Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Caldwell during CMS and state inspections, most recent first.
A facility failed to keep the resident environment free of fire hazards after a dining room fire and a later smoke incident in the same area. A resident with asthma, COPD, and anxiety reported being in the dining room with two other residents when smoke appeared, leaving with breathing difficulty afterward, and not being assessed. The Administrator and Maintenance Supervisor described a ceiling light fire linked to incorrect bulb wattage, but the dining room lights were not checked afterward, the later smoke event was not investigated or reported to the fire department, and staff interviews showed confusion about code red response, extinguisher use, and resident evacuation.
Facility staff failed to report a smoke incident from a ceiling light to required officials and did not complete an investigation after smoke was seen near the kitchen/dining area. The DON obtained a fire extinguisher but did not use it, and a resident who was in the dining room with two other residents reported breathing difficulty afterward, used her nebulizer, and said no one assessed her after the smoke exposure.
Unlocked housekeeping cart with unlabeled chemicals: Housekeeping Cart #1 was left unattended on the hall with its chemical compartment unlocked and containing bleach, disinfectant cleaner, and two unlabeled bottles of chemicals. Housekeeper A stated the cart should be locked whenever she walked away, and the Housekeeping Supervisor and Administrator both stated housekeeping carts were expected to be locked when not in use and chemical bottles were to be labeled.
Medication Cart #1 was observed unlocked and unattended at the nurses' station, with no staff nearby and the cart facing the hall. LVN B stated staff were trained to lock med carts whenever they walked away, and both the DON and Administrator said the assigned nurse or med aide was responsible for keeping the cart locked. The facility policy required meds and biologicals to be stored in locked compartments and carts not left unattended if open or otherwise accessible.
Verbal Abuse of a Resident by CNA: A cognitively intact resident with depression, anxiety, and PTSD reported a CNA for sleeping at the nurses’ station. After an RN addressed the issue, the CNA went to the resident’s room, yelled at her, pointed in her face, called her a liar, and said she did not like her. Another resident heard the shouting, and the resident said the confrontation triggered her PTSD. The facility substantiated the allegation.
A resident with PTSD, major depressive disorder, and anxiety was not care planned for her psychological diagnoses, antidepressant medications, or psych services. Her chart showed Lexapro and trazodone orders and psychiatry follow-up, but the comprehensive care plan had no entries for these conditions. The resident was alert and oriented and reported PTSD triggers related to family conflict and yelling; the MDS RN and RNC acknowledged the care plan was incomplete.
Failure to Provide Ongoing Activity Programming: Two residents with intact cognition and documented activity preferences had no activity participation records for multiple months, and both were observed in their rooms watching TV and reporting boredom. One resident with depression wanted more men’s group activities and said his preferences had not been discussed in a long time, while the other resident with depression and Alzheimer’s disease wanted mass, music, Bible study, and other activities but said she had not been interviewed about her changing preferences for months. The ADON/Administrator stated activity participation was expected to be documented and resident preferences assessed.
Unlocked Medication Carts: Two medication carts were observed unsecured with the locking mechanisms protruding outward, indicating they were unlocked while not in use. RN C and MA D each stated the carts should be locked except when medications are being dispensed, and both the ADON and DON confirmed that medication carts are expected to remain locked when not in use. The carts contained physician-prescribed medications other than narcotics, and the facility policy required medications and biologicals to be stored in locked compartments with access limited to authorized personnel.
A resident’s medical information was left visible on an unlocked laptop screen on a medication cart in the hallway while an MA was in the resident’s room. The MA said she forgot to close the screen, and the DON and ADON stated the screen was expected to be locked whenever staff were away from the cart. The resident had diagnoses including MDD, Alzheimer’s disease, DM2, and COPD, and the facility’s resident rights training stated residents have a right to private and confidential medical records.
Failure to complete baseline care plans within 48 hours for two newly admitted residents. One resident had CVA, DM2, dysphagia, and a G-tube, while the other had ASHD, DM2, morbid obesity, HTN, moderate cognitive impairment, and wounds. The ADON and DON both confirmed the missing baseline care plans in the EMR, and the DON stated the 48-hour baseline care plan requirement was known.
Care Plans Missing Enhanced Barrier Precautions: The facility failed to keep comprehensive, person-centered care plans current for two residents. One resident had severe cognitive impairment and an indwelling catheter, and another had full cognition with a feeding tube; both had physician orders for EBP, but their care plans addressed only the catheter or tube feeding and did not include EBP. The MDS nurse, ADON, and DON all stated that EBP should have been included in the care plans, and the DON acknowledged the omission.
Improper Treatment of an Unstageable Sacral Pressure Ulcer A resident with severe cognitive impairment, total ADL dependence, diabetes, and hospice care had an unstageable sacral pressure ulcer present on admission/reentry. The wound was documented with slough, eschar, undermining, and peri-wound breakdown, and the order called for cleansing, Dakins-moistened gauze packing, and a superabsorbent dressing. During wound care, an LPN used Santyl on the wound edges and peri-wound, did not pack the wound, and covered it with bordered gauze instead of the ordered dressing. The LPN stated Dakins was unavailable and she believed a dry dressing was acceptable; the wound care NP stated the wound should have been packed and Santyl should not have been applied to healthy skin or the peri-wound.
