 4/14/26, revealed her BIMS score was 15 of 15 reflective of not having cognitive impairment and she was dependent on staff for personal hygiene.
Review of Resident #53's Care Plan, dated 4/4/26, revealed she had an ADL self-care performance deficit related to impaired mobility and she required assistance by 1 staff for oral care management and personal hygiene.
Observation and interview on 6/1/26 at 11:18 AM with Resident #53 revealed she was lying in bed. Resident #53 stated she had lived at the facility for years.
She stated she used her power motorized wheelchair for mobility but had chosen not to get out of bed for some weeks.
She stated previously, she would get out of bed and use the sink in the bathroom but the water sprayed out directly from the faucet instead of spraying down.
She stated it was an inconvenience for her and commented it was annoying. Resident #53 stated the faucet had not been working for months and had told a few of the CNA's but the faucet had not been fixed.
Observation in Resident #53's bathroom revealed the sink faucet sprayed outward instead of downward.
When the pressure was turned up the water sprayed onto the floor.
Further observation revealed there was a wet towel on the floor in front of the sink.
Interview on 6/3/26 at 12:45 PM with CNA D revealed Resident #53 mentioned to her the water from the sink faucet would spray outward onto the floor.
She stated she reported it to her charge nurse a few weeks ago. CNA D stated she had also noted it herself when using the sink.
Interview on 6/4/26 at 4:50 PM with the MD revealed he had worked for the facility for a few months. He stated he received a work order on 5/8/26 on the facility internal program from one of the nurses who reported the sink faucet in Resident #53's bathroom needed repairs.
The MD stated he had not looked at it or repaired it because he had other repairs that were a higher priority. He stated he did not have an assistant, and he was the only one to complete all repairs.
Observation and interview on 6/4/26 at 5:00 PM revealed the MD turned on the cold water at the sink in Resident #53's bathroom.
The water sprayed straight outwards. He gradually turned the pressure higher, and the water started spraying out of the sink onto the floor.
The MD stated it was probably inconvenient for Resident #53 and someone could slip and fall on the wet floor.
Review of a facility policy, Resident Rights read in part 1.
Federal and state laws guarantee the residents certain basic rights to all residents of this facility.
These rights include the resident's right to: a. dignified existence and self-determination.
675452 06/04/2026
Avir at Converse 7700 Mesquite Pass Converse, TX 78109
Observation and interview on 6/01/2026 at 10:54 AM with Resident #48 revealed he was lying
Coordinator/RN E revealed she had been in charge of processing PASRR applications for about 9
borderline personality disorder. MDS Coordinator/RN E stated she had inaccurately coded that Resident #48 had a mental illness on the PASRR Level Screening, dated 12/5/25.
She stated his primary diagnosis was Dementia.
Upon reviewing Resident #48's face sheet she stated his primary diagnosis was Parkinsonism.
She stated Resident #48's diagnoses were all in fact qualifying diagnoses and should have referred Resident #48 to the local authority for a PASRR evaluation. MDS Coordinator/RN E stated not following through could result in Resident #48 not receiving services that could improve his quality of life. 3.
Review of Resident #7's face sheet, dated 6/4/26, revealed he was admitted to the facility on [DATE] with diagnosis including post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress).
Review of Resident #7's PASRR Level I screening, dated 6/2/25 revealed he did not have a mental illness.
Review of Resident #7's annual MDS assessment, dated 5/2/26 revealed his BIMS score indicated he was moderately cognitively impaired.
Interview on 6/4/26 at 5:15 PM with the MDS Coordinator/RN E revealed Resident #7 had a diagnosis of post-traumatic stress disorder which was reflective of a mental illness.
She stated she should have completed another PASRR Level I screening to reflect mental illness and referred Resident #7 to the local authority for a PASRR evaluation. MDS Coordinator/RN E stated not following through could result in Resident #7 not receiving services that could improve his quality of life.
Review of facility policy, Policy for PASSR, dated 1/20/2026, reflected When it is determined a PASRR is filled out incorrectly, the MDS coordinator will reach out to the corresponding case worker and ask them to correct the form.
675452 06/04/2026
Avir at Converse 7700 Mesquite Pass Converse, TX 78109
Review of Resident #7's annual MDS assessment, dated 5/2/26 revealed his BIMS score indicated he was moderately cognitively impaired and he had a diagnosis of PTSD.
Review of Resident #7's, Comprehensive Care Plan, dated 4/10/26 did not reflect that he had a diagnosis of PTSD and it did not address how staff would assist Resident #7 in managing his condition.
Observation and attempted interview on 6/03/2026 at 12 PM revealed Resident #7 was sitting at one of the dining rooms tables.
Attempted interview with Resident #7 revealed he did not engage in conversation and propelled away.
Interview on 6/4/26 at 5:15 PM with the MDS Coordinator revealed she was responsible for completing resident care plans.
She stated Resident #7 had a diagnosis of PTSD and his Comprehensive Plan did not reflect this diagnosis, care or services he would receive.
She stated the Care Plan did not accurately describe Resident #7's mental status and could result in staff not knowing how to address behaviors associated with PTSD.
Review of facility policy, Care Plans, Comprehensive Person-Centered read in part 3.
The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 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, including: (3) which professional services are responsible for each element of care.
675452 06/04/2026
Avir at Converse 7700 Mesquite Pass Converse, TX 78109
the care plan directed how the care of a resident was to be provided, what the residents' needs were
comprehensive, person-centered care plan that includes measurable objectives and timetables to
each resident.
Policy Interpretation and Implementation: 11.
Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' conditions changes.
675452 06/04/2026
Avir at Converse 7700 Mesquite Pass Converse, TX 78109
down in bed.
The DOR stated Resident #53 did not want staff to feed her.
The ADON and DOR
aware Resident #53 having any choking incidents.
Both the DOR and ADON stated Resident #53 had
waiver staff could have Resident #53 sign in order to release the facility of any liability.
They stated they had not offered it to Resident #53.
The DOR stated she had not contact with Resident #53 because she had not been on caseload for several months.
The ADON stated he was not aware that Resident #53 wanted a diet upgrade. He stated he talked to Resident #53 often, was aware that she refused to eat the facility food but had never had a discussion with Resident #53 about her preferences.
The ADON stated he could imagine Resident #53 might be frustrated about the situation.
Interview on 6/4/26 at 5:15 PM with the MDS Coordinator revealed she remembered the Care Conference meeting held on 4/22/26 and Resident #53 wanted her diet upgraded to a regular diet.
The MDS Coordinator stated Resident #53 reported she had a swallow study and was able to eat regular food.
The MDS Coordinator stated the DOR was not present for the Care Conference meeting and let Resident #53 know they would get back with her.
She stated this was discussed during the morning meeting on 4/23/26 and her request for a diet upgrade was denied without further discussion.
The MDS Coordinator stated she had not met with Resident #53 about the outcome.
She stated Resident #53 probably felt like nobody was listening to her and that what she wanted did not matter.
Review of a facility policy, Resident Rights read in part 1.
Federal and state laws guarantee the residents certain basic rights to all residents of this facility.
These rights include the resident's right to: a. dignified existence and self-determination.
675452 06/04/2026
Avir at Converse 7700 Mesquite Pass Converse, TX 78109
Review of facility's policy, Employee Hygiene for Food Safety, dated 2023, read
restraint) to prevent hair from contacting exposed food.6.
Use utensils to handle food, avoiding bare
use.
Hands must be washed prior to using gloves and after removing gloves.
Review of facility's policy, Personal Hygiene and Health Reporting, dated 2023, read Policy: All food and nutrition services employee will be trained in appropriate personal hygiene and health reporting.
Procedure: 2.
Personal hygiene criteria to follow include the following: c.
Beards and mustaches should be closely cropped and neatly trimmed.
When near exposed foods, beards must be restrained using beard covers.
Review of facility's policy, Hand Washing, dated 2023, read Policy: Employees will wash their hands as frequently as needed throughout the day using proper hand washing procedures.Procedure: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1.
When to wash hands: f.
After handling soiled equipment or utensils. g.
During food preparation, as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks. j.
After engaging in other activities that contaminate the hands.
Review of facility's policy, Bare Hands Contact with Food and Use of Plastic Gloves, dated 2023, read Policy: Single use gloves or other barriers will used when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served.
Bare hand contact with food is prohibited.
Procedure: 6.
Gloves are just like hands.
They get soiled.
Anytime a contaminated surface is touched the gloves must be changed and hands must be washed.
Review of the Food Code, U.S.
Public Health Service, U.S. FDA, 2022, U.S.
Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.
Review of the Food Code, U.S.
Public Health Service, U.S. FDA, 2022, U.S.
Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;.
675452 06/04/2026
Avir at Converse 7700 Mesquite Pass Converse, TX 78109
The facility failed to ensure that documentation on Resident #28's face sheet ccurately reflected the diagnosis of pain.
This failure could place residents at risk of receiving improper care.
Findings included:
Record review of Resident #28's face sheet, dated 2/17/2026, revealed a [AGE] year old male admitted to the facility on [DATE] and remitted on 7/23/2025 with diagnoses that included: Bipolar Disorder (is a mental disorder characterized by periods of depression and abnormally elevated mood), Dementia (a loss of memory, thinking, reasoning, and other mental abilities), and Diabetes (disease in which the body can not properrtly control the amount in sugar in your blood).
Record review of face sheet for Resident #28, dated 6/3/26, revealed no diagnosis for pain.
Record review of Resident #28's BIMS assessment, completed 5/13/26, revealed a BIM score of 14, which indicated intact cognition.
Record review of Resident #28's history and physical, dated 4/23/2025, revealed a diagnosis of pain.
Record review of Resident #28's care plan, updated 12/20/2022, revealed a care plan with a focus on Pain.
Record review of Resident #28's June 2026 monthly physician orders revealed an order for Morphine Sulfate ( pain medication ) 30 mg, to be administered as one tablet twice a day.
Interview with Resident # 28 on 6/2/2026 at 9:44 am revealed that he has had pain for years due to an old military back injury.
Interview with the MDS nurse on 6/3/2026 at 9:15 AM revealed that she was responsible for entering diagnoses on face sheets and that resident #28's pain diagnosis was not entered on the face sheet.
The MDS Nurse said omitting this diagnosis may have affected staff awareness of the Resident's condition and the provision of appropriate care and services.
She also said she had not yet audited the residents' diagnoses against the corresponding histories and physicals, which was why the information was not correlating.
During an interview on 6/3/2026 at 10:25 a.m., the ADON stated he had been in his role for two months and had not yet audited all prior admissions for face sheet accuracy. He noted that omitting a pain diagnosis from the face sheet could cause confusion for providers and may result in Resident #28 not receiving appropriate care. He explained that the MDS Nurse is responsible for this task, while he conducts random monitoring.
Record review of the facility's policy charting and documentation, dated 2001, revealed: Documentation in the medical record will be objective, complete, and accurate.
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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.