Avir At Rose Trail

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

disorder, altered mental status, shortness of breath, constipation, hemiplegia and hemiparesis, skin changes, pressure ulcer of sacral region, stage 3, disorders of ear, bilateral, candidiasis, dry eye syndrome.

A review of Resident #2 quarterly MDS section C revealed a BIM score of 10 (Brief Interview for Mental Status) score of indicates moderately cognitive impairment. Record review of Resident #2's care plans, there were none initiated since admission on [DATE REDACTED] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During an interview on 10/13/2025 at 12:30 PM resident #2 was observed up in his specialized wheelchair, with hydraulics up high in air, he did not response to verbal stimuli with first attempt, after much encouragement he responded and stated he had no current issues with the facility. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said

the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of

the RN. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

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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

11/18/2025

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 - Some

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

treatment orders. Also stated All the needs were to be met by nurses' staff on this shift. A review of Resident #4 wound care pressure dressing notes dated 10/11/2025 per wound care Md indicated, Wound Care: Stage 4 Pressure Wound of the right buttock full thickness: Clean with NS/WC, pat dry, and pack with gauze damped in Daikin ( half strength) to fill the wound bed completely and cover with super absorbent dressing with adhesive change daily and as needed PRN. A review of Resident #4's Care Plan dated 7/30/2025 indicated an IDT meeting scheduled today at 4:45PM with the residents' mother. Revealed No documentation of Social Worker reference to the interdisciplinary team (IDT) consultation with mother. No care plans were documented or updated by the MDS nurse or the DON RN, regarding IDT meeting with mother consultation or interventions on care for Resident #4. During an interview on 10/15/2025 at 10:18AM, the Wound Care nurse said, after the mother's arrival to facility late in the afternoons after 6:00PM, it had been discovered that the resident's mother had changed the Pressure Ulcer dressing on several occasions. She said it was discussed verbally with the mother to not change the dressing, and to notify the nursing staff if the Pressure Ulcer dressing had been soiled and needed changed. She said she informed the mother that the nursing staff will change the dressing daily and as needed PRN. The wound care nurse stated that she understood that after speaking with the MD and Social Worker that an IDT meeting would be scheduled, and care plans would be updated. During an interview on 10/15/2025 at 10:30AM, the Social Worker said, she only documented that the IDT meeting was scheduled for 07/30/2025 at 4:45PM, but no additional notes were added to progress notes or care plans. During an interview on 10/15/2025 at 1:30PM, the ADON LVN said, that Resident #3 was receiving Hospice care with a skilled nurse once a week and a hospice aide care three times a week. ADON LVN said, Resident #3 hospice care plans should had been added, and Resident #4 IDT care plans should had been added to the comprehensive care plans. The ADON LVN said, she had been with this facility for only 3 to 4 weeks but was informed by the corporate nurse, it is the responsibility of the DON RN to complete, update, and sign

the admission base line care plans, and comprehensive care plans. During an interview on 10/15/2025 at 2:00pm the DON RN said, she was just hired as the interim DON RN due to the recent transition of the previous DON, and the new MDS nurse had been out sick. DON RN said, the team were addressing care plans issue in the daily morning meetings. During an interview on 10/15/2025 at 2:30PM the Administrator said that the RN, DON, and the MDS nurse were responsible for reviewing the admission care plans and updating the current care plans. The Admin. said, the DON and the MDS Coordinator were responsible for ensuring the MDS assessments were accurate and said the RAI manual was used as the guideline for the MDS's assessment. She said the policy would be to follow the Resident Assessment Instrument (RAI). The Administrator confirmed that the care plans did not address or document Hospice Care for Resident #3, nor did the care plans address IDT meeting with Resident # 4 mother's on requesting the nursing staff to change the PU dressing when soiled. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Event ID:

Facility ID:

If continuation sheet