Avir At Willowcreek

Penalties

• Feb 27, 2025 — Fine ($23,794)

Inspection findings

1. May 6, 2026 Health · 8 findings
   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

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

     Corrected May 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected May 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     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 May 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected May 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     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 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 28, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

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

     Corrected May 28, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 28, 2026 · CMS fire safety

2. Dec 19, 2025 Health · 1 finding
   • 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 Jan 12, 2026 · CMS health inspection

3. Apr 30, 2025 Health · 2 findings
   • 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 May 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 12, 2025 · CMS health inspection

4. Feb 27, 2025 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Mar 7, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0552 Resident Rights Deficiencies

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

     Corrected Feb 28, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0570 Resident Rights Deficiencies

     Assure the security of all personal funds of residents deposited with the facility.

     Corrected Feb 28, 2025 · 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 Feb 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0680 Quality of Life and Care Deficiencies

     Ensure the activities program is directed by a qualified professional.

     Corrected Feb 28, 2025 · CMS health inspection

   • Serious Scope/severity K

     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 28, 2025 · 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 Feb 28, 2025 · 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 Feb 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     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 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Mar 7, 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 Mar 7, 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 Mar 7, 2025 · 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 Mar 7, 2025 · CMS fire safety

5. Jan 10, 2024 Fire Safety · 11 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Feb 7, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Feb 7, 2024 · CMS fire safety

   • 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 Feb 7, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Feb 7, 2024 · CMS health inspection

   • Not serious Scope/severity D 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 Feb 7, 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 Feb 7, 2024 · CMS health inspection

   • Not serious Scope/severity D 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 Feb 7, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Feb 7, 2024 · 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 Feb 7, 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 Feb 7, 2024 · CMS fire safety

6. Sep 27, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Oct 12, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BANES, MICHAEL — adp of the snf, NOT APPLICABLE, since 12/09/2024
• GAO, MIN — adp of the snf, NOT APPLICABLE, since 01/01/2011
• HOLCOMB, HOLLY — corporate officer, NOT APPLICABLE, since 05/29/2021
• SILBERSTEIN, ARI — operational/managerial control, NOT APPLICABLE, since 09/01/2023
• STRATTON, EMILEE — corporate officer, NOT APPLICABLE, since 03/18/2018
• 4934 S. 7TH STREET LLC — adp of the snf, NOT APPLICABLE, since 09/01/2023
• 4934 S. 7TH STREET TIC LLC — adp of the snf, NOT APPLICABLE, since 09/01/2023
• CHILDRESS COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2017
• EVERGREEN HOLDCO LLC — operational/managerial control, NOT APPLICABLE, since 01/14/2025
• GAMFAL LLC — adp of the snf, NOT APPLICABLE, since 09/01/2023
• GOLD TX TRUST — operational/managerial control, NOT APPLICABLE, since 01/14/2025
• LICHTSCHEIN FAMILY 2012 TRUST — adp of the snf, NOT APPLICABLE, since 09/01/2023
• SCHEINER FAMILY 2012 TRUST — adp of the snf, NOT APPLICABLE, since 09/01/2023
• SCHEINER HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 09/01/2023
• SILVER TX TRUST — operational/managerial control, NOT APPLICABLE, since 01/15/2025
• WILLOWCREEK REHAB AND NURSING LLC — adp of the snf, NOT APPLICABLE, since 01/14/2025
• WILLOWCREEK REHAB AND NURSING LLC — operational/managerial control, NOT APPLICABLE, since 01/14/2025