Avir at San Angelo
5455 Knickerbocker Rd, San Angelo, TX 76904 · Tom Green County · 125 certified beds · avg 85 residents/day · certified since Apr 11, 2006
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 · Dec 22, 2023 · 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: Dec 23, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 6, 2025 · F-0685
The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Why it matters: Untreated vision and hearing problems lead to falls, isolation, and confusion that could be avoided.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Mar 7, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 6, 2025 · F-0745
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Mar 7, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Sep 13, 2023 · 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 (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Aug 14, 2023 (Past Non-Compliance)
All citations in the current public record (34)
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 |
|---|---|---|
| May 7, 2026 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 7, 2026 | E · Potential for harm, repeated | 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. |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. |
| May 7, 2026 | 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. |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 7, 2026 | 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. |
| May 7, 2026 | 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. |
| Feb 17, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Nov 19, 2025 | 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 |
| Jun 14, 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 |
| Mar 6, 2025 | ▲ H · Actual harm, repeated | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Mar 6, 2025 | ▲ H · Actual harm, repeated | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Mar 6, 2025 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Mar 6, 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. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Dec 22, 2023 | ▲ 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 |
| Dec 22, 2023 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Dec 22, 2023 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Dec 22, 2023 | 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. |
| Dec 22, 2023 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Dec 22, 2023 | E · Potential for harm, repeated | 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. |
| Dec 22, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 22, 2023 | 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 |
| Dec 22, 2023 | 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. |
| Dec 22, 2023 | E · Potential for harm, repeated | 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. |
| Dec 22, 2023 | 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. |
| Dec 22, 2023 | D · Potential for harm, one-off | 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. |
| Dec 22, 2023 | 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. |
| Sep 13, 2023 | ▲ H · Actual 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. · from a complaint |
| Sep 13, 2023 | 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 |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 15 | 2 | K ▲ |
| 2024 | 3 | 0 | D |
| 2025 | 6 | 2 | H ▲ |
| 2026 | 10 | 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 $91,080.
| Date | Type | Amount / length |
|---|---|---|
| Mar 6, 2025 | Fine | $54,919 |
| Dec 22, 2023 | Fine | $23,941 |
| Sep 13, 2023 | Fine | $12,220 |
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) | 3.14 | 3.46 | 3.95 | bottom 34% in Texas; bottom 19% in the U.S. |
| Registered Nurse hours | 0.16 | 0.44 | 0.69 | bottom 3% in Texas; bottom 1% in the U.S. |
| Weekend total nurse staffing | 2.87 | 3.04 | 3.50 | bottom 45% in Texas; bottom 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.13 | 0.34 | 0.48 | bottom 6% in Texas; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
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 2.99, RN 0.15, weekend 2.73. 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: 2/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 5455 Knickerbocker Rd LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 06/01/2024 |
| 5455 Knickerbocker Road Opco, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| 5455 Knickerbocker Road Opco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/23/2025 |
| 5455 Knickerbocker Road Property Owner, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/01/2025 |
| 5455 Knickerbocker Road Property Owner, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Apolinar, Adam | Individual | Corporate Director | NOT APPLICABLE | 06/01/2024 |
| Chang, Peter | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Chang, Peter | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Dagan, Amitai | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/23/2025 |
| Freund, Nochum | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Goldberger, Abraham | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/23/2025 |
| Kofron, Clay | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Travitsky, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Welltower INC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/01/2025 |
| Welltower INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Welltower NNN Group, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/01/2025 |
| Welltower NNN Group, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Welltower Op, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/01/2025 |
| Welltower Op, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
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 is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you arrange eye and hearing care for residents, including appointments and equipment like glasses or hearing aids?"
- "Who provides social services here, and how would they support my family member's emotional and social needs?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can I see where garbage is stored and how often it's removed?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "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 |
|---|---|---|---|---|---|
| St. Juanita Retirement and Rehab | 1.5 mi | San Angelo, TX | —/5 | ||
| Avir at Meadow Creek | 1.9 mi | San Angelo, TX | ★☆☆☆☆ | 1/5 | |
| Regency House | 2.9 mi | San Angelo, TX | ★★★☆☆ | 4/5 | |
| Park Plaza Nursing and Rehabilitation Center | 4.8 mi | San Angelo, TX | ★★★☆☆ | 4/5 | |
| Cedar Manor Nursing and Rehabilitation Center | 5.0 mi | San Angelo, TX | ★★★★☆ | 4/5 | |
| Avir at Arbor Terrace | 5.4 mi | San Angelo, TX | ★☆☆☆☆ | 2/5 | |
| Sagecrest Alzheimers Care Center | 6.2 mi | San Angelo, TX | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 676100.