Avir At Woodlands

Penalties

• Apr 2, 2025 — Fine ($85,613)

Inspection findings

1. Aug 13, 2025 Health · 10 findings
   • Not serious Scope/severity D 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 Sep 23, 2025 · CMS health inspection

   • Not serious Scope/severity D

     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 Sep 23, 2025 · 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 Sep 23, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0802 Nutrition and Dietary Deficiencies

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

     Corrected Sep 23, 2025 · CMS health inspection

   • Not serious Scope/severity F

     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 Sep 23, 2025 · CMS health inspection

   • Not serious Scope/severity C

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected Sep 16, 2025 · CMS fire safety

   • 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 Sep 16, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Sep 16, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Sep 16, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Sep 16, 2025 · CMS fire safety

2. Apr 2, 2025 Health · 3 findings
   • 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 Apr 3, 2025 · CMS health inspection

   • Serious Scope/severity K 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 Apr 3, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Apr 3, 2025 · CMS health inspection

3. Jul 10, 2024 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Aug 15, 2024 · CMS fire safety

   • Not serious Scope/severity E Complaint

     F0552 Resident Rights Deficiencies

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

     Corrected Aug 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 Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E 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 Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 Nursing and Physician Services Deficiencies

     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

     Corrected Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     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 Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E 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 Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Aug 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Aug 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected Sep 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Aug 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0347 Smoke Deficiencies

     Properly provide smoke detection systems in areas open to corridors.

     Corrected Aug 15, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Aug 15, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Aug 15, 2024 · CMS fire safety

4. Oct 9, 2023 Health · 4 findings
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Oct 10, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected Oct 10, 2023 · 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 Oct 10, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected Oct 10, 2023 · CMS health inspection

5. Sep 8, 2023 Health · 3 findings
   • 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 Oct 4, 2023 · 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 Oct 4, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Oct 4, 2023 · CMS health inspection

6. Aug 10, 2023 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Aug 11, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Aug 29, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected Sep 1, 2023 · CMS health inspection

7. Aug 8, 2023 Fire Safety · 1 finding
   • Not serious Scope/severity E Complaint

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Oct 10, 2023 · CMS fire safety

8. May 4, 2023 Health · 12 findings
   • Not serious Scope/severity E

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected May 26, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected May 26, 2023 · CMS health inspection

   • Not serious Scope/severity E

     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 May 26, 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 May 26, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 26, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0232 Egress Deficiencies

     Have corridors or aisles that are unobstructed and are at least 8 feet in width.

     Corrected Dec 13, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Oct 17, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

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

     Corrected Oct 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Oct 15, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Oct 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Dec 13, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• DAGAN, AMITAI — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 08/05/2025
• FREUND, NOCHUM — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• GOLDBERGER, ABRAHAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 08/05/2025
• MICKISH, ALAN — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• MICKISH, ALAN — adp of the snf, NOT APPLICABLE, since 03/01/2025
• STUART, AMANDA — adp of the snf, NOT APPLICABLE, since 03/01/2025
• TRAVITSKY, AARON — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• WRIGHT, LABAN — corporate director, NOT APPLICABLE, since 11/10/2021
• 125 INSPIRATION BOULEVARD OPCO, LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• 125 INSPIRATION BOULEVARD OPCO, LLC — adp of the snf, NOT APPLICABLE, since 06/12/2025
• 125 INSPIRATION BOULEVARD PROPERTY OWNER, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• 125 INSPIRATION BOULEVARD PROPERTY OWNER, LLC — 5% or greater security interest, NOT APPLICABLE, since 03/01/2025
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/28/2015
• WELLTOWER INC — 5% or greater security interest, NOT APPLICABLE, since 03/01/2025
• WELLTOWER INC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• WELLTOWER NNN GROUP, LLC — 5% or greater security interest, NOT APPLICABLE, since 03/01/2025
• WELLTOWER NNN GROUP, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025
• WELLTOWER OP, LLC — 5% or greater security interest, NOT APPLICABLE, since 03/01/2025
• WELLTOWER OP, LLC — adp of the snf, NOT APPLICABLE, since 03/01/2025