Avir At Rose Trail

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#6 was cognitively intact. The MDS assessment indicated Resident #6 was independent with eating and oral hygiene, required set up personal hygiene, supervision of dressing, and dependent for toileting hygiene. Record review of Resident #6's care plan with a target date of 12/24/2025 indicated she was at risk for complications due to refusing care with a goal of no complications related to refusing care through next review. Record review of Resident 6's Order Summary Report dated 10/01/25 : Oxcarbazepine Oral Tablet 300 MG (Oxcarbazepine) Give 1 tablet by mouth two times a day related to bipolar disorder. During

an interview on 09/27/25 at 06:30 PM, Resident #6 stated the facility removed Resident #7 from her room

on or about 7/2025 and she was not told why. Resident #6 stated Resident #7 was her family member and wanted Resident #7 placed back into the same room. [During an interview on 10/01/25 at 1:15 PM, the Administrator stated a couple of months ago, Human Resources and the Maintenance Supervisor reported Resident #6 threatened to push Resident #7 out of a window like she did her first husband. The Administrator stated she immediately called Ombudsman M and reported the incident. The Administrator stated Ombudsman M advised her to separate Resident #6 and Resident #7. The Administrator stated she separated the residents but did not write a report or report it to HHSC. The Administrator stated she was

the abuse coordinator. The Administrator stated allegations of abuse should have been reported to HHSC.

The Administrator said it was important to ensure allegations of abuse were reported to HHSC to ensure a thorough investigation was completed and to protect the residents from further abuse. During an interview

on 10/01/25 at 3:16 PM, the Maintenance Supervisor stated he was not present when Resident #6 threatened Resident #7. The Maintenance Supervisor stated Resident #6 would often talk over Resident #7. He stated he would hear Resident #6 yelling at times but was unsure if anything was said. During an

interview on 10/01/25 at 3:24 PM, Human Resources stated a couple of months ago she was performing angel rounds on Resident #6 and Resident #7's hall. Human Resources stated she heard Resident #6 talking very rudely to Resident #7. Human Resources said Resident #6 stated, I'll do you like I did your [family member] and throw you out the window. Human Resources stated several of the CNAs stated Resident #6 was always saying things like that to Resident #7. Human Resources stated she immediately reported the incident to the Administrator, who was the abuse coordinator. During an interview on 10/01/25 at 3:57 PM, Ombudsman M stated she had years of history with Resident #6 and Resident #7.

Ombudsman M stated Resident #6 was verbally abusive to Resident #7. Ombudsman M stated a few months ago with the Administrator called and stated the facility staff overheard Resident #6 threaten Resident #7. Ombudsman M said she recommended that the Administrator separate Resident #6 and Resident #7 unless she wanted to complete a self-report on verbal abuse to HHSC daily. Ombudsman M stated she recommended the Administrator report the incident to HHSC. Record review of the facility's Abuse , Neglect, Exploitation and Misappropriation Prevention Program with a revised date of 4/2021, indicated, Residents have the right to be free from abuse, neglect.Upon receiving an allegation of abuse committed against a resident, the staff member receiving the allegation must ensure the safety of the resident and immediately notify the supervisor on duty.Investigate and report all allegations within timeframes required by federal requirements.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rose Trail Nursing and Rehabilitation Center

930 S Baxter 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

updating the care plans. ADON K stated the corporate MDS nurse had been assisting the facility because

the MDS Coordinator was new to the position. ADON K stated the care plans should be person-centered so that staff were aware how to take care of the residents. ADON K stated Resident #4's care plan should have reflected the foley catheter was in place and needed to have a security band to keep the Foley tube from being pulled and potentially causing damage to a resident. During an interview on 10/20/25 at 4:45 PM, the interim DON said the ADON, DON and MDS Coordinator were responsible for ensuring the care plans actively related to the resident to show the necessary care needed to allow the residents to meet their goals. The interim DON stated the care plans were a pathway to provide proper and appropriate care for each resident specifically. Record review of the Care Plan , Comprehensive Person policy, revised on March of 2022, stated .This identification and implementation of a plan of care will begin at admission with

the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care within 7 days and no [NAME] than 21 days after admission. The policy further indicated, Acute Care Plans .7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rose Trail Nursing and Rehabilitation Center

930 S Baxter 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

09/28/25 at 12:00 PM Resident #4 was lying in the bed with the head of his bed elevated. Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During an

observation on 09/29/25 at 11:13 AM, Resident #4 was lying in the bed with the head of his bed elevated.

Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During

an observation on 10/02/25 at 11:13 AM, Resident #4 was lying in bed with the head of his bed elevated.

Resident #4's Foley catheter was not secured to his leg. There was no securement device observed. During

an interview on 10/01/25 at 01:15 PM, the Administrator stated she was not clinical, and she expected the ADONs and the DON to have oversight of the nursing staff to ensure the safety and well-being of the resident's health care needs and to ensure the physician orders were followed appropriately During an

interview on 10/02/25 3:46 PM, RN B stated nurses were responsible for ensuring Foley catheters were secured. RN B stated it should have been checked every shift. RN B stated she was unaware Resident #4 had no securement device in place. RN B stated she probably overlooked it. RN B stated it was important to ensure Foley catheters were secured to prevent the catheter being jerked out, causing trauma or injuries.

During an interview on 10/02/25 at 04:35 PM, ADON K said the nurse was responsible for making sure the catheter device was in place to secure the catheter. ADON K said it was important for the catheter to be secured so it did not pull out and for good placement for the urine to flow. During an interview on 10/20/25 at 4:45 PM, the interim DON said the nurses, and everyone needed to ensure the catheters were secured.

The Interim DON said it was important for the catheters to be secured because if they were not, it could pull out and it could hurt the residents. Record review of the facility's policy revised July 2024, titled, Catheter Care, Urinary, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rose Trail Nursing and Rehabilitation Center

930 S Baxter 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

sterile gloves and care kits. The nurses verified they were provided education and competency checkoffs on tracheostomy care and suctioning. The nursing managers were able to verbalize that monitoring will continue during rounds daily and checkoff competencies will be completed for new hires and nursing staff prior to working their next scheduled shift. 16. Record review of the Quality Assessment and Performance Improvement Plan, dated 09/30/25, reflected an impromptu meeting was conducted and 9 staff members were in attendance. The Administrator was informed the IJ was removed on 10/02/25 at 05:13 PM. The facility remained out of compliance at a scope of patterned and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate

the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rose Trail Nursing and Rehabilitation Center

930 S Baxter 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

arriving to the facility for their next shift. The Director of Nursing, Regional nurse consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on

the floor caring for residents. The facility medical Director was informed of the IJ on 09/30/25 by the VP of Clinical Operations.1. Resident #1 is in the hospital 09/30/25. 2. Residents #2 was assessed on 9/29/2025; resident #3 was assessed on 8/21/25 & 9/13/25, resident #4 was assessed on 9/26/25; resident #5was assessed on 9/18/25. All are currently being treated with antibiotics for active infections. The Interim DON performed new assessments on 10/01/25 for residents 3, 4, and 5 on 10/01/2025. No further complications identified. Resident #1 is currently in the hospital. 3. All nurses will be trained in suctioning and care of tracheostomy per sterile technique and suctioning of tracheostomy by RN/DON A who has been trained by

the facility respiratory therapist and by the facility respiratory therapist, on 09/30/2025. All nurses will be trained before they accept residents for their next scheduled shift. 4. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving at the facility for their next shift. This will begin immediately, 09/30/2025. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor cari

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Facility ID:

If continuation sheet