Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an infection prevention and control
program designed to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable disease and infection for 3 of 5 residents (Resident #1,
Resident #2 and Resident #3) reviewed for infection control: 1.The facility failed to ensure Resident #1's
pure wick tubing was not on the floor. 2.The facility failed to ensure Resident #2 had enhanced barrier
precaution signage and supplies by Resident #2's door. 3.The facility failed to ensure Resident #3 had
enhanced barrier precaution signage and supplies by Resident #3's door. These failures could place
residents at-risk for infection due to improper care practices.The findings included: 1. Record review of
Resident #1's face sheet dated 2/3/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]
and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), diabetes (a
chronic medical condition in which the body has trouble regulating blood sugar), chronic kidney disease,
cognitive communication deficit and muscle weakness. Record review of Resident #1's most recent reentry
MDS assessment dated [DATE] reflected the resident was severely impaired, did not have an external
catheter, and was always incontinent of bowel and bladder. Record review of Resident #1's Order Summary
Report dated 2/3/2026 reflected the following: - Change pure wick device (device used to manage urinary
incontinence) q12 hours and pm: two times a day for urinary output supplies provided in room by family with
an order date 1/4/2026 and no end date. Record review of Resident #1's comprehensive care plan with
initiation date 1/4/2026 reflected the resident had a PURE WICK urinary system and at risk for UTI with
interventions that included providing urinary catheter care, assessing for abnormal urine and emptying and
recording output every shift and PRN. During an observation on 2/3/2026 at 12:40 p.m. Resident #1's
bedroom entry revealed a sign which indicated the resident was on Enhanced Barrier Precautions.
Resident #1 was observed in bed, and the pure wick catheter was sitting to the right of the bed, on a pad.
Resident #1's pure wick catheter tubing was touching the floor. During an observation and interview on
2/3/2026 at 12:53 p.m., CNA A stated she was assigned to care for Resident #1 as part of her assignment
in the hall she was working in. CNA A stated Resident #1 had a pure wick catheter and observed the
resident's pure wick catheter tubing touching the floor. CNA A stated the pure wick catheter tubing should
not be touching the floor as it was an infection control issue. CNA A stated she would let the nurse know the
pure wick catheter tubing was on the floor. 2. Record review of Resident #2's face sheet dated 2/3/2026
reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic
kidney disease, retention of urine, and dysphagia (difficulty swallowing). Record review of Resident #2's
admission MDS assessment dated [DATE] reflected the resident had moderate cognitive impairment and
had an unhealed pressure injury/ulcer. Record review of Resident #2's Order Summary Report dated
2/3/2026 reflected the following: - heels protector when in bed due to multiple unstageable wounds, every
shift with order date
Residents Affected - Some
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
675452
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Converse
7700 Mesquite Pass
Converse, TX 78109
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
1/22/2026 and no end date. - unstageable wound to left heel: cleanse with ns or wound cleanser, pat dry.
Apply moisturizer gauze to base of the wound. Secure with ABD, kerlix and ace bandage, every day shift
every Mon, Wed, Fri with order date 1/22/2026 with no end date. -unstageable wound to right heel: cleanse
with ns or wound cleanser, pat dry. Apply moisturizer gauze to base of the wound. Secure with ABD, kerlix
and ace bandage every day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. - left
thigh, upper anterior hematoma (collection of blood outside a blood vessel), cleanse with ns or wound
cleanser, pat dry with betadine moistened gauze to wound base, cover with bordered gauze every day shift
Mon, Wed, Fri order date 1/30/2026 and start date of 2/2/2026 with no end date. Record review of Resident
#2's comprehensive care plan with revision date 1/22/2026 reflected the resident admitted with pressure
ulcers (r/t Hx of ulcers, immobility) unstable right heel and unstageable left heel with interventions that
include administering treatments as ordered and monitor for effectiveness. 3. Record review of Resident
#3's face sheet dated 2/3/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with
diagnoses that included pressure ulcer to part of back, stage 3, pressure ulcer to part of back, stage 4,
pressure ulcer of right heel, pressure ulcer of left heel. Record review of Resident #3's admission MDS
assessment dated [DATE] reflected the resident had moderate cognitive impairment and had an unhealed
pressure injury/ulcer. Record review of Resident #3's Order Summary Report dated 2/3/2026 reflected the
following: - Stage IV sacrum pressure ulcer/injury: cleanse with wound cleanser/normal saline. Apply gentell
blue to base of wound. Secure with superabsorbent dressing, every day shift with order date 1/16/2026 with
no end date. -unstageable wound to lower back: cleanse with ns or wound cleanser, pat dry. Apply betadine
to base of wound, leave open to air, every day shift with order date 1/16/2026 with no end date. -heel up
boots when in bed due to multiple unstageable wounds, every shift with order date 1/22/2026 and no end
date. -stage III wound to caudal space (base of spine) to lower back: cleanse with ns or wound cleanser,
pat dry, apply collagen, calcium alginate to base of the wound. Secure with silicone bordered
superabsorbent dressing, every day shift with order date 1/22/2026 with no end date. -unstageable wound
to right heel: cleanse with ns or wound cleanser, pat dry. Apply betadine moistened gauze to base of the
wound. Secure with ABD, kerlix and secure with tape, every day shift every Mon, Wed, Fri with order date
1/22/2026 with no end date. -unstageable wound to left heel: cleanse with ns or wound cleanser, pat dry.
