Avir At Comanche

Penalties

• Mar 25, 2024 — Fine ($62,078)
• Mar 25, 2024 — Payment Denial · payment denial 15 days

Inspection findings

1. Jun 29, 2026 Health · 1 finding
   • Not serious Scope/severity E 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.

     CMS health inspection

2. May 14, 2025 Health · 9 findings
   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected May 15, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected May 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected May 15, 2025 · 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 May 15, 2025 · 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 May 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     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 May 15, 2025 · 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 Jun 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

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

     Corrected Jun 15, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jun 15, 2025 · CMS fire safety

3. Mar 25, 2024 Fire Safety · 24 findings
   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Apr 15, 2024 · CMS fire safety

   • Serious Scope/severity K Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Apr 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     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 Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     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 Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0712 Nursing and Physician Services Deficiencies

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

     Corrected Apr 15, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0726 Nursing and Physician Services Deficiencies

     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

     Corrected Apr 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Apr 17, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     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 Apr 17, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     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 Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     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 Mar 26, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 15, 2024 · CMS health inspection

   • Not serious Scope/severity F

     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 May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0344 Smoke Deficiencies

     Have an alternate power supply for its alarm system.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

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

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected May 9, 2024 · CMS fire safety

4. Feb 8, 2023 Health · 8 findings
   • 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 Mar 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     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 Mar 9, 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 Mar 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected Mar 9, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

     Corrected Mar 9, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0802 Nutrition and Dietary Deficiencies

     Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

     Corrected Mar 9, 2023 · 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 Mar 9, 2023 · CMS health inspection

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Mar 9, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BYROM, DAVID — corporate director, NOT APPLICABLE, since 10/01/2014
• THOMAS, BRIAN — operational/managerial control, NOT APPLICABLE, since 10/01/2019
• THOMAS, BRIAN — adp of the snf, NOT APPLICABLE, since 10/01/2019
• CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY — operational/managerial control, NOT APPLICABLE, since 10/01/2019
• TGR HEALTHCARE, LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2019
• TGR HEALTHCARE, LLC — adp of the snf, NOT APPLICABLE, since 04/18/2025