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Avir at Arbor Terrace

609 Rio Concho Dr, San Angelo, TX 76903 · Tom Green County · (325) 653-1266

126 certified beds, about 65 residents a day · For profit - Individual · Medicare and Medicaid since 2002

Inside a hospital Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
CMS note: This facility reported a high number of days without a registered nurse onsite.
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 675932 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 30, 2026, inspectors cited 6 health deficiencies (the Texas average is 9.4, the national average 9.2).

Of 36 health citations since September 2023, 3 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).

CMS lists 3 fines totaling $121,840 in the last three years; the largest was $68,572, and the latest is dated August 10, 2024.

Nurses and nurse aides worked 3.05 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.14 of those hours.

75.3% of nursing staff left within the year CMS measured (Texas average 55.3%).

CMS links it to Avir Health Group, an affiliated group of 118 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 36 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
2K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
12E
1F
Potential for minimal harm
0A
0B
0C
April 30, 2026Standard inspection, Complaint inspection · 6 citations
  1. E
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 25, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received reasonable accommodation of needs for 2 of 20 residents (Resident #10 and #55) reviewed for resident rights activities of daily living, received reasonable accommodation of needs . The facility failed to place Residents #10 and #55's call lights within reach. This deficient practice could affect all residents who need assistance with activities of daily living of not having needs met. Findings Include: Record review of Resident #10's admission record dated 04/30/2026 indicated he was admitted to the facility on [DATE] with diagnoses of stroke and heart failure. He was [AGE] years of age. Record review of Resident #10's MDS assessment dated [DATE] indicated in part: BIMS score of = 10 indicating resident was moderately cognitively impaired. [...]
  2. E
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #18) and (Resident #13) of three residents reviewed for PASRR Level 1 screenings. The facility failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #18. The PASRR Level 1 Screening did not indicate a diagnosis of mental illness, although the diagnosis of schizophrenia was present on admission. The facility failed to refer Resident #13 for a PASARR Level II review when she was newly diagnosed with schizophrenia. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs. [...]
  3. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2026
    Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person -centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 9 residents (Resident #13, #18, and #26) reviewed for care plans.1. The facility failed to ensure a care plan was developed to address Resident #13's psychotropic medication use and schizophrenia diagnosis.2. The facility failed to ensure a care plan was developed to address Resident #18's psychotropic medication use and schizophrenia diagnosis.3. The facility failed to ensure a care plan was developed to address Resident #26's psychotropic medication use and PTSD diagnosis. [...]
  4. E
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2026
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, and comfortable environment for residents in 5 of 6 halls (A, B, C, D and F) in that: Resident rooms and other areas accessible to the residents had drywall damage, lose baseboards, exhaust fan vents with lint built up and restrooms in need of repair. These failures affected the residents and placed them at risk of living in an unsafe and uncomfortable environment .
  5. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2026
    Inspectors wroteBased on interviews and record review the facility failed to develop a baseline care plan within 48 hours of admission that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 5 residents (Resident #80) reviewed for baseline care plans. The facility failed to develop the baseline care plan for Resident #80 within 48 hours following his admission on [DATE]. This failure could place residents at risk for complications due to the potential for their immediate needs not being identified so interventions could be planned and initiated.
  6. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2026
    Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 of 8 (Resident #45) reviewed for respiratory care in that: Resident #45's oxygen nasal cannula were bagged when not in use. These failures could place all residents who use respiratory equipment at risk for respiratory infections.
November 18, 2025Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 31, 2025
    Inspectors wroteBased on interviews and record review, the facility failed to report allegations of abuse, neglect, exploitation, or mistreatment that did not result in bodily injury within 24 hours. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 2 (Residents #2 and #3) of 3 residents reviewed for abuse, neglect, and misappropriation of property, in that; [...]
May 22, 2025Complaint inspection · 2 citations
  1. D
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    F561 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 2, 2025
    Inspectors wroteBased on observation, interview and record review, the facility to ensure that the residents had the right to self determination and that the facility promoted and facilitated resident self-determination for 1 (Resident #33) of 7 resident who were reviewed for resident rights. - The facility failed to ensure Resident #33's right to make choices about aspects of his life that were significant to the resident by failing to honor Resident #33's request to be sent to the hospital for evaluation on 05/02/2025 at approximately 3 pm. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and decrease their quality of life.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 2, 2025
    Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 7 residents (Resident #33) reviewed for quality of care. - The facility failed to ensure Resident #33 received treatment immediately after she requested to be sent to the hospital for evaluation on 05/02/2025 at approximately 3 pm. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.
February 7, 2025Standard inspection, Complaint inspection · 10 citations
