Health inspection·November 18, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 7 residents (Resident #1) reviewed for resident records. The facility failed to ensure the Business Office Manager completed Resident #1's Medicare UB form accurately. This failure could place the resident at risk for not receiving appropriate care due to incomplete/inaccurate information being documented. Findings included:Record review of Resident #1's face sheet, dated [DATE], indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He was discharged on [DATE]. His diagnoses included heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen) and dementia (a general term for a group of conditions that cause a decline in cognitive function, memory, and thinking abilities, interfering with daily life). Record review of Resident #1's quarterly MDS assessment, dated [DATE], indicated he had a BIMS score of 03, which indicated severe cognitive impairment. He was able to make himself understood and he was able to understand others. Record review of Resident #1's Medicare UB form, dated [DATE] through [DATE], indicated box 17 was marked 20 which indicated the resident had expired. Record review of Resident #1's progress note, dated [DATE] at 02:52PM, reflected this information: Notified of resident transferring to a different facility today. Report called to [Receiving Nursing Home] nurse. [Receiving Nursing Home] transfer staff here to transport resident from [Sending Nursing Home] to [Receiving Nursing Home]. Medications sent with transport staff for the other facility. Residents [family member] here, [name], gathering residents belongings. During an interview on [DATE] at 11:05AM, the Business Office Manager said she put the wrong status code on the resident's census in the medical record for Resident #1. She said she accidentally put 20 which means expired. She said she should have put 03 which means discharged to another facility. She said when she fills out the Resident status in the census section it generates the Medicate UB form that is sent to Medicare for billing. During an interview on [DATE] at 12:20PM, the Business Office Manager said she did not know the risk that would negatively affect the resident. She said she was unaware of the issue because she was not told that this issue was occurring by the resident or his family. She said no one else checks the Medicare UB claim. She said she does not go back and check the UB form to verify it was accurate. During an interview on [DATE] at 12:51PM, the Administrator said her expectation was for medical records to be completed accurately. She said the Business Office Manager was the only one that reviews the UB forms. She said this could cause an issue in that a resident could be marked as expired and unable to receive Medicare benefits. She said she did not have a policy that addressed accurate documentation of Medicare claim forms. She did provide a Month End Close Cheat Sheet. She said the Business Office Manager uses the sheet to review billing forms prior to the end of the month. Record review of an undated Month End Close Cheat Sheet, reflected: .Once UBs are received from [external billing company for the facility], you will (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: 455678 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 455678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Longview 301 Hollybrook Dr Longview, TX 75605 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)