Avir at Caldwell

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent fire affecting 44 of 44 Residents. The facility failed to implement effective interventions to prevent a second fire on [DATE] after a fire on [DATE] in the dining room. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:37 pm. While the IJ was removed on [DATE] at 3:45 pm, the facility remained out of compliance at a scope of widespread and severity level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for injury and even death.

Inspectors wroteBased on interview and record review; the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (Including the State Agency) for incidents involving the environment for 44 of 44 residents. The facility failed to report smoke coming from the light fixture on 07/28/2026 in the dining room and assess Resident #1 after the smoke in the dining room on 07/28/2026. This failure could place residents at risk for injury or even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accidents hazards as was possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards. The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage and labeling. The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from verbal abuse from staff for 1 of 5 residents (Residents #1) reviewed for verbal abuse. The facility failed to ensure Resident #1 was protected from verbal abuse on 04/25/2026 when CNA A confronted Resident #1 and proceeded to yell and threaten her after Resident #1 reported her for sleeping at the nurse's station. This failure could place residents at risk of fear, depression, intimidation, and diminished quality of life.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychological well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 comprehensive care plan reflected a plan of care for her diagnoses of PTSD and major depressive disorder that included medication management and psychiatric services. This failure could place residents at risk of increased symptoms, lack of treatment or diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 (Residents #28 and #40) of 10 residents reviewed for activities. The facility failed to provide activities for Resident #28 and Resident #40 for the months of November and December 2025. This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 3 medication carts (Medication Cart #1 and Medication Cart #2) reviewed for medication storage. The facility failed to ensure Medication Cart #1 and Medication Cart #2 were locked and medications were secured and not accessible to other staff, residents, or visitorsThis failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 3 residents (Resident #40) reviewed for personal privacy and confidentiality of records The facility failed to ensure MA D provided privacy by locking the privacy screen on the laptop and leaving the laptop unattended in the hallway on the medication cart which displayed Resident #40's medical information on 01/07/2026. This failure could place residents at risk of having medical information, personal or care instructions exposed to others and misuse of personal information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the residents, for 2 of four residents (Resident #53 and Resident #55) reviewed for baseline care plans. A) The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #53. B) The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #55. This failure could place residents at risk of not receiving necessary care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for 2 of 7 residents (Residents #1 and #5) reviewed for care plans. The facility failed to ensure Resident #1's care plan was comprehensive and updated to reflect Resident #1 was on Enhanced Barrier Precautions. The facility failed to ensure Resident #5's care plan was comprehensive and updated to reflect Resident #1 was on Enhanced Barrier Precautions. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one of three residents reviewed for pressure ulcers. (Resident #46) The facility failed to ensure Resident #46's unavoidable sacral unstageable pressure ulcer (a severe type of wound where the full depth cannot be assessed due to the presence of necrotic tissue, slough or eschar covering the wound base) treatment was done per physician orders. These failures could cause severe pain, and lead to systemic infections for residents that have or are at risk for pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is fed by enteral means received appropriate treatment and services for 1 of 1 resident reviewed for feeding tubes. (Resident #53) The facility failed to ensure Resident #53 had physician's orders for care of his gastrostomy tube site treatment, tube placement checks, or water flushes. The facility further failed to have a plan of care in place for Resident #53's gastrostomy tube. This failure placed residents with tube feedings at risk of injury, pain, and/or significant changes in condition. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 25 residents (Resident #56 and Resident #27) reviewed for infection control practices during medication pass. MA B failed to sanitize the blood pressure cuff during medication pass before and after using it on Resident #56 and Resident #27. These failures could place residents at risk for cross-contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: 1. Ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused large papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet.2. Accurately document in Resident #1's EMR regarding the presence of ants/ant bites on his body.3. Ensure Resident #1 was moved to a different room after ants were found on his body on 08/13/25 until 08/15/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one (Resident #1) of five residents reviewed for physical environment. The facility failed to ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, 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. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the ice machine scoop receptacle, storing, and stacking wet dishes on top of each other, ensure dish machine sanitizer levels are within the required range, utilization of an ice scoop receptacle with a lid, cleaning the walk-in cooler floor of food debris) for facility annual survey 10/14/2024-10/16/2024. 2. The facility failed to ensure temperature logs were being completed for nourishment refrigerators for the facility annual survey 10/14/2024-10/16/2024. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Monday, 10/14/2024 and Tuesday, 10/15/2024. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The kitchen test tray of the lunch meal on 10/15/2024, the foods were bland, unappealing, and inedible. The kitchen test tray beverages of iced tea and iced water lacked ice. The kitchen test tray's cornbread and cake were both very dry and crumbly. 2. The facility failed to follow the puree diet recipe. The pureed garlic bread, pureed vanilla cake, pureed meat sauce and pureed pasta were all mixed with water during the puree process for the lunch meal on 10/15/24 and 10/16/2024 instead of something with nutritive value such as broth, milk, or juice. [...]

