Inspection·September 30, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few without acute distress. Dressing to surgical wound dry and intact. v/s BP 103/56, temp. 99.3 oxygen saturation 100% on room air heart rate 109. Will continue routine care and monitoring.During an observation on 09/29/2025 at 8:20 AM Resident #1 was at the nurses' station in her specialized wheelchair with the back tilted backwards. She was alert to her surroundings and looking about. She was clean and dressed appropriately for the day.During an observation on 09/29/2025 at 2:20 PM Resident #1 was in her bed. The head of the bed was elevated 45 degrees and she was lying on her left side. She opened her eyes when the room was entered but laid her head back down and closed her eyes. The bed was in the low position and bolsters were present on the bed on both sides of the resident. The bolsters were short in length and covered the middle length of the mattress.During an interview on 09/29/2025 at 2:25 PM CNA U was in Resident #1's room and said she had worked at the facility about a year. She said Resident #1 was to have bolsters on her bed when she was in the bed because she moved around a lot and could fall out of bed.During an interview on 09/29/2025 at 3:15 PM, ADON A said she was next door to Resident #1's room on the afternoon of 08/28/2025 and heard a loud bump or thud sound; She said LVN Q was making his start of shift rounds and called to her to come to Resident #1's room. She said the resident was on the floor. She said a wedge cushion was in front of the closet at the foot of the roommate's bed. She said the bed was also left in the higher position where it would normally be during a mechanical lift transfer. She said she did not see any bolsters or wedge cushions on the bed or around the resident. She said the resident required the bolsters because she wiggled and moved about in the bed and had very poor control over her body. During an observation on 09/30/2025 at 9:25 AM Resident #1 was sitting in her specialized wheelchair at the bedside. LVN E was taking the resident's blood pressure prior to administering medications. Resident #1 was calm and alert and did not exhibit any fear. Bolsters were present on both sides of her bed.During an interview on 09/30/2025 at 9:45 AM the DON said CNA B said she had placed a black wedge positioning device under the sheet on Resident#1's bed on 08/28/2025 when she returned her to bed between 1:00 PM-1:30 PM prior to leaving her shift. She said the resident was asleep in bed when she left at 2:00 PM. She said LVN Q told her he did not see the wedge when Resident #1 was found on the floor. She said CNA B demonstrated how she placed the black wedge on the bed. She said CNA B told her the bolsters were not on the bed when she came on shift at 6:00 AM and the black wedge was being used. She said the CNA B said she did not know why the bolsters were not being used as in the past, but she used the wedge like she had seen that morning. The DON said CNA B was suspended immediately pending the results of the investigation. She said the bolsters were found in front of the closet in the resident's room. She said all direct care staff had access to the Kardex through computers on the hall, in the break room and at the nurses' station. She said the Kardex designated care needs and procedures to be done for each individual resident in the facility. She said it was a plan of care and contained everything a staff member may need to know to properly care for a resident including positioning/safety devices. She said she had verified with CNA B she knew how to use the Kardex and she indicated she did. She said the facility immediately began developing an action plan regarding the fall with major injury.During an interview on 09/30/2025 at 4:00 PM LVN Q said he was making his beginning of shift rounds on 08/28/2025 and found Resident #1 on the floor by her bed. He said he could not recall for sure if there was a black positioning wedge present on or around her bed. He said he received assistance from ADON A who happened to be next door. He said the resident had small cuts on her left eyebrow and her right leg was turned inward, and she expressed pain when being repositioned. LVN Q said he along with all staff received in-services on fall prevention and safety, abuse and neglect, resident rights and use of the Kardex. He said he made rounds at least 2-3 times per shift and always at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 2 of 4 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few beginning and end of shift. Record review of a printed form of the Kardex for Resident #1 dated 08/28/2025 indicated under Safety bolster on mattress to for safe boundaries to minimize risk for rolling out of bed and under Monitors bed at appropriate height when