  1. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for 2 of 3 medication carts reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure that medication carts 1 and 2 were not left unlocked and unsupervised. These failures could cause access, loss, diversion, or accidental ingestion of medications.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #30, #64, #63 and #331) of 4 residents reviewed for infection control practices. 1. The facility failed to ensure LVN C used appropriate PPE during dressing changes for Residents #30, #64 and #331 who were on Enhanced Barrier Precautions (EBP). 2. The facility failed to ensure CNA G changed her gloves after they became contaminated during incontinent care for Resident #63. 3. The facility failed to ensure LVN C used appropriate infection control principles while performing dressing changes for Resident #331. [...]
  3. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #2) reviewed for reasonable accommodations, in that: CNA A and CNA B failed to put Resident #2's call light within reach after performing a transfer. This deficient practice could place residents at risk of not having their needs/preferences met to not being able to use call lights for assistance in to achieve independent functioning, dignity, and well-being.
  4. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interview and record review, the facility failed to immediately consult Resident #1's physician for a decision to discharge the resident after a change in condition for one (Resident #1) of three residents reviewed for notification of changes. The facility failed to immediately notify Resident #1's physician regarding an incident with the resident's change of behavior resulting in Resident #1 being discharged from facility. This failure could place residents at risk of not having their physician informed of medical diagnoses not getting treated and a decreased quality of life.
  5. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the confidentiality of personal and medical records for 2 (LVN C and CMA D) of 5 staff reviewed for confidentiality of records. 1. The facility failed to ensure LVN C locked her laptop before she left the treatment cart unattended exposing residents personal and medical records. 2. The facility failed to ensure CMA D locked her laptop while she was in a resident's room administering medication exposing a resident's medication record. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy.
  6. D
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide documentation for transfer or discharge by resident's physician for 1 (Resident #1) reviewed for discharge requirements. The facility failed to provide reason for discharge by resident's physician which must include specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at current facility. This failure placed residents at risk of not having the needed records when transferring care and services.
  7. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 resident (Resident #2 and #63) reviewed for accidents, hazards, supervision. The facility failed to safely transfer Resident #2 with a mechanical lift transfer by not locking his wheelchair. The facility failed to safely complete a two-person gait belt transfer with Resident #63 by not locking his wheelchair. These failures could place residents at risk for injuries due to not receiving the appropriate level of supervision.
  8. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #28) reviewed for respiratory care. The facility failed to ensure staff remained with Resident #28 while he received his nebulizer treatment. This failure could place residents at risk for respiratory distress.
  9. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents and failed to ensure medications were disposed of when expired for 2 of 3 nurses carts inspected for medication storage. The facility failed to ensure the medication cart 1 did not contain expired docusate sodium and loratadine. The facility failed to ensure the medication cart 2 did not contain expired loratadine. These failures could place residents at risk of receiving medications that were expired and not produce the desired effect.
  10. D
    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.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interviews and record review the facility failed to notify hospice of emergency transfer of 1 (Resident #1) of 1 resident reviewed for discharge. The facility failed to immediately notify resident's hospice provider of discharge to another facility. This failure placed residents at risk of not receiving necessary care and services.
November 20, 2024Complaint inspection · 2 citations
  1. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #2) of 3 residents reviewed for baseline care plans. The facility failed to ensure Resident #2 had a baseline care plan developed within 48-hours after admission with goals, services, and interventions. This failure could place newly admitted residents at risk of not receiving the care and services needed to promote good health and continuity of services.
  2. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #2) of one resident observed for infection control practices in that: The facility failed to ensure the WCN performed adequate hand hygiene by scrubbing hands with soap for at least 20 seconds or greater before and after performing wound care on Resident # 2. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections.
August 10, 2024Complaint inspection · 1 citation
  1. K
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Immediate jeopardy to resident health or safety, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 11, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication regimen. The facility did not administer physician ordered medications to Resident #1 that included handheld nebulizer breathing treatments, inhalers, nasal sprays, and tablets for diagnosed respiratory diseases. This resulted in the need for Resident #1 to be transferred to ED on 08/04/2024 at 8:55 PM and admitted to hospital with diagnosis of acute exacerbation of chronic obstructive pulmonary disease (lung disease causing breathing problems) and symptoms of shortness of breath. An Immediate Jeopardy was identified on 08/09/2024. The Immediate Jeopardy Template was provided to the Administrator on 08/09/2024 at 3:40 PM. [...]
March 29, 2024Complaint inspection, Infection control · 7 citations
  1. K
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, pattern · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on observations, interview, and record review the facility failed to ensure the environment remained free of accidents hazards and provided adequate supervision to prevent accidents for 5 of 9 (Resident #1, #8, #9, #10 and #11) residents reviewed. 1. The facility failed to ensure Resident #1, #8, #9, and #10 were provided direct supervision of staff when smoking. Residents #1, #8, #9, and #10 were allowed to sign out and go outside to smoke in an undesignated smoking area unsupervised in an area with flammable objects of dry grass and dry wood. Residents #1 and #8 were observed to cross the street in front of the facility to the picnic table at the park and smoke in their wheelchairs unsupervised near a creek with an 8-foot drop off. 2. The facility failed to ensure Resident #1 was safe when smoking with no supervision as evidence by a burn on his clothing, fanny pack and blanket. [...]
