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Complaint Investigation

Avir At Caldwell

August 26, 2025 · Caldwell, TX · 1022 Presidential Corridor Hwy 21 E
Citations 2
CMS Rating 1/5
Beds 112
Provider ID 675885
Healthcare Facility
Avir At Caldwell
Caldwell, TX  ·  View full profile →
Inspection Summary

Avir at Caldwell in Caldwell, TX — inspection on August 26, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Immediate Jeopardy

During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation.

Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance.

Review of an in-service entitled Pest Control and Resident Assessment/Safety, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy.

The in-service also covered abuse and neglect, accurate skin assessments, and nursing documentation.

Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm).

Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (including bites).

Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not.

Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed.

Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on abuse and neglect.

Review of an in-service, dated 08/25/25 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on safety and supervision of residents.

Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite.[TF1] Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy.

Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all nurses were in-serviced on skin assessments: Skin assessments should be completed no less than weekly and should reflect all skin impairments and documented in the resident's chart and notification of any new skin impairments should be communicated to the RP, physician, and DON.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed.

While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Caldwell

1022 Presidential Corridor Hwy 21 E Caldwell, TX 77836

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited Avir at Caldwell in Caldwell, TX for a deficiency under regulatory tag F-F0925 during a complaint investigation conducted on 2025-08-26.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Scope/Severity Level K: pattern, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 2 deficiencies cited during this inspection of Avir at Caldwell.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-08-27.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Caldwell, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Caldwell or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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