Avir At Rose Trail
Inspection Findings
F-Tag F0583
F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
#10's Face Sheet, dated 12/31/2025, reflected a [AGE] year old female admitted on [DATE REDACTED]. The resident was diagnosed with Type 2 diabetes mellitus with diabetic neuropathy (high blood sugar that has caused nerve damage). Observation on 12/31/2025 at 10:00 a.m. of the public survey binder in the foyer of the facility revealed care plans for Residents #1, #2, #5 and #6 including PHI such as SSN, health diagnoses and treatments they were receiving. This observation further revealed the PIR dated 7/2025 submitted by
the facility which showed PHI of Residents #3 and #4 including their names, SSN, Medicaid and Medicare numbers as well as health diagnoses. This binder also included a resident identifier sheet with a list of resident names and numbered identifiers as well as the survey for that identifier sheet with PHI in the survey. During an interview with the administrator on 12/31/2025 at 10:25 a.m., she stated the survey binders were kept in the lobby for anyone who was interested to see what tags were written at the facility and the facility's accepted plan of correction. She stated the only thing that should have been in the binder was the tag and plan of correction. She stated a resident's care plan should not have been in the binder as that was protected health information with diagnoses, treatment and other personal information that should not have been readily available to the public. She stated that the PIR should also not have been in the binder as it contained PHI. She stated that it was her and all staff's responsibility to ensure that PHI was protected from any unauthorized people. She stated she did not know who placed the care plans, PIR, and resident identifier sheets in the binder but those documents did not belong in the public binder. During an
interview with the DON on 1/2/2026 at 2:00 p.m., he stated PHI was information was not available to the public as residents at the facility had a right to privacy. He stated all staff were trained to protect this information in their new hire training as well as frequent refresher in-services throughout the year. He stated
he was in this position for a couple of weeks and would ensure staff were trained to safeguard this information. He stated this was important so residents felt safe and that their information was kept confidential from those without a valid reason to access this information. During an interview with the ADON on 12/31/2025 at 2:15 p.m., she stated PHI was to be safe-guarded by all staff and that they were trained initially on the importance of this in their onboarding process and were reminded frequently in in-service training. She stated it was important to keep PHI protected as there was information included that others might use to exploit the resident, such as their name, DOB, SSN, and health diagnoses as residents had a right to privacy. The ADON stated disclosure of this information would be a violation if HIPAA. Record
review of the facility's HIPAA Policy, dated April 2025, indicated, All patient, personnel, and financial information are considered privileged and confidential. Access should not be granted to these confidential documents without proper authorization or in accordance with the Resident/Patient [NAME] of Rights.in accordance with HIPAA regulations, access to personal medical information is limited to qualified, designated personnel.your personal medical information will be maintained as confidential unless you allow
the release of the information.
Event ID:
Facility ID:
If continuation sheet
Avir at Rose Trail in TYLER, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TYLER, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Rose Trail or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.