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 2 of 4 (Resident #16, Resident #20) residents reviewed for resident's rights. The facility failed to ensure Resident #16 and #20 had privacy covers for their urinary catheter bags. This failure could place residents at risk of low self-esteem resulting in a diminished quality of life.
  3. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, and homelike environment for 1 of 4 resident rooms (Resident #1's room) reviewed for environment. 1. The facility failed to ensure Resident #1's room was cleaned of vomit that was on the wall, blinds, bedrails, floors, and mattress. 2. For Resident #3, the facility failed to ensure the room was free of smeared feces on the window blinds, oxygen machine, and wall. This failure could place residents at risk for a diminished clean and homelike environment.
  4. E
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals, and preferences for 3 of 4 residents (Resident #14, Resident #17, Resident #3) reviewed for respiratory care. 1. The facility failed to ensure Resident #14 and #17's nebulizer tubing was kept in bag while not in use. 2. The facility failed to ensure Resident #3's room was free of smeared feces on the oxygen machine These failures could place residents at risk for respiratory infections.
  5. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on interview and record review, the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant change in a resident physical or mental condition for 1 (Resident #1) of 9 residents reviewed for significant change in condition. The facility failed to recognize and complete a comprehensive significant change MDS assessment after Resident #1 began refusing medication, wound care, and showering. This failure placed residents at risk of not developing interventions to meet their needs for care assistance and services and possible deterioration in their condition.
  6. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 (Resident #1 and Resident #10) of 12 resident reviewed for care plans in that: 1. For Resident #1, the comprehensive care plan did not reflect the resident refused wound care and showers. 2. For Resident #10, the comprehensive care plan did not reflect the resident was on dialysis. These failures could result in residents at risk of receiving inadequate interventions not individualized to their care needs.
  7. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · infection control inspection · Corrected (the home has a date of correction) March 30, 2024
    Inspectors wroteBased on interview and record reviewed the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmacy services as the facility failed to ensure Resident #1 received ordered glucose readings and insulin when Resident #1 signed out on pass to exit the facility to smoke. The failure placed residents at risk of not receiving the daily therapeutic dosage of medication prescribed by the physician.
February 29, 2024Complaint inspection · 1 citation
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to notify the Resident's representative/legal guardian requiring intervention by legal guardian for one (Resident #5) of three residents reviewed for resident representative notification. The facility failed to immediately notify Resident #5's Legal Guardian regarding Resident #5 expiring at facility. The failure of the facility not notifying Resident #5's Legal Guardian of the incident led to a delay in arrangement for Resident #5's remains.
January 4, 2024Standard inspection · 4 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) January 31, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. The facility failed to: Ensure the handheld multi juice dispenser spigot was cleaned; Ensure the ice machine filter was free from lint and dirt build-up; Ensure proper hand washing to prevent re-contamination. these failures could place residents who receive food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses.
  2. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 31, 2024
    Inspectors wroteBased on observation, interviews and record review the facility failed to provide a homelike environment and comfortable and safe temperature levels withing a range of 71 degrees to 81 degrees Fahrenheit for 2 of 10 rooms (F7 and F10) reviewed for environment. In Resident #54's room F7 the ambient temperature was 69.0 degrees Fahrenheit In Residents #32's room F10 the ambient temperature was 68.5 degrees Fahrenheit This failure could place residents at risk of an uncomfortable environment and diminish their quality of life.
  3. E
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 31, 2024
    Inspectors wroteBased on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: The facility had no Registered Nurse coverage on 08/06/2023, 08/12/2023, 09/10/2023 and 09/17/ 2023. This failure could affect residents and put them at risk of improper care.
  4. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 31, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significan medication errors for 1 of 10 residents (Residents #33) reviewed for pharmacy services and medication administration in that: The facility failed to administer medications as prescribed for Residents #33. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.
December 1, 2023Complaint inspection · 1 citation
  1. J
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    F678 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interviews, and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 9 residents reviewed for CPR, in that; The facility failed to ensure Resident #1 received life saving measures including CPR (Cardiopulmonary Resuscitation) when she was found unresponsive on [DATE]. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life saving measures including CPR and could lead to death.
September 29, 2023Complaint inspection · 1 citation
  1. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 15, 2023
    Inspectors wroteBased on interviews and record reviews, the facility failed to store narcotics in double locked compartments to ensure only authorized personnel to have access to the medication for 1 of 15 residents reviewed. The facility failed to ensure controlled substances received from pharmacy were secured at all times and to permit only authorized personnel access to the medication (Hydrocodone-Acetaminophen 7/5-325mg - an opioid used to treat moderate to severe pain) were diverted from the medication room. This failure could place residents at risk of not receiving their medications timely, missing a dose of a medication and other personal items being diverted.