A resident admitted with CVA, DM2, and dysphagia was fed by G-tube, but the facility had only an order for tube feeding and no orders for G-tube site care, placement checks, or water flushes. The base line care plan was also not completed within 48 hours of admission, and staff interviews confirmed the missing orders were not identified at admission.
Failure to clean a reusable BP cuff between residents occurred during med pass when an MA used the same rolling BP machine on two residents without sanitizing the cuff first. The MA stated she should have cleaned it and that she did not have wipes on her cart; the DON stated staff were expected to clean reusable resident equipment between residents to prevent cross contamination. The facility policy on Standard Precautions required reusable equipment to be cleaned and reprocessed before use on another resident.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
Surveyors identified multiple deficiencies in kitchen sanitation and food storage, including improper cleaning of the ice machine and equipment, incomplete temperature logs for nourishment refrigerators, improper labeling and dating of food items, and failure to discard expired products. Staff did not consistently follow required cleaning procedures during food preparation, and cleaning schedules were not fully completed or documented.
The facility did not serve meals according to posted menus during two observed lunch services, with substitutions such as chicken fried steak for chicken fried chicken and pureed chicken for pureed pork chop, and failed to properly document these changes or update posted menus. Communication of substitutions was inconsistent, and required logs were incomplete, contrary to facility policy.
Surveyors found that meals were served bland, unappealing, and at improper temperatures, with beverages lacking ice and baked goods being dry and crumbly. Dietary staff pureed foods using water instead of nutritive liquids as required by recipes, and did not have recipes available during preparation. Staff interviews revealed confusion about proper procedures, and management had not ensured recipes were accessible to staff.
A resident with multiple medical conditions and intact cognition did not receive required quarterly statements for her personal trust fund, despite repeated requests. The Business Office Manager acknowledged the delay and inability to provide a current statement, citing challenges after a change in facility ownership. Facility policy and interviews confirmed that residents are entitled to timely financial statements, but this was not met, potentially affecting all residents with trust fund accounts.
A resident with multiple chronic conditions did not have their ADL care assistance levels documented in their comprehensive care plan, despite these needs being identified in the baseline care plan and initial MDS assessment. Staff interviews confirmed that this information should have been included, and facility policy requires comprehensive care plans to address all identified needs.
A resident with multiple chronic conditions did not have her care plan updated to reflect her current needs for meal assistance and her refusal of such assistance. Observations and staff interviews showed that she fed herself but needed help with meal setup, and her refusals were not documented in the care plan as required by facility policy. This failure placed her at risk of not receiving appropriate care.
Two residents with cognitive impairment and chronic pain conditions did not receive consistent evaluation of their pain medication effectiveness, despite care plan requirements and facility policy. Both residents were on scheduled pain medications, but staff failed to document daily assessments of pain control, as confirmed by interviews with the DON and ADM.
Staff failed to disinfect a blood pressure cuff between use on two residents with significant cognitive and physical impairments, despite facility policy and routine infection control education. This lapse was observed by surveyors and confirmed by staff and leadership interviews.
A medication cart was left unlocked and unattended in a hallway, allowing potential unauthorized access to medications. Med-Aide A, who was in a resident's room, was unaware of the cart's status despite having been trained to lock it when not in use. Interviews with staff and a review of facility policy confirmed that carts should be locked unless actively in use, highlighting a failure to adhere to established protocols.
The facility failed to honor residents' right to choose their attending physician after terminating the Medical Director agreement and changing the attending physician without notifying residents or their representatives. Interviews revealed that residents and their families were not informed of the change, and staff were also surprised by the decision. The facility could not provide evidence of notification letters being sent, and the letter they claimed to have sent only mentioned a change in the medical director.
The facility failed to secure two medication carts in the 300 hallway, leaving them unlocked and unattended for over an hour. Staff interviews confirmed that the carts should have been locked when not in direct use or view. The facility's Drug Diversion Policy requires all medications to be stored in locked compartments, but this was not adhered to, posing a risk of unauthorized access.
A facility failed to develop a comprehensive care plan within seven days for a resident with severe cognitive impairment and multiple diagnoses, including a hip fracture and chronic kidney disease. Despite an initiated care plan date, the file contained no information. Interviews revealed reliance on an MDS Consultant due to the absence of an MDS Coordinator, and the DON acknowledged the oversight. The resident reported not having a meeting to discuss her care plan.
