Health inspection·November 18, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of the residents' admission for 2 of 2 residents (Resident #1, Resident #2). The facility failed to ensure Resident #1, and Resident #2 had a baseline care plan.This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Findings included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual functioning, anemia, atrial fibrillation, mood disorder, pressure ulcer, rhabdomyolysis, acute kidney failure, Systemic inflammatory response syndrome, hyperkalemia, hyperlipidemia and hypertension. A review of Resident #1 quarterly MDS section C dated [DATE], revealed a BIM score of 05 (Brief Interview for Mental Status) score of 5 indicates severe cognitive impairment. Record review of Resident #1's care plans, there were none initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level, any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a phone interview on 10/14/2025 at 10:20 AM with a daughter of resident #1, she said she has not had a care plan meeting with the facility. During an observation and interview on 10/14/2025 at 11:00 AM, Resident #1 was resting in her bed. Sher was awake with some noticeable confusion, she was totally dependent on staff for ADL's, room was clean without any odors noted she said she was going to be going back to her hometown to another facility which was closer to her family. She said she knew that the social worker was contacting the other facility to help get her transferred. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. A Review of the physician's orders and face sheet dated [DATE] indicated Resident #2 was a 63 -year-old male who admitted on [DATE] and re-admitted on [DATE] with hypertension, Dementia, severity with other Behavioral Disturbance, lack of Coordination, abnormal posture difficulty in walking, not elsewhere classified, unsteadiness on feet, muscle weakness, cerebral infarction, type 2 diabetes with diabetic neuropathy, anxiety Page 1 of 5 455429 455429 11/18/2025 Avir at Rose Trail 930 S Baxter Tyler, TX 75701

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disorder, altered mental status, shortness of breath, constipation, hemiplegia and hemiparesis, skin changes, pressure ulcer of sacral region, stage 3, disorders of ear, bilateral, candidiasis, dry eye syndrome. A review of Resident #2 quarterly MDS section C revealed a BIM score of 10 (Brief Interview for Mental Status) score of indicates moderately cognitive impairment. Record review of Resident #2's care plans, there were none initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During an interview on 10/13/2025 at 12:30 PM resident #2 was observed up in his specialized wheelchair, with hydraulics up high in air, he did not response to verbal stimuli with first attempt, after much encouragement he responded and stated he had no current issues with the facility. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 455429 Page 2 of 5 455429 11/18/2025 Avir at Rose Trail 930 S Baxter Tyler, TX 75701

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 4 of 4 residents reviewed for care plans (Resident #1, Resident #2 Resident #3, and Resident #4).The facility failed to ensure Residents 1, 2, 3, and 4 had documented a completed Comprehensive Care Plan. This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Finding included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual functioning, anemia, atrial fibrillation, mood disorder, pressure ulcer, rhabdomyolysis, acute kidney failure, Systemic inflammatory response syndrome, hyperkalemia, hyperlipidemia and hypertension. A review of Resident #1 quarterly MDS section C dated [DATE], revealed a BIM score of 05 (Brief Interview for Mental Status) score of 5 indicates severe cognitive impairment.Record review of Resident #1's care plans initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a phone interview on 10/14/2025 at 10:20 AM with a daughter of resident #1, she said she has not had a care plan meeting with the facility. During an observation and interview on 10/14/2025 at 11:00 AM, Resident #1 was resting in her bed. She was awake with some noticeable confusion, she was totally dependent on staff for ADL's, room was clean without any odor noted she said she was going to be going back to her hometown to another facility which was closer to her family. She said she knew that the social worker was contacting the other facility to help get her transferred. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of resident's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, ADON said the care plans were the responsibility of the MDS Nurse (RN) she was a LVN, and it is the responsibility of the RN. A Review of the physician's orders and face sheet dated [DATE] indicated Resident #2 was a 63 -year-old male who admitted on [DATE] and re-admitted on [DATE] with hypertension, Dementia, severity with other Behavioral Disturbance, lack of Coordination, abnormal posture difficulty in walking, not elsewhere classified, unsteadiness on feet, muscle weakness, cerebral infarction, type 2 diabetes with diabetic neuropathy, anxiety disorder, altered mental status, shortness of breath, constipation, hemiplegia and hemiparesis, skin changes, pressure ulcer of sacral region, stage 3, disorders of ear, bilateral, candidiasis, dry eye syndrome. A review of Resident #2 quarterly MDS section C revealed a BIM score of 10 (Brief Interview for Mental Status) score of indicates moderately cognitive impairment. Record review of Resident #2's care plans initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During an interview on 10/13/2025 at 12:30 PM with resident #2 was observed up in his specialized 455429 Page 3 of 5 455429 11/18/2025 Avir at Rose Trail 930 S Baxter Tyler, TX 75701

