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 (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: 455485 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 455485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Petal Hill 900 S Baxter Ave 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)