Failure to Prevent Repeat Dining Room Fire Hazard
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent fire affecting all 44 residents. The deficiency centered on two fire-related incidents in the dining room and the facility’s response to them. The report states that after a fire in the dining room, the facility did not implement effective interventions to prevent a second fire in the same area. An Immediate Jeopardy was identified, and the facility remained out of compliance after the IJ was removed because the effectiveness of the corrective systems still needed evaluation. Resident #1 was a female resident with diagnoses including mild persistent asthma, COPD, allergic rhinitis, and anxiety disorder. Her MDS reflected a BIMS score of 10, indicating moderately impaired cognition. Her care plan identified an increased risk of impaired respiratory status related to asthma, and she had an order for ipratropium-albuterol nebulizer treatment. During the second smoke incident, Resident #1 stated she was in the dining room playing dominoes with two other residents when smoke appeared and staff asked them to leave. She reported that the smoke bothered her, that she had some difficulty breathing afterward, and that she used her nebulizer in her room. She also stated no one assessed her after she had been around the smoke. The Administrator stated that during the first incident, a dietary aide saw smoke and flames coming from a ceiling light in the dining room, left the area, and reported it to the Business Office Manager. The Administrator and Business Office Manager went toward the dining room while yelling code red, and the fire was extinguished before the fire department entered the facility. The Maintenance Supervisor stated the wrong wattage bulbs were in the light fixture and that the dining room lights were not checked after the first fire. The report also documents a later smoke incident in the corridor near the kitchen in the same general area, which the Administrator said was not investigated and was not reported to the fire department, HHSC, electricians, or the sprinkler/fire alarm company because there were no flames. Interviews with staff showed inconsistent understanding of fire response procedures, including uncertainty about how to use a fire extinguisher, how to activate emergency communication, and where residents should be moved during a fire. The Fire Marshal stated he was concerned about future fire safety, noted that the facility did everything wrong during the dining room fire, and said the fire department was not notified of the second fire.
Failure to Report Smoke Incident and Assess Resident After Exposure
Penalty
Summary
The facility failed to ensure that an alleged incident involving smoke from a light fixture was reported immediately and no later than 24 hours to the administrator and other required officials, including the State Agency. The Administrator stated the facility had an incident on 07/28/2026 with smoke coming from a light in the corridor near the kitchen, in the same area as a prior fire incident on 07/22/2026. She stated the facility did not complete an investigation of the smoke incident and did not contact the Fire Department, HHSC, electricians, or the sprinkler/fire alarm company because there were no flames, only smoke coming from the ceiling light. The Administrator stated the Dietary Manager smelled smoke and saw smoke coming from the ceiling, yelled code red, and the DON obtained a fire extinguisher but did not use it. Resident #1 stated she was in the dining room with two other residents when smoke was seen, and they were asked to leave. She reported having some difficulty breathing afterward, used her nebulizer in her room, and stated no one assessed her after the smoke exposure. The Administrator also stated the facility did not have a reporting policy or protocol and followed HHSC provider letter guidance, but did not provide the letter.
Unlocked housekeeping cart with unlabeled chemicals
Penalty
Summary
The facility failed to ensure Housekeeping Cart #1 was locked when it was left unattended on the 100 hall in front of room [ROOM NUMBER]. During observation, the cart’s chemical compartment was unlocked and contained micro-kill bleach, disinfectant cleaner, and two unlabeled bottles filled with chemicals. Housekeeper A was not standing near the cart at the time of the observation and was inside room [ROOM NUMBER] with the door partially closed before returning to the cart a few minutes later. During interview, Housekeeper A stated the cart was expected to be locked anytime she walked away from it and that all chemical bottles were required to have labels. The Housekeeping Supervisor stated all bottles with chemicals were expected to be labeled and all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Administrator stated the cart was expected to be locked at all times when the housekeeper was not obtaining an item from it, and that all chemical bottles were expected to be labeled with the correct chemical name and directions for use. Record review of the facility policy titled, Facilities Hazardous Areas, Devices and Equipment, reflected hazardous areas, devices, and equipment were to be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication Cart #1 was found not locked and unattended at the 300 hall nurses' station during an observation, with the cart facing toward the hall area and no staff present in the hall or near the nurses' station at that time. The report states that Med Aide B later exited a room on 300 hall and walked toward the nurses' station. The facility's policy required medications and biologicals to be stored in locked compartments and for carts not to be left unattended if open or otherwise potentially available to others. During interviews, LVN B stated staff were trained to lock medication carts any time they walked away from them and that the nurse or medication aide working on the cart was responsible for locking it. The DON and Administrator both stated medication carts were expected to be locked whenever the nurse or medication aide was not standing in front of them, and that the assigned nurse or medication aide was responsible for ensuring the cart was locked. The DON and Administrator stated they did not know why LVN B left the medication cart unlocked.
Verbal Abuse of a Resident by CNA
Penalty
Summary
The facility failed to ensure a resident was protected from verbal abuse by staff. The resident was a cognitively intact female with diagnoses including major depressive disorder, anxiety, and post-traumatic stress disorder. Her quarterly MDS reflected a BIMS score of 13, and her care plan did not include entries related to verbal abuse or her psychological diagnoses. Psychiatry notes reflected she had no behaviors and was being seen for major depressive disorder and PTSD. The incident occurred when the resident went to the nurses’ station to ask for medication and observed a CNA asleep there with her head wrapped and resting on the desk. After the resident reported this to the RN, the RN told the CNA she could not sleep at the nurses’ station or while on duty. The CNA then went to the resident’s room and yelled at her, pointed her finger in her face, called her a liar, and told her she did not like her. The RN intervened and told the CNA to leave the area, then contacted the DON. The facility’s self-report stated the allegation was first learned that evening, and the investigation confirmed the allegation. The resident later stated the confrontation triggered her PTSD and that the CNA got right in her face and threatened her. A neighboring resident reported hearing shouting for 7 to 10 minutes and said the staff member was yelling at the resident and calling her a liar. The CNA denied using profanity or abusive language, but acknowledged that confronting the resident was not an appropriate response and that she should have gone to a supervisor instead. The facility’s investigation concluded the allegation was substantiated, and the CNA was terminated for misconduct.
