Comfort, TX

Avir at Comfort

4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

615 Faltin Ave, Comfort, TX

(830) 995-3757

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Avir Health Group

Operator or chain grouping

Approved since

2001-04-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

90 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.64

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.02

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.74

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.41

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.67

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.85

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.39

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.25

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.72

CMS adjusted RN staffing hours

Adjusted total hours

3.83

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,747

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.68

Composite VBP score used to determine payment impact.

Payment multiplier

0.9829

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.93

Performance 47.62% · Measure score 3.93 · Achievement 3.93 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.61

Baseline 2.61 hours · Performance 2.96 hours · Measure score 0.61 · Achievement 0 · Improvement 0.61

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.91%	10.72% 2.2 pts worse	No Different than the National Rate · Eligible stays 45 · Observed rate 20% · Lower 95% interval 8.53%
Discharge to community	49.11%	50.57% 1.5 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 46.88% · Lower 95% interval 32.87%
Medicare spending per beneficiary	1.35	1.02 0.3 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 13 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 51
Staff flu vaccination coverage	35.38%	42% 6.6 pts worse	Numerator 23 · Denominator 65
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	2.1 0.9 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	2.1 1.3 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.7%	3.3% 2.6 pts better	3.3% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	2.7% 0.5 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	0.9%	3.3% 2.4 pts better	5.4% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 0.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.5%	18.9% 8.4 pts better	19.6% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.3% · Q3 6.9% · Q4 11.5% · 4Q avg 10.5%
Percentage of long-stay residents who received an antipsychotic medication	8.3%	10.8% 2.5 pts better	16.7% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.3% · Q3 8.7% · Q4 13.0% · 4Q avg 8.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	26.0%	15.4% 10.6 pts worse	16.3% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	32.7%	16.1% 16.6 pts worse	14.9% 17.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 26.9% · Q3 32.1% · Q4 48.0% · 4Q avg 32.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.9%	15.0% 15.9 pts worse	19.8% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 41.1% · Q3 25.6% · Q4 30.1% · 4Q avg 30.9%
Percentage of long-stay residents with pressure ulcers	0.0%	4.2% 4.2 pts better	5.1% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	12.0% 12 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	51.9%	88.0% 36.1 pts worse	79.7% 27.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 51.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.8%	25.9% 9.1 pts better	23.9% 7.1 pts better	Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 14.3% · Expected 20.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-22 · Fire 2025-08-22

4 health deficiencies

Top issue: Nursing and Physician Services (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-07-10 · Fire 2024-07-10

7 health deficiencies

Top issue: Nursing and Physician Services (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-06-08 · Fire 2023-06-08

23 health deficiencies

Top issue: Resident Assessment and Care Planning (8 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-22

K321 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-10-04

F · Potential for more than minimal harm 2025-08-22

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-10-03

E · Potential for more than minimal harm 2025-08-22

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-10-04

E · Potential for more than minimal harm 2024-07-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-31

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-22

F727 · Nursing and Physician Services Deficiencies

Health

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 2025-08-31

D · Potential for more than minimal harm 2025-08-22

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-25

F · Potential for more than minimal harm 2025-04-18

F725 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-04-25

E · Potential for more than minimal harm 2024-07-10

F727 · Nursing and Physician Services Deficiencies

Health

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 2024-07-31

D · Potential for more than minimal harm 2024-07-10

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-07-31

D · Potential for more than minimal harm 2024-07-10

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-07-31

C · Minimal harm 2024-07-10

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2024-07-31

C · Minimal harm 2024-07-10

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-07-31

D · Potential for more than minimal harm 2024-03-01

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-03-29

D · Potential for more than minimal harm 2024-03-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-29

F · Potential for more than minimal harm 2023-06-08

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-06-08

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2023-07-10

E · Potential for more than minimal harm 2023-06-08

F940 · Administration Deficiencies

Health

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

Corrected 2023-07-10

E · Potential for more than minimal harm 2023-06-08

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2023-07-19

E · Potential for more than minimal harm 2023-06-08

F942 · Resident Rights Deficiencies

Health

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected 2023-07-19

E · Potential for more than minimal harm 2023-06-08

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected 2023-07-19

E · Potential for more than minimal harm 2023-06-08

F945 · Infection Control Deficiencies

Health

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Corrected 2023-07-19

E · Potential for more than minimal harm 2023-06-08

F946 · Administration Deficiencies

Health

Provide training in compliance and ethics.

Corrected 2023-07-19

E · Potential for more than minimal harm 2023-06-08

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2023-07-19