Avir at Arbor Terrace
609 Rio Concho Dr, San Angelo, TX 76903 · Tom Green County · 126 certified beds · avg 65 residents/day · certified since Oct 1, 2002
Part of chain: AVIR HEALTH GROUP (116 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Aug 10, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 11, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Mar 29, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 30, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 1, 2023 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 26, 2023 (Past Non-Compliance)
All citations in the current public record (36)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 30, 2026 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Apr 30, 2026 | E · Potential for harm, repeated | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Apr 30, 2026 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Apr 30, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Apr 30, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Nov 20, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Nov 20, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Aug 10, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 29, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 29, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 29, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 29, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Mar 29, 2024 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · from a complaint |
| Mar 29, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 29, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 4, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 4, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 4, 2024 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jan 4, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Dec 1, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 1 | J ▲ |
| 2024 | 15 | 2 | K ▲ |
| 2025 | 13 | 0 | E |
| 2026 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $121,840.
| Date | Type | Amount / length |
|---|---|---|
| Aug 10, 2024 | Fine | $68,572 |
| Jan 4, 2024 | Fine | $37,999 |
| Dec 1, 2023 | Fine | $15,269 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.58 | 3.46 | 3.95 | top 31% in Texas; bottom 41% in the U.S. |
| Registered Nurse hours | 0.16 | 0.44 | 0.69 | bottom 4% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 3.32 | 3.04 | 3.50 | top 23% in Texas; bottom 48% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.14 | 0.34 | 0.48 | bottom 8% in Texas; bottom 4% in the U.S. |
| Total nursing staff turnover (%) | 75.3 | 55.3 | 45.8 | bottom 15% in Texas; bottom 3% in the U.S. |
| RN turnover (%) | 83.3 | 54.6 | 42.9 | bottom 17% in Texas; bottom 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.05, RN 0.14, weekend 2.82. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Stratford Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/15/2022 |
| 609 Rio Concho Dr Opco LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2025 |
| 609 Rio Concho Dr Opco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/27/2026 |
| 609 Rio Concho Dr Property Owner LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2025 |
| Chumley, Richard | Individual | Corporate Director | NOT APPLICABLE | 06/01/2023 |
| Dagan, Amitai | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/19/2026 |
| Freund, Nochum | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2025 |
| Goldberger, Abraham | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/20/2026 |
| Goldberger, Faigy | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/20/2026 |
| Hunt, John | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| Kohlleppel, Alta | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| Travitsky, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2025 |
| Welltower INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2025 |
| Welltower NNN Group, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2025 |
| Welltower Op, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sagecrest Alzheimers Care Center | 1.0 mi | San Angelo, TX | ★★★★★ | 5/5 | |
| Cedar Manor Nursing and Rehabilitation Center | 3.1 mi | San Angelo, TX | ★★★★☆ | 4/5 | |
| Park Plaza Nursing and Rehabilitation Center | 3.6 mi | San Angelo, TX | ★★★☆☆ | 4/5 | |
| St. Juanita Retirement and Rehab | 3.9 mi | San Angelo, TX | —/5 | ||
| Avir at Meadow Creek | 5.4 mi | San Angelo, TX | ★☆☆☆☆ | 1/5 | |
| Avir at San Angelo | 5.4 mi | San Angelo, TX | ★☆☆☆☆ | 2/5 | |
| Regency House | 6.3 mi | San Angelo, TX | ★★★☆☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675932.