Failure to Care Plan PTSD, Depression, and Psych Services
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one resident with diagnoses of PTSD and major depressive disorder. The resident's face sheet reflected admission with major depressive disorder and anxiety, and the quarterly MDS showed a BIMS score of 13, indicating she was cognitively intact, with no behaviors identified. Her consolidated physician orders included Lexapro and trazodone HCL for major depressive disorder, and psychiatry progress notes reflected that she was being seen by psychiatry and was diagnosed with major depressive disorder and PTSD. Review of the resident's comprehensive care plan showed no entries related to her PTSD, major depression, antidepressant medication use, or psychiatric services. During observation and interview, the resident was alert and oriented in her room and stated she had PTSD from a bad relationship with her family and that yelling and aggressive behaviors were triggers for her; she also stated she was seeing psych services. The MDS RN stated the resident was not care planned for her psychological diagnoses or treatment and should be, and the RNC stated care plans should include all problems and be updated when needs change to accurately reflect residents' needs.
Failure to Provide Ongoing Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices for facility-sponsored group activities, individual activities, and independent activities for two residents reviewed. Resident #28 had diagnoses including major depressive disorder, osteoarthritis, and generalized muscle weakness, and his MDS assessments showed intact cognition with BIMS scores of 15 and 14. His activity preferences included doing favorite activities, keeping up with the news, and going outside for fresh air. His care plan noted that he did not want to attend group activities, enjoyed working on puzzles in his room, visiting with other residents, and watching sports on television, with an intervention to help him glue his puzzles. Record review showed no activity participation records for Resident #28 for November 2025, December 2025, or January 1 through January 6, 2026. During observation and interview, he was sitting in his room watching the news on television. He stated he was bored a lot, wished there were more activities, and wanted more things for men to do as a group, especially at night and on weekends. He said he enjoyed jigsaw puzzles but wanted something new, and he stated no one had discussed his activity preferences with him in a long time. Resident #40 had diagnoses including major depressive disorder, muscle weakness, and Alzheimer’s disease. Her MDS assessments reflected BIMS scores of 13 and 15, indicating intact cognition. Her documented activity preferences included group activities, favorite activities, religious services or practices, music, books or magazines, and going outside for fresh air. Her care plan stated she was active in groups and independent activities, with preferences for church, music, Bible study, crafts, and food-related activities, and interventions included keeping dominoes available and providing appropriate activities. Record review showed no activity participation records for Resident #40 for November 2025, December 2025, or January 1 through January 6, 2026. During observation and interview, she was sitting in her room watching the news on television. She stated there were not many activities in the facility, that she was bored, and that she was not aware of any activities in the past month. She said she preferred mass on Sundays, had not been interviewed about her activity preferences for over 4 months, and wanted to speak privately with staff about her changing preferences rather than discuss them in a group meeting. The Activity Director stated she did not have participation records for either resident during the cited months and said she had begun working at the facility on 12/08/2025 and was in the process of interviewing residents about activity preferences. The Administrator stated she expected a variety of activities for all residents, that each resident’s preferences needed to be assessed and care plans revised, and that activities such as independent, in-room, and group activities were to be documented on participation records.
Unlocked Medication Carts
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments for 2 of 3 medication carts reviewed. On 01/06/2026 at 7:04 a.m., Medication Cart #1 on unit 3 was observed with the locking mechanism protruding outward, indicating it was unlocked, while RN C was nearby and did not initially see the cart was unsecured. RN C then locked the cart immediately. She stated all medication carts were to be locked except when a nurse was obtaining medications, and that the cart contained all types of physician-prescribed medications except narcotics. On 01/07/2026 at 8:35 a.m., Medication Cart #2 was also observed with the locking mechanism protruding outward, indicating it was unlocked, while MA D was in a resident room and then walked to the cart. MA D stated the cart was supposed to always be locked except when dispensing medications and that she was responsible for keeping it secure; she also stated the cart contained all other physician-prescribed medications except narcotics. The ADON and DON both stated their expectation was that medication carts be locked when not in use, and the facility policy stated all medications and biologicals are to be stored in locked compartments under proper temperature, humidity, and light controls with access limited to authorized personnel.
