Caldwell, TX

Avir at Caldwell

1-star overall rating with 1-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

1022 Presidential Corridor Hwy 21 E, Caldwell, TX

(979) 567-0920

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

112

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Avir Health Group

Operator or chain grouping

Approved since

2001-09-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

90 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.23

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.49

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

0.88

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

1.61

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

0.72

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

1.32

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.05

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.28

CMS adjusted RN staffing hours

Adjusted total hours

1.97

CMS adjusted total nurse staffing hours

Case-mix index

1.12

Higher values indicate more complex resident acuity

RN turnover

83%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

92%

Annual nurse turnover · state 52% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.55	1.02 0.5 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 23 · Denominator 23
Falls with major injury	4.35%	0.77% 3.6 pts worse	Numerator 1 · Denominator 23
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 23 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 57
Staff flu vaccination coverage	79.82%	42% 37.8 pts better	Numerator 91 · Denominator 114
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	2.1 0.4 pts better	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.3	2.1 1.2 pts worse	1.8 1.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.7 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	97.1% 2.3 pts better	93.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.3% 1 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.0%	2.7% 0.3 pts worse	11.4% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.0%
Percentage of long-stay residents who lose too much weight	2.8%	3.3% 0.5 pts better	5.4% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.6% · Q3 5.4% · Q4 0.0% · 4Q avg 2.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.7%	18.9% 1.2 pts better	19.6% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 17.5% · Q3 20.5% · Q4 14.7% · 4Q avg 17.7%
Percentage of long-stay residents who received an antipsychotic medication	9.3%	10.8% 1.5 pts better	16.7% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.4% · Q3 10.0% · Q4 12.0% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.2%	15.4% 1.2 pts better	16.3% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q3 7.5% · Q4 3.9% · 4Q avg 14.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.5%	16.1% 7.6 pts better	14.9% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 15.8% · Q3 2.6% · Q4 9.1% · 4Q avg 8.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	0.8% 0.2 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.8%	15.0% 5.8 pts worse	19.8% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 15.3% · Q3 31.8% · Q4 21.1% · 4Q avg 20.8%
Percentage of long-stay residents with pressure ulcers	8.0%	4.2% 3.8 pts worse	5.1% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.2% · Q3 9.0% · Q4 7.1% · 4Q avg 8.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.0%	89.7% 7.3 pts better	81.7% 15.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 97.3% · Q4 95.1% · 4Q avg 97.0%
Percentage of short-stay residents who had an outpatient emergency department visit	7.7%	12.0% 4.3 pts better	12.0% 4.3 pts better	Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 8.0% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.6%	25.9% 7.7 pts worse	23.9% 9.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.6% · Observed 32.0% · Expected 22.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-16 · Fire 2024-10-16

11 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-08-18 · Fire 2023-08-18

11 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2022-06-09 · Fire 2022-06-09

5 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-16

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-05-15

F · Potential for more than minimal harm 2024-10-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-25

F · Potential for more than minimal harm 2024-10-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-01

F · Potential for more than minimal harm 2024-10-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-01

D · Potential for more than minimal harm 2024-10-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-05-01

D · Potential for more than minimal harm 2024-10-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-15

D · Potential for more than minimal harm 2024-10-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-15

F · Potential for more than minimal harm 2023-08-18

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-06-29

F · Potential for more than minimal harm 2023-08-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-29

E · Potential for more than minimal harm 2023-08-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-06-29

E · Potential for more than minimal harm 2023-08-18

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-06-29

E · Potential for more than minimal harm 2023-08-18

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-06-29

E · Potential for more than minimal harm 2023-08-18

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-06-29

D · Potential for more than minimal harm 2023-08-18

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-06-29

E · Potential for more than minimal harm 2022-06-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-02-24

E · Potential for more than minimal harm 2022-06-09

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-02-24

E · Potential for more than minimal harm 2022-06-09

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-02-24

Inspection history

Recent health citations

K · Immediate jeopardy 2025-08-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-27

K · Immediate jeopardy 2025-08-26

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-08-27

F · Potential for more than minimal harm 2024-10-16

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-11-04

E · Potential for more than minimal harm 2024-10-16

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-11-04

E · Potential for more than minimal harm 2024-10-16

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-16

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-16

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-16

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-16

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-16

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-08-24

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-09-12

F · Potential for more than minimal harm 2024-07-19

F555 · Resident Rights Deficiencies

Health

Honor the resident's right to choose his or her attending physician.

Corrected 2024-08-03

E · Potential for more than minimal harm 2024-06-12

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-07-08

D · Potential for more than minimal harm 2024-06-12

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-07-08

E · Potential for more than minimal harm 2023-08-18

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-09-29

E · Potential for more than minimal harm 2023-08-18

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-09-29

E · Potential for more than minimal harm 2023-08-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-09-29

E · Potential for more than minimal harm 2023-08-18

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-08-18

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-08-18

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-08-18

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-09-29

E · Potential for more than minimal harm 2022-06-09

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2022-07-08

E · Potential for more than minimal harm 2022-06-09

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F550 · Resident Rights Deficiencies

Health

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

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-07-08

D · Potential for more than minimal harm 2022-06-09

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2022-07-08

Penalties and ownership

What sits behind the stars

Ownership

Burleson County Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 2 facilities 2014-04-15

Caldwelltx LLC

Operational/Managerial Control · Organization

0% 1 facilities 2024-04-01

Chapman, Wayne

Corporate Director · Individual

0% 2 facilities 2014-04-15

Jian, Peter

Operational/Managerial Control · Individual

0% 5 facilities 2024-04-15

Mistretta, Cassandra

Operational/Managerial Control · Individual

0% 8 facilities 2024-04-15

Pfeifer, Mary

Operational/Managerial Control · Individual

0% 6 facilities 2024-04-15

Nearby options

Other facilities in reach

Copperas Hollow Nursing & Rehabilitation Center

Caldwell, TX

2-star overall rating with 2-star inspections with $61,546 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

Overall: 2 / 5
Health: 2 / 5
Staffing: 2 / 5
Fines: $61,546