Inspection·September 11, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure individuals with mental health disorders were provided an accurate PASRR for 2 of 6 residents (Residents #1 and Resident #56) reviewed for PASRR Level 1 screenings. The facility failed to verify the accuracy of the negative PASRR Level 1 Screening for Resident # 1 and Resident #56, who had diagnoses of mental illness. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.Findings Included:Resident #1 Record review of Resident #1's face sheet dated 09/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: Schizoaffective disorder, Bipolar type onset date 03/15/2025 (Mental Illness), Post Traumatic Stress disorder( a mental health condition that develops after experiencing or witnessing a traumatic event), chronic onset date 03/15/2025, adjustment disorder with mixed anxiety and depressed mood (mental health condition) onset date 03/15/2025, and Depression onset date 03/15/2025. Record review of Resident #1's Quarterly MDS dated [DATE], revealed, A BIMS score of 15 out of 15 indicating no cognitive impairment, no behaviors in the reviewed period, extensive assistance with most ADLs, use of a wheelchair, frequent incontinence of bowel and use of indwelling catheter, Paraplegia, Depression, Schizophrenia, and Post Traumatic Stress Disorder. Record review of Resident #1's PASRR Level I Screening dated 03/14/2025 completed at the hospital, reflected Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record review of Resident #1's Order summary report dated 9/11/2025 revealed, May have psych therapy or psychological services as indicated and needed, Divalproex Sodium oral tablet delayed release 125 MG give 1 tablet by mouth two times a day for mood, Effexor XR oral capsule extended release 24 hour 75 mg give 1 capsule by mouth one time a day related to depression, Quetiapine Fumarate oral tablet 100 MG give 2 tablets by mouth at bedtime related to schizoaffective disorder, bipolar type. Record review of Resident #1's care plan Date initiated 3/19/2025 revealed: Focus care area: Resident #1 is taking antidepressant medication related to depression. Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Date initiated 3/19/2025 and revised on 4/19/2025, Focus care area: Resident #1 uses psychotropic medications related to Behavior management of schizoaffective disorder, bipolar type. Resident #56 Record review of Resident #56's face sheet dated 09/10/2025, revealed a [AGE] year-old female who was originally admitted on [DATE]. She had diagnoses including: Paranoid Schizophrenia (Mental Illness) onset date 3/18/2016, anxiety disorder (Mental health disorder) onset date 3/18/2016, and Delusional disorders onset date 3/18/2016. Record review of Resident #56's Quarterly MDS dated [DATE], revealed she had a BIMS score of 15 out of 15 indicating she had no cognitive impairment. No behavior issues were noted during the assessment period. Her current active diagnoses included Depression, Psychotic disorder, and schizophrenia. Record review of Resident #56's PASRR Level I Screening dated 02/01/2018 completed at the facility, reflected Mental Illness is there evidence or an indicator this is an individual that has a Mental Illness? NO. Record review of Resident #56's care plan revealed:-Date Initiated 3/30/2018 Revised 1/01/2023: Focus care area: Resident #56 has mood problem related to bipolar disorder/schizophrenia. Intervention: Behavior health consults as need (Psycho-geriatric team, psychiatrist etc.) In an interview on 09/11/2025 with the Regional Reimbursement Coordinator at 4:32 PM revealed: It is the responsibility of the MDS coordinator upon admission to have a completed PASRR Level I. The facility has been without one since May. She started on 08/01/2025 and is regional as the facility is looking to hire an MDS coordinator. Level I's are usually completed on admission but no later than 72 hours after Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455613 If continuation sheet Page 2 of 3 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 455613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Courtyard 7499 Stanwick Dr Houston, TX 77087 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete admission. If the Level I is completed at the hospital and it's identified, it was not completed correctly she fills out a form 1012 and looks to see if Resident has a diagnosis of Dementia. If the Resident doesn't have Dementia, then a repeat Level I will be submitted. If a Resident doesn't have a correct Level I completed, they can miss out on the services that PASRR offers. She follows the state guidelines for PASRR services. In an interview with the Former MDS Coordinator on 09/11/2025 at 4:40 PM revealed: She retired 04/03/2025, and she was Responsible for submitting PASRR Level I's. She would submit them within 48-72 hours after Resident was admitted . The Level II is completed by the Local authority, and she would follow up with them if they did not respond to an alert of a Positive Level I. If a Level I was found to not be done correctly she would correct it and would resubmit it as long as residents' primary diagnosis was not Dementia. Possible diagnosis for a Level I could be any serious mental illness or intellectual disability. She couldn't name specifics as she's been away from it and has forgotten. Not having a correct Level I could stop the Resident from getting possible services they are entitled to. Record review of the facility policy titled PASRR dated 07/29/2025 revealed: The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individuals' needs. Negative indicates the person has a negative PLI screening, and is not suspected of having intellectual disability, developmental disability and or mental illness. Screening process: Level Screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission. Event ID: Facility ID: 455613 If continuation sheet Page 3 of 3