Failure to Protect Resident Medical Information on Medication Cart Laptop
Penalty
Summary
The facility failed to ensure a resident’s personal privacy and confidentiality of medical records when a medication aide left a laptop on the medication cart unattended in the hallway with the privacy screen unlocked and the resident’s medical information visible. During observation, the medication cart was parked near the resident’s room, and the laptop screen displayed the resident’s medications and other medical information while the aide was in the resident’s room for about 3 minutes. The resident reviewed had diagnoses including major depressive disorder, muscle weakness, Alzheimer’s disease, type 2 diabetes, and COPD, and had a BIMS score of 13 indicating intact cognition. During interview, the medication aide stated she forgot to close the resident’s information and acknowledged she was expected to place the computer screen on privacy whenever she walked away from the medication cart. The Assistant Director of Nurses and the Director of Nurses both stated all computers on medication carts were expected to be locked when not in use and that unauthorized people could view resident medical information if the screen was left open. The facility’s resident rights in-service dated 08/08/2024 to 08/14/2024 stated residents have a right to personal privacy and confidentiality of personal and medical records.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for 2 of 4 residents reviewed. Resident #53 was admitted with diagnoses of cerebral infarction, type 2 diabetes mellitus, and dysphagia, and the admission assessment reflected that he was oriented x3 and fed by gastrostomy tube. Review of the electronic medical record on 01/08/2026 showed no baseline care plan had been completed within 48 hours of admission. During interview, the ADON stated Resident #53 should have had orders for G-tube care and maintenance immediately on admission and that these should have been included on the baseline care plan. Resident #55 was admitted with diagnoses of atherosclerotic heart disease, type 2 diabetes mellitus, morbid obesity, and hypertension. The admission assessment reflected a BIMS score of 6, indicating moderate cognitive impairment, and the resident was assessed to have wounds. Review of the electronic medical record showed no baseline care plan had been completed. During interview, the DON stated the baseline care plan may not have been started yet, acknowledged that the MDS coordinator was new, and confirmed after reviewing the EMR that no baseline care plan was present for Resident #55. The DON also stated she knew baseline care plans should be completed within 48 hours of admission and that PCC showed triggered items already.
Care Plans Missing Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that reflected current needs for 2 of 7 residents reviewed. For one resident, the record showed diagnoses including metabolic encephalopathy, hypokalemia, cerebral infarction, and type II diabetes, with a quarterly MDS indicating severe cognitive impairment and an indwelling catheter. A physician order dated 9/18/2025 required Enhanced Barrier Precautions (EBP), but the resident’s comprehensive care plan, last reviewed on 09/15/2025 and revised on 10/14/2025, only addressed the indwelling catheter and did not include EBP as a focus area or intervention. For the second resident, the record showed diagnoses including nontraumatic intracerebral hemorrhage, dysphagia, and other encephalopathy. The quarterly MDS indicated full cognition and identified a feeding tube. A physician order upon admission required EBP, but the resident’s comprehensive care plan, completed on 08/07/2025 with a scheduled review date left incomplete, addressed tube feeding and related complications only and did not include EBP as a focus area or intervention. During interviews, the MDS nurse stated that responsibility for ensuring EBP was included in comprehensive care plans rested with the MDS nurse, ADON, DON, nursing, and social work, and that EBP should be incorporated into the care plan when identified. The ADON stated that residents with catheters, G-tubes, tracheostomies, wounds, or IVs are assessed for EBP and that it should be included in the comprehensive care plan when identified. The DON acknowledged that the EBP interventions were missed on the care plans. Facility policy stated that comprehensive, person-centered care plans must include measurable objectives and timetables, be developed within required timeframes, and be revised when resident conditions change and at least quarterly.
Improper Treatment of an Unstageable Sacral Pressure Ulcer
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for a resident with an unstageable sacral pressure ulcer that was present on admission/reentry. The resident had a history of unspecified intracranial injury, schizophrenia, diabetes mellitus type II, intellectual disabilities, severe cognitive impairment, total dependence for ADLs, and hospice care. The resident’s care plan identified an unstageable pressure ulcer to the coccyx related to immobility and directed staff to administer medications and treatments as ordered. A wound assessment documented the sacral wound as an unstageable end-of-life skin failure measuring 9.40 cm by 4.8 cm by 0.4 cm, with 30% slough and 30% eschar. The documented treatment at that time was cleansing with wound cleanser, applying Dakins-moistened fluffed gauze, and covering with a superabsorbent dressing. The physician order later reflected cleansing the sacrum with wound cleanser, patting dry, applying Dakins-moistened fluffed gauze to the base of the wound, and securing it with a superabsorbent dressing twice daily, with normal saline permitted if Dakins was unavailable. During observation, an LVN gathered wound care supplies that included wound cleanser, Santyl, betadine, and bordered gauze dressings. The LVN removed the prior dressing, observed the wound had substantial depth with undermining, slough, necrotic wound edges, and red, excoriated peri-wound tissue, then cleaned the wound edges and peri-wound with wound cleanser. She applied Santyl to the wound edges and peri-wound using her finger, changed gloves, and covered the wound with a bordered gauze dressing. She did not pack the wound and did not use a superabsorbent dressing. In interview, the LVN stated she did not pack the wound because Dakins solution was unavailable and said she believed the order meant to use a dry dressing if Dakins was not available. The wound care NP stated the wound should have been packed, that normal saline or wound cleanser-moistened gauze would have been an appropriate substitute if Dakins was unavailable, and that Santyl should not have been applied to healthy skin or the peri-wound. The DON and RNC also stated the treatment should have been done as ordered and that Santyl should not be used on healthy skin or the peri-wound.
