Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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 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.
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
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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 34 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
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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 | — | 0 | 0 |
| Crossroads Nursing & Rehabilitation | 22.8 mi | — | 9 | 0 |
| Lampstand Nursing And Rehabilitation | 24.3 mi | — | 5 | 2 |
| St. Joseph Manor | 24.5 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.