left unattended.A review of the facility investigation report indicated the incident occurred on 08/28/2025 at 2:55 PM and was reported to the state agency on 08/28/2025 at 6:16 PM. Resident #1 was found lying on the floor beside her bed. She had a laceration to her left eyebrow and under her left eye. Her right leg was turned inward and she expressed pain and discomfort upon movement. She was immediately sent to the ER and she was diagnosed with a fracture to her right femur. The resident was supposed to have bolsters on the mattress to minimize risk of rolling out of bed. The CNA had used a black wedge instead of the bolsters when the resident was returned to bed prior to her leaving her shift at 2:00 PM. The CNA was immediately suspended during the investigation. Record review of a handwritten statement dated 08/28/2025 CNA B stated she had put Resident #1 to bed after lunch and placed a pad under her.Record review of a handwritten statement dated 08/28/2025 at 7:45 PM by an unknown interviewer indicated CNA B got Resident #1 out of bed for breakfast and she stayed up through lunch. She was put back to bed after lunch, and she inserted a black pad underneath the sheet. The CNA stated the resident was asleep in bed when she left the facility at 2:00 PM.Record review of a handwritten statement dated 08/28/2025 at 9:00 PM by the DON indicated CNA B was interviewed at the facility regarding her activities with Resident #1 on 08/28/2025. The CNA said the resident did not have any special devices in bed with her. When asked about the bolsters she said she used the small one which was the same one on the bed that morning. She said the resident usually had long ones but someone must have taken them off the bed and replaced them with the small one. The DON had the CNA demonstrate how she placed the black wedge on the bed in the room. She asked the CNA about the long bolsters she was referring to and the CNA indicated 2 bolsters half the length of the mattress in front of the closet. When asked why she did not use the bolsters she replied she did not know why and shrugged her shoulders. She said she just put back what had been there that morning. She said she usually used the bolsters but did not because they had been taken off the bed. The CNA was then told she was suspended pending the rest of the investigation.During multiple interviews on 09/30/2025 with nurses, CNAs, and MAs from two shifts (6AM-2PM and 2PM-10PM) (RN D, LVN E, CNA/MA F, CNA G, CNA H, CNA J, CNA/MA K, CNA L, LVN M, CNA N, CNA P, CNA R, CNA/MA S, CNA/MA T, CNA U, CNA V, CNA W, CNA/MA X, CNA Y) from 9:25 AM-11:38 AM and 4:00 PM 4:35 PM indicated they were trained on Fall Prevention and Safety, Abuse and Neglect, Resident Rights, and use of the Kardex. They could explain what information was contained in the Kardex and knew how to access the Kardex for any information regarding residents' care. They were aware Resident #1's need for bolsters when she was in bed and for the bed to be in a low position.The Administrator was informed of PNC IJ on 09/30/2025 at 2:40 PM.The facility completed the following to correct the noncompliance prior to state surveyor entrance:CNA B was immediately suspended pending investigation and terminated 09/02/2025 due to disregard for resident safety.Record review of documentation of training of all staff conducted beginning 08/28/2025 after the fall and completed 09/01/2025 on Fall Prevention and Safety, Abuse and Neglect, Resident Rights, and use of the Kardex.Record review of documentation indicated the MDS Coordinator completed 100% care plan and Kardex audit to validate accuracy of level of care needed with ADLs and transfers was completed 08/28/2025.Record review of documentation of Safe Surveys done on random residents and staff completed 08/29/2025. Residents indicated they felt safe in the facility and had no incidents of mistreatment by staff.Record review of documentation of Monitoring Response indicated: 1) weekly rounds to validate interventions related to fall prevention are in place 1-7 days for 2 months; 2) conduct random skills validation regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 3 of 4 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 675289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Azalea Heights 3505 Old Jacksonville Rd 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Kardex use 3-7 days a week for 2 months. 3) additional education based on needs observed during this process; 4) all findings to be reported to QAIP during monthly meeting until 100% compliance was met.The noncompliance was identified as PNC. The IJ began on 08/28/2025 and ended on 09/02/2025. The facility had corrected the noncompliance before the survey began. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675289 If continuation sheet Page 4 of 4