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wheelchair, with hydraulics up high in air, he did not response to verbal stimuli with first attempt, after much encouragement he responded and stated he had no current issues with the facility During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of resident's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. A review of Resident #3's, face sheet and physician's orders both dated for [DATE], indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis including unspecified dementia, late onset Alzheimer, hypertension, dysphagia (difficulty swallowing foods or liquids), ataxia ( a disorders that affect co-ordination, balance and speech), schizophrenia, major depression, hyperlipidemia, bipolar disorder, and encephalopathy (a disease or damage that affects brain function or structure). A review of Resident #3's quarterly MDS assessments dated 08/25/2025 revealed a BIM score 0f (00) which indicated she was severely impaired. Observation of Resident #3 on 10/13/2025 at 09:30AM, revealed she was not Interview able. She was in her room lying in bed with her eyes closed, C/D & well groomed, bed in low position, fall mat at bedside, water at bedside, call light was in reach, no signs of abuse/neglect. The resident's room was clean and homelike and there was no physical environment hazards identified. The resident was cognitively impaired and unable to answer questions regarding her care at the facility. A review of Resident #3 's physician's orders dated 07 25/2025 indicated an order for Hospice for evaluation and treatment. Plus, an MD order for an Assignments of a skilled nurse 1xwk. social worker 1x months and, a hospice aide 3x week.A review of Resident #3's Hospice Group in-facility contract dated 07/2025 was signed and agreed to the terms and conditions by all parties.A review of Resident #3's Progress notes dated 10/10/2025, 10/13/2025, and 10/15/2025 revealed Resident #3 received hospice aide care three times a week.A review of Resident #3's comprehensive care plans dated 06/25/2025, was missing care plans for Hospice's care plans, goals, or intervention, and identified no documentation of Hospice care plans initiated or updated. A review of Resident #4, face sheet and physician's orders both dated for [DATE], indicated Resident #4 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis including hepatic encephalopathy (a disease or damage that affects brain function or structure), dysphagia (difficulty swallowing foods or liquids), tachycardia, sepsis, methicillin resistant staphylococcus infection, cognitive communication deficit, pressure ulcer of sacral region , other cirrhosis of liver, hypertension, and lack of co-ordination, balance and speech. A review of Resident #4's quarterly MDS assessments dated 10/10/2025 revealed a BIM score of (03) indicated she was severely impaired. Observation of Resident #4 on 10/13/2025 at 10:00AM, revealed she was not interview able. She was in her room lying in bed, with eyes closed, C/D & well groomed, bed in low position, water at bedside, call light was in reach, no signs of abuse/neglect. The resident's room was clean and homelike and there was no physical environment hazards identified. The resident was cognitively impaired and unable to answer questions regarding her care at the facility. A review of Resident #4's 's physician's orders dated 10/1/2025 indicated that the resident returned to facility from hospital on [DATE]. The wound care MD stated, resume previous wound orders treatments, and he will be here on Thursday to do round and see the resident. The wound care nurse notified the resident and the mother about the wound 455429 Page 4 of 5 455429 11/18/2025 Avir at Rose Trail 930 S Baxter Tyler, TX 75701

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatment orders. Also stated All the needs were to be met by nurses' staff on this shift. A review of Resident #4 wound care pressure dressing notes dated 10/11/2025 per wound care Md indicated, Wound Care: Stage 4 Pressure Wound of the right buttock full thickness: Clean with NS/WC, pat dry, and pack with gauze damped in Daikin ( half strength) to fill the wound bed completely and cover with super absorbent dressing with adhesive change daily and as needed PRN. A review of Resident #4's Care Plan dated 7/30/2025 indicated an IDT meeting scheduled today at 4:45PM with the residents' mother. Revealed No documentation of Social Worker reference to the interdisciplinary team (IDT) consultation with mother. No care plans were documented or updated by the MDS nurse or the DON RN, regarding IDT meeting with mother consultation or interventions on care for Resident #4. During an interview on 10/15/2025 at 10:18AM, the Wound Care nurse said, after the mother's arrival to facility late in the afternoons after 6:00PM, it had been discovered that the resident's mother had changed the Pressure Ulcer dressing on several occasions. She said it was discussed verbally with the mother to not change the dressing, and to notify the nursing staff if the Pressure Ulcer dressing had been soiled and needed changed. She said she informed the mother that the nursing staff will change the dressing daily and as needed PRN. The wound care nurse stated that she understood that after speaking with the MD and Social Worker that an IDT meeting would be scheduled, and care plans would be updated. During an interview on 10/15/2025 at 10:30AM, the Social Worker said, she only documented that the IDT meeting was scheduled for 07/30/2025 at 4:45PM, but no additional notes were added to progress notes or care plans. During an interview on 10/15/2025 at 1:30PM, the ADON LVN said, that Resident #3 was receiving Hospice care with a skilled nurse once a week and a hospice aide care three times a week. ADON LVN said, Resident #3 hospice care plans should had been added, and Resident #4 IDT care plans should had been added to the comprehensive care plans. The ADON LVN said, she had been with this facility for only 3 to 4 weeks but was informed by the corporate nurse, it is the responsibility of the DON RN to complete, update, and sign the admission base line care plans, and comprehensive care plans. During an interview on 10/15/2025 at 2:00pm the DON RN said, she was just hired as the interim DON RN due to the recent transition of the previous DON, and the new MDS nurse had been out sick. DON RN said, the team were addressing care plans issue in the daily morning meetings. During an interview on 10/15/2025 at 2:30PM the Administrator said that the RN, DON, and the MDS nurse were responsible for reviewing the admission care plans and updating the current care plans. The Admin. said, the DON and the MDS Coordinator were responsible for ensuring the MDS assessments were accurate and said the RAI manual was used as the guideline for the MDS's assessment. She said the policy would be to follow the Resident Assessment Instrument (RAI). The Administrator confirmed that the care plans did not address or document Hospice Care for Resident #3, nor did the care plans address IDT meeting with Resident # 4 mother's on requesting the nursing staff to change the PU dressing when soiled. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 455429 Page 5 of 5