Apply betadine moistened gauze to base of the wound. Secure with ABD, kerlix and secure with tape, every
day shift every Mon, Wed, Fri with order date 1/22/2026 with no end date. -unstageable wound to left lateral
ankle: cleanse with ns or wound cleanser, pat dry. Apply Hydrogel Gauze to the base of the wound and
secure with bordered gauze dressing, every day shift every Mon, Wed, Fri with order date 1/22/2026 with
no end date. -unstageable wound to right lateral ankle: cleanse with ns or wound cleanser, pat dry. Apply
Collagen to base of the wound, then betadine moistened gauze over collagen and secure with ABD, Kerlix,
and ace bandage, every day shift every Mon, Wed, Fri with an order date of 1/20/2026 with no end date.
Record review of Resident #3's comprehensive care plan with revision date 1/22/2026 reflected the
resident admitted with pressure ulcers (r/t Hx of ulcers, immobility) unstable right heel and unstageable left
heel with interventions that include administering treatments as ordered and monitor for effectiveness.
During an observation on 2/3/2026 at 1:10 p.m. revealed Resident #2 and Resident #3 resided in the same
room. Resident #2 and Resident #3's bedroom entry revealed lack of signage of EBP and supplies. During
an observation and interview on 2/3/2026 at 1:16 p.m., LVN C stated any residents with open wounds
would need to be on EBP. LVN C stated staff would know if a resident was on EBP if they had a sign stating
so and a cart with supplies alongside it. When asked if Resident #2 or/and Resident #3 would need to be
on EBP, LVN
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675452
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675452
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Converse
7700 Mesquite Pass
Converse, TX 78109
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
C stated LVN C wasn't sure and would need to ask the DON. LVN C stated if staff do not know a resident is
on EBP there could be a risk of cross contamination or/and spreading infectious diseases. During an
interview on 2/3/26 at 1:26 p.m., LVN D stated any residents with wounds would need to be on EBP. LVN D
stated staff would know if a resident was on EBP if there were a sign and cart by their room. LVN D stated
Resident #2 and Resident #3 should have had EBP signage and supplies due to both Residents having
wounds. LVN D stated the risk of not having EBP or signage/using would be infections in the wound. During
an interview on 2/3/2026 at 1:54 p.m., LVN B stated she oversaw Resident #1's care as she oversaw the
hall Resident #1 was in. LVN B stated Resident #1's pure wick catheter tubing should not be on the floor.
LVN B stated the risk could be contamination. During an interview on 2/3/2026 2:52 p.m., the DON stated
residents were placed on EBP if they have indwelling catheters or chronic wounds. The DON stated staff
know if a resident was on EBP if they had signs outside their door saying so and a cart. The DON stated
the purpose of EBP was to prevent transmission of bacteria. The DON stated catheter tubing should not be
on the floor due to the risk of bacteria being on the outside of the tube. Record review of the facility
document titled Enhanced Barrier Precautions Program with revision date March 2024, reflected:5. EBPs
are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or
indwelling medical devices regardless of MDRO colonization a. Wounds generally include chronic wounds
(i.e. pressure ulcers.) b. indwelling medical devices include central lines, urinary catheters.
Event ID:
Facility ID:
675452
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the February 5, 2026 survey of Avir at Converse?
This was a inspection survey of Avir at Converse on February 5, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Avir at Converse on February 5, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.