Fire safety inspections

16 fire safety citations on file: 8 on April 30, 2026, 4 on February 7, 2025, 4 on January 4, 2024.

Every fire safety citation16 citations
  1. F
    Have simulated fire drills held at unexpected times.
    K 712 · April 30, 2026 · Corrected (the home has a date of correction)
  2. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · April 30, 2026 · Corrected (the home has a date of correction)
  3. E
    Provide properly protected cooking facilities.
    K 324 · April 30, 2026 · Corrected (the home has a date of correction)
  4. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · April 30, 2026 · Corrected (the home has a date of correction)
  5. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · April 30, 2026 · Corrected (the home has a date of correction)
  6. E
    Have properly installed electrical wiring and gas equipment.
    K 511 · April 30, 2026 · Corrected (the home has a date of correction)
  7. E
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · April 30, 2026 · Corrected (the home has a date of correction)
  8. C
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · April 30, 2026 · Corrected (the home has a date of correction)
  9. F
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · February 7, 2025 · Corrected (the home has a date of correction)
  10. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · February 7, 2025 · Corrected (the home has a date of correction)
  11. C
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · February 7, 2025 · Corrected (the home has a date of correction)
  12. C
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · February 7, 2025 · Corrected (the home has a date of correction)
  13. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · January 4, 2024 · Corrected (the home has a date of correction)
  14. E
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · January 4, 2024 · Corrected (the home has a date of correction)
  15. C
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · January 4, 2024 · Corrected (the home has a date of correction)
  16. C
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · January 4, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
August 10, 2024Fine $68,572
January 4, 2024Fine $37,999
December 1, 2023Fine $15,269

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTexasUnited States
All nursing staff (RN, LPN and aides)3.053.393.86
Registered nurses0.140.430.69
All nursing staff on weekends2.822.983.42
Nurse aides1.80
Licensed practical nurses1.11
Nursing staff turnover (share who left in a year)75.3%55.3%45.8%
Registered nurse turnover83.3%54.6%42.9%
Administrators who left0

