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Inspection visit

Health inspection

AVIR AT PETAL HILLCMS #4554851 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

455485 08/22/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701
F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post Nursing Staffing Data information daily as required for 6 of 21 days (08/16/23, 08/17/23, 08/18/23, 08/19/23, 08/20/23, and 08/21/23) reviewed for August 2023 nursing staffing. Residents Affected - Many The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the daily census for August 16th , 17th , 18th , 19th , 20th and 21st of 2023. This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements. Findings included: During an observation on 08/16/23 at 10:20 p.m., the staffing sheet posted was dated 08/15/23. During an observation on 08/16/23 at 11:43 p.m., the staffing sheet posted was dated 08/15/23. During an observation on 08/21/23 at 1:50 p.m., the staffing sheet posted was dated 08/15/23. During an observation on 08/21/23 at 1:35 p.m., the staffing sheet posted was dated 08/15/23. During an observation on 08/21/23 at 3:32 p.m., the staffing sheet posted was dated 08/15/23. During an interview on 08/21/23 at 3:58 p.m., RN A said during the week she was responsible for posting the staffing sheet daily and the RN supervisor was responsible for posting it on the weekend. RN A said she worked the night shift on 08/16/23 and 08/17/23 as a charge nurse and was off on 08/18/23. RN A said she did not post the staffing sheets on 08/16/23, 08/17/23 and 08/18/23. RN A said she did not know who was responsible for ensuring the staffing was posted daily when she was unable to. RN A said she did not have the staffing sheets for 08/16/23, 08/17/23, 08/18/23, 08/19/23 and 08/20/23. RN A said had been busy and still needed to post the staffing sheet for today. During an observation and interview on 08/21/23 at 4:24 p.m., the DON said she expected the staffing to be posted daily so residents and family members could be assured adequate staffing was being provided. The DON said during the week RN A was responsible for posting the staffing sheet daily and the RN supervisor was responsible for posting it on the weekend. The DON observed the posted staffing sheet and said it was dated 08/15/23 and had not been updated since. The DON said she would post an updated staffing sheet for today. The DON said RN A worked the night shift on 08/16/23 and 08/17/23 as a charge nurse and was off on 08/18/23. The DON said she did not know who was responsible for posting staffing sheets on 08/16/23, 08/17/23 and 08/18/23 or if someone had been designated to do so. Page 1 of 2 455485 455485 08/22/2023 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701
F 0732 Level of Harm - Potential for minimal harm The DON said she would be responsible for the staffing sheets when RN A was unavailable. The DON said she was not sure why the staffing sheets were not posted on 08/19/23 and 08/20/23 and would talk to the weekend RN supervisor about it. During an observation on 08/21/23 at 5:11 p.m., the staffing sheet posted was dated 08/21/23. Residents Affected - Many A record review of the facility's staffing sheets for August 2023 indicated there were no documented staffing sheets on 08/16/23, 08/17/23, 08/18/23, 08/19/23 and 08/20/23. The staffing sheet on 08/21/23 was documented after surveyor intervention. 455485 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0732GeneralS&S Cno actual harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

FAQ · About this visit

Common questions about this visit

What happened during the August 22, 2023 survey of AVIR AT PETAL HILL?

This was a inspection survey of AVIR AT PETAL HILL on August 22, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AVIR AT PETAL HILL on August 22, 2023?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Post nurse staffing information every day."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.