Cycle 1
Health 2025-06-27 · Fire 2025-06-27
32 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Kerrville, TX
Avir at Kerrville
1-star overall rating with 1-star inspections with $26,313 in total fines with 32 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1555 Bandera Hwy, Kerrville, TX
(830) 412-2366
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
2024-07-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.20
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.12
Nurse aide staffing
Weekend hours
3.19
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.1%
1.3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.5% |
3.3%
4.2 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
18.9%
6.1 pts worse
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.7% |
10.8%
8.1 pts better
|
16.7%
14 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 45.5% |
15.4%
30.1 pts worse
|
16.3%
29.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
16.1%
6.9 pts worse
|
14.9%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
0.8%
1.7 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
15.0%
7.4 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
89.7%
4 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
12.0%
3.4 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
88.0%
1 pts worse
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
25.9%
2.5 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
17 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-30
C · Minimal harm
2024-05-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-15
D · Potential for more than minimal harm
2026-01-14
F761 · Pharmacy Service Deficiencies
Health
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 2026-01-15
H · Actual harm
2025-12-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-12-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-13
D · Potential for more than minimal harm
2025-12-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-13
E · Potential for more than minimal harm
2025-11-21
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-21
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 2025-11-24
D · Potential for more than minimal harm
2025-11-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-22
E · Potential for more than minimal harm
2025-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-27
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 2025-06-30
E · Potential for more than minimal harm
2025-06-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
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 2025-06-30
D · Potential for more than minimal harm
2025-06-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
F761 · Pharmacy Service Deficiencies
Health
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 2025-06-30
D · Potential for more than minimal harm
2025-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-07
D · Potential for more than minimal harm
2025-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-17
D · Potential for more than minimal harm
2025-05-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-17
C · Minimal harm
2025-05-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-17
J · Immediate jeopardy
2025-04-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-04-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-04-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-04-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-04-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-04-06
F761 · Pharmacy Service Deficiencies
Health
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 2025-04-08
E · Potential for more than minimal harm
2025-04-06
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 2025-04-08
E · Potential for more than minimal harm
2025-04-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-02-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-23
E · Potential for more than minimal harm
2024-11-26
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-11-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-11-26
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 2024-11-27
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-09-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-20
K · Immediate jeopardy
2024-07-01
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 2024-07-02
J · Immediate jeopardy
2024-07-01
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 2024-07-02
D · Potential for more than minimal harm
2024-07-01
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-07-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-07-01
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-07-01
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-02
F · Potential for more than minimal harm
2024-05-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-05-08
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F803 · Nutrition and Dietary Deficiencies
Health
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 2024-05-09
E · Potential for more than minimal harm
2024-05-08
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-05-09
Penalties and ownership
What sits behind the stars
$17,200
2025-12-12
Fine
Fine · fine $17,200
Fine
$9,113
2025-04-06
Fine
Fine · fine $9,113
Fine
Ownership
Kerrville Healthcare Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Conquest Healthcare Management LLC
Operational/Managerial Control · Organization
Conquest Healthcare Operations
5% Or Greater Indirect Ownership Interest · Organization
Douglas 2016 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Douglas, Lloyd
5% Or Greater Indirect Ownership Interest · Individual
Douglas, Lloyd
Operational/Managerial Control · Individual
Kerr Skilled Property Holdings
5% Or Greater Indirect Ownership Interest · Organization
Kerrville Healthcare Operations LLC
5% Or Greater Indirect Ownership Interest · Organization
Kerrville Healthcare Operations LLC
Operational/Managerial Control · Organization
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#3
Hilltop Village Nursing And Rehabilitation
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