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Nursing HomeMedicaid Investigative

Avir at San Angelo

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

5455 Knickerbocker Rd, San Angelo, TX 76904125 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.0/5

based on 4 Google reviews

Avir at San Angelo Nursing Home in San Angelo, TX — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)

Bottom 25% in Texas · Critically understaffed (RN) · Worst in AVIR HEALTH GROUP chain · $241,795 in fines

Source: Medicare data

What this means for your family

This facility presents significant risks regarding resident safety and basic hygiene. If you choose to consider them, you must verify their maintenance protocols and observe staff responsiveness during night shifts, as multiple reports indicate severe neglect and unaddressed facility issues.

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.16hrs
22%
Registered nurses for medical care
Total Nursing
3.23hrs
79%
All nurses + aides combined

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

7

measures

Worse Than Avg

7

measures

Mixed Results

3

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility32.1%
Worse than Avg
Here
32.1%
US
15.3%
TX
14.9%
Tom green
19.2%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility30.8%
Worse than Avg
Here
30.8%
US
14.4%
TX
16.1%
Tom green
15.3%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.8%
Mixed vs Avgs
Here
0.8%
US
12.1%
TX
2.5%
Tom green
0.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility23.3%
Worse than Avg
Here
23.3%
US
19.4%
TX
14.2%
Tom green
22.7%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility15.3%
Better than Avg
Here
15.3%
US
19.5%
TX
18.4%
Tom green
19.0%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility97.5%
Better than Avg
Here
97.5%
US
93.4%
TX
96.9%
Tom green
95.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility97.9%
Better than Avg
Here
97.9%
US
79.7%
TX
88.0%
Tom green
96.9%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility96.6%
Mixed vs Avgs
Here
96.6%
US
81.8%
TX
89.2%
Tom green
98.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility3.3%
Worse than Avg
Here
3.3%
US
1.6%
TX
1.5%
Tom green
0.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

7deficiencies
4penalties
Near state avg (9.1)
18 complaint-triggered
$241,795 in fines

Multiple families have filed complaints triggering 18 deficiencies at this facility, with recurring issues in resident protection from abuse and neglect, infection control, and care planning. The facility shows a pattern of repeated problems, including recent violations in accident prevention (June 2025), abuse protection (October 2024), and ongoing concerns with infection control appearing across multiple surveys since 2022, though the provider reports correcting each identified issue.

Feb 17, 2026Complaint
1
0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nov 19, 2025Complaint
1
0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Jun 14, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Mar 6, 2025Routine
7
0685Actual harm · PatternCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0745Actual harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

0908Potential for harm · WidespreadCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Oct 3, 2024Complaint
3
0559Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Dec 22, 2023Routine
10
0881Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0582Potential for harm · PatternCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

0655Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure 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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Federal Penalties

Fine

Mar 6, 2025

$54,919

Fine

Dec 22, 2023

$23,941

Fine

Sep 13, 2023

$12,220

Fine

Jul 28, 2023

$126,135

Ownership & Operations

Who Operates This Facility

Owner / Operator

Uvalde County Hospital Authority

Organization Type

for profit

Management Company

5455 KNICKERBOCKER ROAD OPCO LLC

Administrator

CLAY J KOFRON

Chain Affiliation

Chain Name

Avir Health Group

Chain Size

117 facilities nationwide

Chain avg rating: 2.3/5 · Rank 74 of 90 (Worst)

Ownership & Management

Owners

Uvalde County Hospital Authority

Owner · Organization

100%

Dagan, Amitai

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Goldberger, Abraham

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

5455 Knickerbocker Rd LLC5% or Greater Mortgage Interest5455 Knickerbocker Road Property Owner, LLC5% or Greater Security InterestHccf Management Group Xi LLC5% or Greater Security InterestWelltower INC5% or Greater Security InterestWelltower Nnn Group, LLC5% or Greater Security Interest
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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