Avir At Cowhorn Creek

Penalties

• Aug 15, 2025 — Payment Denial · payment denial 5 days
• Aug 15, 2025 — Fine ($30,105)

Inspection findings

1. Apr 13, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 14, 2026 · CMS health inspection

2. Feb 12, 2026 Health · 21 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0565 Resident Rights Deficiencies

     Honor the resident's right to organize and participate in resident/family groups in the facility.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0637 Resident Assessment and Care Planning Deficiencies

     Assess the resident when there is a significant change in condition

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0813 Nutrition and Dietary Deficiencies

     Have a policy regarding use and storage of foods brought to residents by family and other visitors.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 11, 2026 · CMS fire safety

3. Aug 15, 2025 Health · 7 findings
   • Not serious Scope/severity D Complaint

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Aug 18, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 16, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0675 Quality of Life and Care Deficiencies

     Honor each resident's preferences, choices, values and beliefs.

     Corrected Aug 16, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0838 Administration Deficiencies

     Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

     Corrected Aug 18, 2025 · CMS health inspection

4. Apr 9, 2025 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Apr 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Apr 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Apr 10, 2025 · CMS health inspection

5. Dec 4, 2024 Health · 12 findings
   • Not serious Scope/severity E

     F0553 Resident Rights Deficiencies

     Allow resident to participate in the development and implementation of his or her person-centered plan of care.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity B

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0809 Nutrition and Dietary Deficiencies

     Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Dec 6, 2024 · CMS health inspection

6. Oct 29, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Oct 31, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Oct 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Oct 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 30, 2024 · CMS health inspection

7. Mar 13, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Mar 15, 2024 · CMS health inspection

8. Nov 16, 2023 Health · 17 findings
   • Not serious Scope/severity C Complaint

     F0575 Resident Rights Deficiencies

     Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Nov 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 22, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0712 Nursing and Physician Services Deficiencies

     Ensure that the resident and his/her doctor meet face-to-face at all required visits.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Nov 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0940 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program for all new and existing staff members.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 19, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 8, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Feb 8, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• BETTS, BRITNEY — adp of the snf, NOT APPLICABLE, since 09/01/2025
• DAGAN, AMITAI — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 09/14/2025
• FERGUSON, CLAY — adp of the snf, NOT APPLICABLE, since 09/01/2025
• FREUND, NOCHUM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 09/14/2025
• GANN, KODY — corporate officer, NOT APPLICABLE, since 09/01/2025
• GOLDBERGER, ABRAHAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 09/14/2025
• GOLDBERGER, FAIGY — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 09/14/2025
• TRAVITSKY, AARON — operational/managerial control, NOT APPLICABLE, since 09/01/2025
• 5524 COWHORN CREEK OPCO LLC — operational/managerial control, NOT APPLICABLE, since 09/01/2025
• 5524 COWHORN CREEK PROPERTY OWNER, LLC — adp of the snf, NOT APPLICABLE, since 09/01/2025
• GUADALUPE COUNTY HOSPITAL BOARD — 5% or greater direct ownership interest, 100%, since 09/01/2025
• WELLTOWER INC — adp of the snf, NOT APPLICABLE, since 09/01/2025
• WELLTOWER NNN GROUP, LLC — adp of the snf, NOT APPLICABLE, since 09/01/2025
• WELLTOWER OP, LLC — adp of the snf, NOT APPLICABLE, since 09/01/2025