Map showing the location of Avir at Comfort in COMFORT, Texas
615 FALTIN AVE, COMFORT, TX, 78013

Overall Score

CMS Five-Star Quality Rating
4/5Above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasAbove 69% of peers1,167 rated homes · average 2.8★
  • Kendall CountyAbove 80% of peers6 rated homes · average 2.8★
  • United StatesAbove 61% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point4★+1.2 vs TX avg
  • StaffingCan add or remove a star1★−1.1 vs TX avg
  • Quality measuresCan add or remove a star5★+1.2 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 means
Health inspection ratingCMS stars from the last three on-site inspection cycles4★Above 67% 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 assessments5★Above 68% 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 staff3.41hrsAbove 64% 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 only0.64hrsAbove 88% 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 better46%Above 64% of peersTX avg51%RN turnover60%
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$0Above 71% of peersTX avg$55,368Fines · denials0 · 0
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 cycles
34citations
5inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Aug 22, 2025most recent

Citations by monthJun 2023 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 22, 20252 citationsCycle 1worst F · no actual harm
  1. F727Have 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.Nursing and Physician ServicesF · widespreadCorrected Aug 31, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 25, 2025
Apr 18, 20252 citationsCycle 1worst F · no actual harm
  1. 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 25, 2025
  2. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Apr 25, 2025
Jul 10, 20245 citationsCycle 2worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Jul 31, 2024
  2. F727Have 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.Nursing and Physician ServicesE · patternCorrected Jul 31, 2024
  3. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Jul 31, 2024
  4. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 31, 2024
  5. F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsC · widespreadCorrected Jul 31, 2024
Mar 1, 20242 citationsCycle 2worst D · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Mar 29, 2024
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 29, 2024
Jun 8, 202323 citationsCycle 3worst F · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 7, 2023
  2. 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 Jul 7, 2023
  3. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 7, 2023
  4. 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 Jul 5, 2023
  5. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Jul 5, 2023
  6. 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 Jul 19, 2023
  7. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jul 7, 2023
  8. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Jul 10, 2023
  9. F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsE · patternCorrected Jul 19, 2023
  10. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Jul 19, 2023
  11. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlE · patternCorrected Jul 19, 2023
  12. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jul 5, 2023
  13. F946Provide training in compliance and ethics.AdministrationE · patternCorrected Jul 19, 2023
  14. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationE · patternCorrected Jul 19, 2023
  15. 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 Jul 5, 2023
  16. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Jul 5, 2023
  17. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jul 5, 2023
  18. F642Ensure a qualified health professional conducts resident assessments.Resident Assessment and Care PlanningD · isolatedCorrected Jul 5, 2023
  19. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jul 5, 2023
  20. 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 Jul 5, 2023
  21. 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 Jul 5, 2023
  22. F727Have 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.Nursing and Physician ServicesD · isolatedCorrected Jul 27, 2023
  23. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Jul 10, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.41hrsAbove 64% of peers+0.01 vs TX avg
  • Registered nursesRN hours only0.64hrsAbove 88% of peers+0.20 vs TX avg
  • Licensed practical nursesLPN hours1.02hrs
  • Nurse aidesCNA hours1.74hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.85hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better46%Above 64% of peersTX avg 51%
  • RN turnoverRegistered nurses only60%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy76 certified beds · ~34 residents a day44%Above only 11% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above 71% of peersFewer fines than 71% of rated homes in Texas

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Texas facilities average 1.8 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Slp Operations27 facilities in the chain2.6★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Hamilton County Hospital District
Operational or managerial control
  • Slp Comfort LLC
  • Joshua Leonard
Corporate officers
  • Grady Hooper
Mortgage or security interest (5%+)
  • Wm 41 Hamilton Re LLC

Person Organization

Sources & notes

Public data, updated quarterly

Data 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 675871 · 615 FALTIN AVE, COMFORT, TX, 78013.
  • Percentiles compare this facility with every rated nursing home in Texas and Kendall 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.

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