CMS expects 3.26 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.14 on weekdays and 2.82 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 7.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.27 in April to June 2025 to 3.05 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.050.143.142.82 7.6%5 of 9065
Oct to Dec 20253.130.173.262.79 2.6%2 of 9266
Jul to Sep 20253.240.233.362.94 8.1%3 of 9269
Apr to Jun 20253.270.283.422.90 23.4%0 of 9178
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Texas, Jan to Mar 20263.330.403.502.932.2%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Texas

JobMedianMiddle halfEmployed
Texas, all employers
CNAs (nursing assistants)$18.03$16.97 to $20.7188,680
LPNs and LVNs$29.92$27.46 to $32.8957,560
Registered nurses$46.14$38.06 to $50.53271,380
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Avir at Arbor Terrace. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
Employed by
Usual shift
Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTexasUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
22.315.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.30.30.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.00.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
5.73.33.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.51.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
25.314.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.03.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
3.79.615.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
25.525.723.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
11.812.312.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.92.21.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.12.11.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Avir at Arbor Terrace's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (51.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

51.9% this home

No different from the national rate

US median of homes 51.5% · Texas: 116 better, 50 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 59 eligible stays.

Potentially preventable readmissions

11.4% this home

No different from the national rate

US median of homes 10.7% · Texas: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 88 eligible stays.

Infections that led to a hospital stay

8.5% this home

No different from the national rate

US median of homes 7.1% · Texas: 4 better, 11 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 44 eligible stays.

Self-care and mobility at discharge

52.4% this home

Median of homes: Texas57.3% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 21 residents counted.

Falls with major injury

0.0% this home

Median of homes: Texas0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 35 residents counted.

New or worsened pressure ulcers

0.0% this home

Median of homes: Texas1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 35 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Texas98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 10 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: STRATFORD HOSPITAL DISTRICT. CMS links this home to Avir Health Group, a group of 118 nursing homes averaging 2.3 stars overall.

NameRoleTypeShareSince
Stratford Hospital District5% or greater direct ownership interestOrganization100%08/15/2022
Chumley, RichardCorporate directorIndividual06/01/2023
609 Rio Concho Dr Opco LLCOperational/managerial controlOrganization10/01/2025
Freund, NochumOperational/managerial controlIndividual10/01/2025
Travitsky, AaronOperational/managerial controlIndividual10/01/2025
Dagan, AmitaiIndividual is an owner, partner or trustee of any ADP of the SNFIndividual02/19/2026
Goldberger, AbrahamIndividual is an owner, partner or trustee of any ADP of the SNFIndividual02/20/2026
Goldberger, FaigyIndividual is an owner, partner or trustee of any ADP of the SNFIndividual02/20/2026
609 Rio Concho Dr Opco LLCAdp of the SNFOrganization01/27/2026
609 Rio Concho Dr Property Owner LLCAdp of the SNFOrganization10/01/2025
Welltower IncAdp of the SNFOrganization10/01/2025
Welltower Nnn Group, LLCAdp of the SNFOrganization10/01/2025
Welltower Op, LLCAdp of the SNFOrganization10/01/2025
Hunt, JohnAdp of the SNFIndividual06/01/2023
Kohlleppel, AltaAdp of the SNFIndividual06/01/2023

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 10 problems in this area, most recently on April 30, 2026: "Reasonably accommodate the needs and preferences of each resident."
  2. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 7 problems in this area, most recently on April 30, 2026: "Provide safe and appropriate respiratory care for a resident when needed."
  3. When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on April 30, 2026: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on February 7, 2025: "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."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.82 hours per resident per day, below the Texas average of 2.98.

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Common questions

What is Avir at Arbor Terrace's Medicare star rating?
CMS rates Avir at Arbor Terrace 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Avir at Arbor Terrace get at its last inspection?
6 health deficiencies at the standard inspection on April 30, 2026. The Texas average is 9.4.
Has Avir at Arbor Terrace been fined?
Yes. CMS lists 3 fines totaling $121,840 in the last three years.
Does Avir at Arbor Terrace accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Avir at Arbor Terrace?
CMS lists 15 owners and managers, and links the home to Avir Health Group. Legal business name: STRATFORD HOSPITAL DISTRICT.

Sources

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