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to ensure a quarterly trust fund statement was provided to the resident for 1 (Resident # 6) of 3 residents reviewed for personal funds. The facility failed to provide quarterly statements to the resident receiving insurance funds. The failed practice had the potential to affect any resident who had a trust fund account managed by the facility.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Residents #41) reviewed for comprehensive care plans. Resident #41's comprehensive care plan did not reflect Resident #41's ADL care requirements listed in their baseline care plan. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 1 of 10 residents (Resident #3) reviewed for care plans. The facility failed to update Resident #3's care plan to reflect current needs for meal assistance and refusal of meal assistance. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 6 (Resident is #7, and Residents #32) residents reviewed for pain management. The facility failed to ensure Resident #7, and Resident #32 had effective pain management by not evaluating effectiveness of current pain medications. This failure could place resident at risk for increased pain causing undo suffering.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 4 residents (Resident #38) reviewed for unnecessary medications. The facility failed to ensure Resident #38's GDR recommended by the pharmacist consultant was followed up on for 6 months for Resident #38's antipsychotic, antianxiety, and antidepressant medications. This failure could place residents receiving antipsychotic medications at risk for adverse health consequences.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 6 (Resident #11, and Residents #15) residents reviewed for infection control. LVN B failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Residents #11 and #15. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals, were in locked compartments and inaccessible to unauthorized staff, visitors , and residents for 1 of 2 medication carts (Medication Cart #1) reviewed for medication storage. The facility failed to prevent Medication Cart #1 from 8:30 AM to 8:40 AM being unattended and unlocked on the 400 hall on 08/24/2024. This failure could allow residents unsupervised access to prescription and over-the-counter medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the residents right to choose his or her attending physician for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) and the entire facility reviewed for resident rights. The facility did not honor any residents right to choose his/her primary care physician as his/her attending physician after the facility terminated their Medical Director agreement and changed the attending physician without notice to the residents or their representatives effective 07/04/24. This deficient practice could place residents at risk of decreased quality of care and treatment due to their lack of free choice for their attending physician care while in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were stored in a locked compartment for 2 (300 Hallway) of 4 medication carts reviewed for medication storage in the facility. The facility failed to ensure that both medication carts for the 300-hallway remained locked at all times when not in use and direct view of staff. This failure could result in harm due to unauthorized access to medications by residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after the comprehensive MDS assessment was completed for one (Resident #1) of five residents reviewed for comprehensive care plans. The facility failed to complete a comprehensive person-centered care plan to address Resident #1's needs within seven days after the comprehensive MDS assessment was completed. This failure could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 3 of 9 residents (Resident #21, Resident #31, and Resident # 41) reviewed for call lights in that: Resident #21's, and Resident #31's call lights were on the floor and Resident #41's call light was in drawer and not in reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation , interview, and record review the facility failed to ensure residents had the right to personal privacy of his or her personal male and right to send and promptly receive unopened mail and other letters, packages, materials delivery to the facility for residents for one of one facility. The facility failed to implemet a system for delivering mail received on Saturdays to residents the date of receipt and instead of distributed mail received Saturday on Mondays. This failure could place the residents in facility at risk of not receiving mail in a prompt manner and could result in a decline in the residents' psychosocial well-being and cause them to feel disconnected from family, friends, and current events.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of fifteen residents (Resident # 21, Resident #18, Resident #31 and Resident #13) reviewed for quality of life. The facility failed to ensure Resident#21s, Resident #18's, Resident #31's, and Resident #13's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that menus were developed and followed to meet resident nutritional, religious, cultural, or ethnic needs, and resident choices in accordance with the national guidelines for one of one facility. The facility failed to provide residents in the facility with a varied menu, having utilized the same menu for the facility for over a year. This failure could place the residents in the facility at risk of reduced appetite resulting in their nutritional needs not being met and / or weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for three of fifteen residents reviewed for care plans. (Resident #20, #22, and #30) A) The facility failed to ensure Resident #20's Comprehensive Care Plan reflected a revision of decline in cognitive abilities that impact a person's ability to do everyday activities. B) The facility failed to ensure Resident #22's Comprehensive Care Plan reflected a revision of Resident #22 had shortness of breath. C) The facility failed to ensure Resident #30's Comprehensive Care Plan reflected a revision of his plan of care to reflect Resident #30's current skin condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 of 2 Residents (Resident #20 and #29) reviewed for respiratory care. The facility failed to ensure that Resident #29's suction equipment was properly cleaned and dated. 1. Failed to date suction tubing and canister. 2. Failed to bag yaunker. 3. Failed to clean suction tubing. The facility failed to replace Resident #20's oxygen tubing. These failures could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates 2 of 3 medication carts reviewed for medication storage. -The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 08/16/2023 at 2:31 PM revealed the facility Unit 2 Medication cart with a bottle of Ferrous Gluconate 324mg capsules with the expiration date of 06/30/2023. [...]