Your report for Avir at Converse
Overall Score
CMS Five-Star Quality RatingMuch below averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasLowest tier among peers1,167 rated homes · average 2.8★
- Bexar CountyLowest tier among peers62 rated homes · average 2.4★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs TX avg
- StaffingCan add or remove a star1★−1.1 vs TX avg
- Quality measuresCan add or remove a star3★−0.8 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersTX avg2.1★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 15% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff2.61hrsAbove only 3% of peersTX avg3.40Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.22hrsAbove only 10% of peersTX avg0.44Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better70%Above only 10% of peersTX avg51%RN turnover88%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$64,590Above only 25% of peersTX avg$55,368Fines · denials3 · 1
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles43citations
11inspection dates
0actual harm (G–I)
4immediate jeopardy (J–L)
Sep 4, 2025most recent
Citations by monthJan 2023 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 4, 2025Cycle 1worst D · no actual harm
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Sep 7, 2025
Apr 4, 2025Cycle 1worst E · no actual harm
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected Apr 22, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 10, 2025
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 10, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 10, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 7, 2025
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Apr 7, 2025
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryD · isolatedCorrected Apr 10, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 10, 2025
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Apr 22, 2025
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationE · patternCorrected Apr 22, 2025
- F946Provide training in compliance and ethics.AdministrationE · patternCorrected Apr 22, 2025
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Apr 22, 2025
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationE · patternCorrected Apr 22, 2025
Mar 28, 2025Cycle 1worst E · no actual harm
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Apr 30, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Apr 30, 2025
Mar 23, 2025Cycle 1worst D · no actual harm
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 23, 2025
Sep 6, 2024Cycle 2worst D · no actual harm
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Oct 1, 2024
Jul 27, 2024Cycle 2worst J · immediate jeopardy$23,845
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareJ · isolatedCorrected Jul 28, 2024
May 22, 2024Cycle 2worst D · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 24, 2024
Apr 9, 2024Cycle 2worst J · immediate jeopardy
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 10, 2024
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Apr 10, 2024
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Apr 10, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Apr 10, 2024
Feb 25, 2024Cycle 2worst J · immediate jeopardy$15,440, $25,305, payment denial
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 22, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 22, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 22, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 22, 2024
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareJ · isolatedCorrected Mar 22, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 25, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 22, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 22, 2024
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsJ · isolatedCorrected Mar 22, 2024
- F584Honor 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.Resident RightsD · isolatedCorrected Mar 25, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 22, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 25, 2024
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Mar 25, 2024
Aug 18, 2023Cycle 3worst D · no actual harm
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Sep 8, 2023
Jan 10, 2023Cycle 3worst E · no actual harm
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jan 11, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 10, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.61hrs
- Registered nursesRN hours only0.22hrs
- Licensed practical nursesLPN hours0.93hrs
- Nurse aidesCNA hours1.46hrs
- Weekend nursingAll staff on Saturdays and Sundays2.29hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better70%Above only 10% of peersTX avg 51%
- RN turnoverRegistered nurses only88%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy100 certified beds · ~47 residents a day47%Above only 14% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $64,590In fines
- 3Fines
- 1Payment denial
- $55,368TX avg in fines
Above only 25% of peersFewer fines than 25% of rated homes in Texas
Actions on record
- Jul 27, 2024Civil money penalty$23,845
- Feb 25, 2024Civil money penalty$15,440
- Feb 25, 2024Civil money penalty$25,305
- Feb 25, 2024Denial of payment for new admissionsfrom Mar 26, 2024
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Operational or managerial control
- Converse Senior Care LLC
- McCulloch County Hospital District
- Jack Cook
- Laura Givens
- Timothy Jones
- Lisa Kesterson
Corporate directors
- Catherine Cook
- Jack Cook
- Michele Derrick
- Timothy Jones
- Terry Keltz
- Kirk Roddie
- Michael Schaffner
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 675452 · 7700 MESQUITE PASS, CONVERSE, TX, 78109.
- Percentiles compare this facility with every rated nursing home in Texas and Bexar County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