Missing G-tube Care Orders and Care Plan
Penalty
Summary
Resident #53, a male admitted with diagnoses of cerebral infarction, diabetes mellitus type 2, and dysphagia, was assessed on admission as oriented to person, place, and time and was fed by gastrostomy tube. The facility failed to complete a base line care plan within 48 hours of admission, and the consolidated physician’s orders dated 01/05/2026 included only an order for Glucerna 1.5 via G-tube four times daily for nutrition. The record contained no other physician’s orders for G-tube care, including treatment of the G-tube site, tube placement checks, or water flushes. During observation and interview, the resident stated he had been at the facility since the prior day and was receiving feeds through his G-tube. Staff interviews confirmed the resident should have had orders for G-tube care and maintenance immediately on admission, and the admitting LVN stated she did not see orders for placement checks, flushing, or site treatment.
Failure to Clean Reusable Blood Pressure Cuff Between Residents
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when MA B did not sanitize a reusable blood pressure cuff between residents during medication pass. On 01/06/2026 at 7:38 AM, MA B prepared to administer medications to Resident #56, a male resident with congestive heart failure, type II diabetes mellitus, and hypertension, and took his blood pressure using a rolling blood pressure machine from the hall without cleaning the cuff first. Later that morning at 8:02 AM, MA B used the same blood pressure machine on Resident #27, a male resident with hypertension, and again took his blood pressure without cleaning the cuff. During interview, MA B stated she should have cleaned the cuff before using it on both residents and said she did not have wipes on her cart. The DON stated staff were expected to clean reusable resident equipment between residents to prevent cross contamination. The facility policy on Standard Precautions stated reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pest infestations within the facility. No additional details regarding specific residents, staff, or observed pests were provided in the report.
Deficient Food Storage, Sanitation, and Preparation Practices Identified in Kitchen
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and sanitation practices in the kitchen, as observed during the annual survey. Surveyors noted multiple sanitation issues, including an ice scoop receptacle containing standing water with visible black and brown debris, a broken lid, and mold growth on the inside of the ice machine door and seal. Clean dishes and food storage bins were stacked while still wet, and the dish machine sanitizer levels were not verified to be within the required range. The walk-in cooler floor was found to have food debris, and the nourishment refrigerator temperature logs were incomplete, with several entries missing. Food storage practices were also deficient. Several opened packages of dry goods, such as noodles and cereal, were not properly sealed, labeled, or dated, and some items were found with unclear or missing receipt, open, or discard dates. Expired food products, including granola and popcorn, were present in storage areas. Additionally, a scoop was left inside a dry supply bin of oatmeal, and a bag of shredded cheese in the walk-in cooler was not sealed properly. The baking ingredient shelf contained an opened package of brownie mix with an unclear date, and the walk-in cooler floor was not clean. Food preparation procedures were not followed according to professional standards. During meal preparation, a staff member rinsed a blender under hot water between uses for different food items, rather than washing and sanitizing it as required. The staff member admitted to skipping the proper cleaning process due to the presence of a state surveyor and a desire to expedite the process. Interviews with staff and management confirmed that labeling, dating, and cleaning responsibilities were not consistently met, and cleaning schedules for various kitchen areas and equipment were incomplete or not followed as documented.
Failure to Follow and Document Menu Substitutions
Penalty
Summary
The facility failed to ensure that meals served matched the posted menus and met the nutritional needs of residents according to established guidelines. During two observed lunch meal services, the food items served did not correspond with the posted menus. On one occasion, chicken fried steak was served instead of the posted chicken fried chicken, and on another, pureed chicken was provided instead of pureed pork chop, with additional discrepancies in dessert items and the absence of pureed cornbread for residents on pureed diets. These substitutions were not properly documented in the substitution log, and the posted menus were not updated to reflect the changes. Interviews with the Dietary Manager and the Administrator revealed that while substitutions were sometimes communicated verbally or on a dry erase board, the required documentation and menu updates were not consistently completed. The Dietary Manager acknowledged that the substitution log was not filled out for certain changes due to time constraints, and the Administrator emphasized the importance of accurate posted menus for resident awareness. Review of facility policy confirmed that all menu changes should be recorded and posted, but this procedure was not followed during the observed meal services.
Failure to Serve Palatable and Nutritive Meals Due to Improper Food Preparation
Penalty
Summary
The facility failed to ensure that food and beverages served were palatable, attractive, and prepared in a manner that conserved nutritive value, flavor, and appearance. During observations of a kitchen test tray, foods were found to be bland, unappealing, and inedible, with beverages lacking ice and baked items such as cornbread and cake being very dry and crumbly. Additionally, dietary staff were observed pureeing foods such as vanilla cake, garlic bread, meat sauce, and pasta with water instead of using liquids with nutritive value like milk, broth, or juice, as specified in the facility's recipes. Staff did not have recipes available during food preparation and were unsure about the impact of using water on the nutritive value of pureed foods. Interviews with dietary staff and management revealed a lack of clarity and adherence to proper pureeing procedures, with some staff unaware of the appropriate liquids to use and others relying on water due to convenience or lack of recipe access. The dietary manager acknowledged responsibility for providing recipes but had not ensured they were printed and available for staff. Review of the facility's recipes and training records indicated that the correct procedures were outlined, but staff were not consistently following them during meal preparation.
