Health inspection·December 5, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to submit a complete and accurate request for NFSS in the LTC Online Portal for 1 of 3 residents reviewed for PASRR assessments (Resident #1). The facility did not ensure the required NFSS form for Resident #1 to receive an OT Assessment and OT Services was submitted within 20 business days (6/21/2024) of the IDT meeting held for Resident #1 on 5/22/24 to the PASRR department via the LTC Online Portal. This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life.Findings included: Record review of the face sheet dated 12/5/2025 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities (clearly shows intellectual disability but the severity is unknown), anxiety disorder, unspecified (the person experiences anxiety, but the cause and type are unknown), major depressive disorder, recurrent, unspecified (the person experiences depression, but the cause and type are unknown. Record review of the MDS assessment dated [DATE] indicated that Resident #1 had medically complex conditions, anxiety disorder, depression, and received no special treatments, procedures or programs. The document indicated that a BIMS should not be conducted. Record review of the Care Plan for Resident #1 dated 11/17/2025 which does not include OT services. Record review of the PASRR Comprehensive Service Plan dated 11/19/2024 which indicated a new service needed for Resident #1 for a specialized occupational therapy assessment and specialized occupational therapy. Record review of the Habilitation Service Plan last updated 11/11/2025 which indicated that Resident #1 was receiving IDD Habilitative specialized services including habilitation coordination and independent living skills. The document indicated that Resident #1 received the following NF Specialized Services: occupational therapy and physical therapy. During an interview on 12/4/2025 at 8:30 a.m. The PASRR Unit Program Specialist stated that the facility failed to submit and complete an accurate request for NFSS in the LTC Online portal within 20 business days after the date of the interdisciplinary team meeting and that due to that the resident had not received a Medicaid service. The facility was notified and instructed to submit an NFSS request on 12/31/2024 regarding the services directed for PASRR on 5/22/2024. A follow-up call was made to the facility on 1/14/2025 and as a result of this, the service was denied. During an interview on 12/5/25 at 2:30 p.m. the MDS Coordinator indicated that she did not have an NFSS form for Resident #1 for OT Services. She stated that she was new to the MDS position and that before she took over, the social worker was handling PASRR. She stated that she had some training on PASRR but was not aware of the timelines related to submitting the NFSS form. She stated that the risk of not sending the NFSS form was that the PASRR positive resident did not get the identified services that they needed. During an interview on 12/5/2025 at 2:48 p.m. the Social Worker indicated that she started working for the facility in April of 2025 and anything that happened before that she was not aware of. She stated that she has been trained on PASRR and that if a resident was coming to Page 1 of 2 455485 455485 12/05/2025 Avir at Petal Hill 900 S Baxter Ave Tyler, TX 75701

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility from the hospital she would receive their PASRR before their arrival and she would enter it into the system and that was all that she did. She stated that she had never completed or had to submit an NFSS form and believed the MDS Coordinator was responsible for that. She stated that the importance of entering all of the documentation timely was that it was crucial for ensuring that all residents receive all of the services that were available to them so that they could have the highest quality of care possible. During an interview on 12/5/2025 at 3:44 p.m. the DON stated that PASRR responsibilities have been split between the Social Worker and the MDS Coordinator. She stated that had a result of the investigation they would be moving all of the PASRR responsibilities to the MDS Coordinator so that there was no confusion on roles and responsibilities. Record review of the facility's PASRR Policy dated 7/29/2025 which indicated that preadmission for PASRR happens when a person is coming from the community. This includes anywhere other than a medical acute care hospital or another nursing facility. The person, coming from the community with a PASRR Level 1 that indicates a suspicion of IDD.must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility. This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission .The Level I screening process determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission.If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate. In regard to documentation facilities must maintain thorough documentation of the PASRR assessments, including the Level I and Level II evaluations, as well as recommendations made. Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Residents who are admitted under PASRR guidelines may undergo periodic reviews to ensure that their needs are being met and that they continue to require nursing home care. Nursing homes must comply with all federal and state regulations regarding PASRR. Failure to do so can result in penalties or loss of funding. The facility follows HHS PASRR For Nursing Facility guidelines. 455485 Page 2 of 2