Inspection·August 25, 2024

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of residents for 1 of 5 residents (Resident #1) reviewed for laboratory services. Residents Affected - Few The facility did not obtain UA labs as ordered by the physician for Resident #1. This failure could place residents at risk of not receiving treatment and services to meet their needs. Findings included: Record review of Resident #1's face sheet, printed on [DATE], reflected he was a [AGE] year-old male who originally admitted to facility on [DATE], readmitted to facility on [DATE] and expired in the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus diabetic neuropathy (A chronic condition that affects the way the body processes blood sugar (glucose);With type 2 diabetes, the body either doesn't produce enough insulin, or it resists insulin) Diabetic neuropathy, which affects people with diabetes, causes pain or numbness in the hands, feet or limbs because the nerves are damaged.); Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); Lack of coordination (a neurological sign that causes a lack of voluntary muscle coordination. It can affect any part of the body, but people often have difficulty with balance and walking, speaking, swallowing, writing, and eating.); and Muscle weakness (occurs when your muscles don't contract properly, making them weaker than usual.) Record review of Resident #1's quarterly MDS date [DATE] reflected he had a BIMS of 13 and was cognitively intact. Resident #1 was able to make himself understood and had no issues understanding others. Also, revealed Resident #1 required moderate to substantial assistance with most ADLs. Record review of Resident #1's progress notes reflected the following: -On [DATE] at 11:56pm - Urine amber color [Physician] called at that time n.o lab order Urinalysis collected and ready to be picked up. Completed by: LVN B. -On [DATE] at 2:32am - n.o lab waiting to be collected at this time. Completed by: LVN B. Record review Resident #1's physician order dated [DATE] indicated LVN B created the order on [DATE] for UA with C/S. Directions: one time only to rule out UTI. Record review of Resident #1's electronic health records from [DATE] to [DATE] indicated there was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455429 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Rose Trail 930 S Baxter Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)