Failure to Provide Quarterly Trust Fund Statements to Resident
Penalty
Summary
The facility failed to provide a quarterly trust fund statement to a resident with intact cognition who had been requesting information about her personal funds for several months. Despite the resident's repeated requests, the Business Office Manager (BOM) did not provide the required financial statements, and the last statement given was not up to date due to challenges following a change in facility ownership. The BOM acknowledged that the statement for the most recent quarter had been printed but not delivered, and could not provide a reason for the ongoing delay. The resident maintained her own records and was approached by the BOM to compare them with the facility's records, but still did not receive the official statement as required by policy. Interviews with both the BOM and the Administrator confirmed that residents are entitled to quarterly and upon-request statements of their trust fund accounts, and that failure to provide these statements could result in residents being unaware of their account balances. Facility policy and resident rights documents reviewed also confirmed the requirement for residents to have access to their financial records and statements. The deficiency was identified for one resident reviewed, but the practice had the potential to affect any resident with a trust fund account managed by the facility.
Failure to Document ADL Needs in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulation. Specifically, the comprehensive care plan for a female resident with multiple complex diagnoses, including cerebral infarction, diabetes, major depressive disorder, and chronic heart and kidney conditions, did not include documentation of her Activities of Daily Living (ADL) care assistance levels. This omission was identified through a review of the resident's records, which showed that while the baseline care plan detailed the resident's ADL needs, these were not carried over into the comprehensive care plan. The initial Minimum Data Set (MDS) assessment indicated the resident required varying levels of assistance for ADLs such as toileting, bathing, dressing, eating, and personal hygiene. The baseline care plan reflected these needs, specifying the degree of assistance required for each activity. However, the comprehensive care plan, developed after the baseline, failed to document these ADL care requirements, leaving a gap in the resident's documented plan of care. Interviews with facility staff, including the MDS Coordinator and the Administrator, confirmed that ADL care information should have been included in the comprehensive care plan and that its absence could negatively affect resident care. The facility's policy requires that comprehensive care plans include measurable objectives and timeframes to address all identified needs from the assessment, but this was not followed in the resident's case.
Failure to Update Care Plan for Resident's Meal Assistance Needs and Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and time frames to address a resident's mental and psychosocial needs. Specifically, the care plan for a female resident with multiple diagnoses, including Parkinson's disease, anxiety disorder, diabetes, dementia, and a history of falls and cancer, was not updated to reflect her current needs for meal assistance and her refusal of such assistance. The care plan, last revised several months prior, indicated that the resident required staff assistance to eat, but did not address her preferences or refusals regarding meal assistance. Observations revealed that the resident was able to feed herself but required assistance with meal setup, such as unwrapping food items. Staff interviews confirmed that the resident often refused assistance and preferred to feed herself, with one CNA stating that only setup help was needed. The MDS Coordinator acknowledged that refusals should be documented and reflected in the care plan, and that failure to do so could negatively impact the resident's care. The facility's policy requires that care plans be comprehensive, person-centered, and updated to reflect the resident's current needs and preferences, including any refusals of care. However, the care plan for this resident did not include interventions or documentation related to her refusal of meal assistance, nor did it specify the type of assistance she required. This omission placed the resident at risk of not receiving appropriate care and services to maintain her highest practical well-being.
Failure to Evaluate Effectiveness of Pain Management for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not evaluating the effectiveness of their prescribed pain medications as required by professional standards, the residents' care plans, and facility policy. For one resident with severe cognitive impairment and diagnoses including osteoarthritis and post laminectomy syndrome, records showed he was receiving scheduled pain medications, but there were no documented assessments of medication effectiveness for the months reviewed. The resident's care plan specifically required evaluation of pain medication effectiveness every shift, but this was not completed. The resident reported occasional pain but stated it was controlled at the time of interview. Another resident with moderate cognitive impairment, osteoarthritis, and a history of amputation was also receiving scheduled pain medication. Although his care plan required monitoring and reporting of pain, there were no documented daily assessments of pain medication effectiveness. This resident reported occasional phantom pain but stated his pain was controlled at the time of interview. Interviews with the DON and ADM confirmed that routine pain monitoring was expected and necessary to ensure adequate pain management, but this was not consistently performed or documented for the residents in question.
