Report
TheVardellReport
Avir at Enchanted Rock
Skilled nursing facility and nursing facility
210 West Windcrest St
Fredericksburg, TX 78624
Report
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The Vardell Report.Avir at Enchanted Rock
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Fredericksburg, TX
- Record Period
- 2023–2026
- Source Documents
- 12
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 10 inspections from December 2023 to June 2026, state surveyors documented 48 findings at Avir at Enchanted Rock; 48 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 10
- 2023–2026, complaint, standard and infection control
- Findings
- 48
- Deficiencies cited by state inspectors
- Corrected
- 48
- Of 48 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 0 | 0 |
| 2024 | 2 | 19 | 3 |
| 2025 | 3 | 15 | 1 |
| 2026 | 4 | 14 | 1 |
What the Record Shows
- 48 of 48 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $63,121, their payment not published.
- 6 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, May 2, 2026, recorded 11 findings (most serious: Level J).
What to Ask About
- Reporting Suspected Abuse, Cited in Four Inspections
- Care Plans, Cited in Four Inspections
- Accident Hazards and Supervision, Cited in Four Inspections
- Infection Control, Cited in Four Inspections
- Investigating Alleged Violations, Cited in Three Inspections
- Pharmacy Services, Cited in Three Inspections
- Significant Medication Errors, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
- Medical Records, Cited in Two Inspections
Report at a Glance
- Facility
- Avir at Enchanted Rock
- Address
- 210 West Windcrest St, Fredericksburg, TX 78624
- CMS Certification Number
- 455941
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 120
- Ownership
- Government - Hospital district
- Record Window
- December 21, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 24, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 16, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Standard health inspection
11 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 4, 2026
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected May 4, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected May 4, 2026
- 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.Level ENo actual harm, potential for moreCorrected May 4, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected May 4, 2026
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected May 4, 2026
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 4, 2026
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 4, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected May 4, 2026
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 4, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 4, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jan 10, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
3 findings
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 11, 2025
- F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jul 11, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
9 findings
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Feb 13, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- 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.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Feb 13, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
3 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level KImmediate jeopardyCorrected Feb 9, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jan 20, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jan 20, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 24, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
18 findings
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level JImmediate jeopardyCorrected Feb 15, 2024
- F610Respond appropriately to all alleged violations.Level JImmediate jeopardyCorrected Feb 15, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Feb 15, 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.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Feb 15, 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.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Feb 15, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 15, 2024
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 15, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 15, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Feb 15, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 15, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Feb 15, 2024
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level BPotential for minimal harmCorrected Feb 15, 2024
Enforcement Action
Civil money penalty, $13,916 imposed January 13, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 13, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $49,205 imposed January 19, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 13, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Infection control inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Reporting Suspected Abuse, Cited in Four Inspections
Inspectors cited F609 in January 2024, January 2025, February 2025 and May 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F609 across all 10 inspections, oldest to newest - 2
Care Plans, Cited in Four Inspections
Inspectors cited F656 in January 2024, January 2025, February 2025 and May 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F656 across all 10 inspections, oldest to newest - 3
Accident Hazards and Supervision, Cited in Four Inspections
Inspectors cited F689 in January 2024, June 2024, January 2025 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level K (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F689 across all 10 inspections, oldest to newest - 4
Infection Control, Cited in Four Inspections
Inspectors cited F880 in January 2024, February 2025, January 2026 and May 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F880 across all 10 inspections, oldest to newest - 5
Investigating Alleged Violations, Cited in Three Inspections
Inspectors cited F610 in January 2024, February 2025 and May 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F610 across all 10 inspections, oldest to newest - 6
Pharmacy Services, Cited in Three Inspections
Inspectors cited F755 in February 2025, July 2025 and June 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F755 across all 10 inspections, oldest to newest - 7
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in January 2024 and May 2026. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F760 across all 10 inspections, oldest to newest - 8
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in January 2024 and May 2026. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F812 across all 10 inspections, oldest to newest - 9
Medical Records, Cited in Two Inspections
Inspectors cited F842 in May 2026 and May 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242425252526262626F842 across all 10 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in four inspections, most seriously at level D.
- 02
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in four inspections, most seriously at level E.
- 03
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level K.
- 04
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level E.
- 05
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in three inspections, most seriously at level J.
- 06
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in three inspections, most seriously at level D.
- 07
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level E.
- 08
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level E.
- 09
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D.
- 10
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 11
What led to the 2025 fine, and has it been paid?
A $49,205 civil money penalty was imposed January 19, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jan 13, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 22, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jan 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Feb 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jul 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jan 8, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection May 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Texas state survey agency
Inspection Jun 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 455941
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowDecember 21, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before December 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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