Failure to Sanitize Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not properly sanitizing a blood pressure cuff between use on two residents. Specifically, an LVN did not disinfect the blood pressure cuff when moving from one resident to another while administering medications and obtaining blood pressure readings. This was directly observed by surveyors, and both the LVN and facility leadership acknowledged that the cuff should have been cleaned between residents, in accordance with facility policy and standard precautions. The two residents involved had significant medical histories, including cognitive impairments, diabetes, dementia, and physical limitations requiring staff assistance with activities of daily living. Facility records and care plans indicated their vulnerability and need for careful infection control. Despite routine in-service education on infection control, the failure to sanitize shared equipment was observed and confirmed through staff interviews and review of facility policy, which mandates cleaning and disinfection of reusable equipment between residents.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an incident involving Medication Cart #1. On the morning of August 24, 2024, the medication cart was observed to be unattended and unlocked in the hallway outside a resident's room. Med-Aide A was inside the resident's room with her back to the door, unaware that the cart was unsecured. Surveyor B was able to open and close the drawers of the cart without Med-Aide A noticing until the second drawer was opened. This lapse in security could have allowed unauthorized access to medications. Interviews with Med-Aide A, LVN C, the Director of Nurses, and the Administrator revealed a misunderstanding and lack of adherence to the facility's policy regarding medication cart security. Med-Aide A believed it was acceptable to leave the cart unlocked if the drawers were facing the resident's room, despite having been in-serviced on the importance of locking the cart when not in use. Both LVN C and the Director of Nurses confirmed that the expectation was for medication carts to be locked unless a nurse or med-aide was actively administering medications. The Administrator reiterated this policy, emphasizing that there were no exceptions. A review of the facility's policy on medication use administration, last updated in May 2023, confirmed that medication carts must be locked when not in use or when not within the sight of licensed staff. Additionally, a record review of a nursing in-service from July 2024 showed that Med-Aide A had attended training that included instructions not to leave medication carts unlocked when unattended. Despite this training, the incident on August 24, 2024, demonstrated a failure to comply with these protocols, potentially compromising the safety of residents and others in the facility.
Failure to Honor Residents' Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting all residents reviewed for this right. The issue arose when the facility terminated their Medical Director agreement and changed the attending physician without notifying the residents or their representatives. This change took effect on July 4, 2024, and was not communicated to the residents or their families, leaving them without the opportunity to select their preferred physician. Interviews with residents and their family members revealed that they were not informed of the change in attending physician. For instance, one resident's family member, who was the responsible party, stated that they were not notified of the change and were not given the option to choose another physician. Another family member expressed concern over the lack of notification and the inability to select a new attending physician, especially since the previous physician had an established relationship with the resident. Staff interviews further confirmed the lack of communication regarding the change. A medical assistant mentioned that the change was a surprise to both staff and residents, and the previous attending physician and nurse practitioner were not informed in advance, preventing a proper transfer of care. The Director of Nursing, although new to the role, stated that residents should have been informed of the change and had the right to choose their doctor. The facility's administration could not provide evidence of notification letters being sent to residents or their families, and the letter they claimed to have sent only mentioned a change in the medical director, not the attending physician.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medications were stored in locked compartments for two medication carts located in the 300 hallway. During an observation, it was noted that a multi-drawer, rollable medication cart was left unlocked in front of the nurse's station, with staff members present but not directly monitoring the cart. This situation persisted for over an hour, during which time a second medication cart was also left unlocked in the same area. Interviews with staff, including LVN A, RN C, and the DON, confirmed that the medication carts should have been locked when not in direct use or view. LVN A acknowledged that the carts were not secured as required, and the DON emphasized the importance of keeping carts locked to prevent unauthorized access by residents or visitors, particularly given the presence of residents with dementia in the facility. The facility's Drug Diversion Policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. Despite this policy, the unlocked carts were left unattended, posing a risk of unauthorized access to medications. The Interim Administrator reiterated the necessity of locking medication carts immediately after use to prevent potential adverse reactions from unauthorized access.
Failure to Develop Timely Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days after completing the comprehensive MDS assessment for one resident. This resident, an elderly female, was admitted with diagnoses including an intertrochanteric fracture of the right femur, malignant neoplasm of an unspecified ovary, and chronic kidney disease. The MDS Admission Assessment indicated severe cognitive impairment and the need for additional care due to an ostomy. Despite an initiated care plan date, the comprehensive care plan file contained no information, indicating a lack of completion. Interviews with the Director of Nursing (DON), MDS Consultant, and Interim Administrator revealed that the facility was utilizing an MDS Consultant due to the absence of an MDS Coordinator. The DON acknowledged the failure to complete the care plan in the required timeframe, emphasizing the importance of comprehensive care plans for meeting residents' needs. The MDS Consultant confirmed the facility's responsibility to complete the care plan within seven days, and the Interim Administrator reiterated that care plans should be a team effort. The resident reported not having a meeting to discuss and approve her care plan, further highlighting the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 84 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Caldwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copperas Hollow Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Rockdale Estates & Rehabilitation | 18.4 mi | ★★★★★ | 5 | 0 |
| Crossroads Nursing & Rehabilitation | 22.8 mi | ★★★★★ | 10 | 0 |
| Lampstand Nursing And Rehabilitation | 24.3 mi | ★★★★★ | 22 | 0 |
| Avir At Bryan | 24.5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Caldwell.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.