Health inspection·July 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #5, Resident #20 and Resident #53) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #20 had a care plan in place for use of a mechanical lift.The facility failed to ensure Resident #53 had a care plan in place for hospice services. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs safely.The findings included the following:Resident #5Review of Resident #5's Resident Face Sheet dated 07/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of heart failure, type 2 diabetes mellitus, stage 4 (an ulcer that extends through the muscle) pressure ulcer, peripheral vascular disease (insufficient blood circulation to the arms and legs), dementia, difficulty sleeping, anxiety, gout (a type of arthritis), major depressive disorder, amputation of left foot, weakness, iron deficiency, high blood pressure, alcohol abuse, nicotine dependence, and nausea. Review of Resident #5's Quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #5 scored 15 out of 15 indicating intact cognition. Section GG - Functional Abilities, subsection GG0110 Prior Device Use C. Mechanical Lift was not selected. Record review of Resident #5's Comprehensive Care Plan reviewed/revised 07/22/2025 did not include use of a mechanical lift for transfers as a focus of care or intervention. During an interview and observation on 07/23/2025 at 10:10 AM, Resident #5 was sitting in his wheelchair in the dining room. Noted mechanical lift sling under the resident. Resident stated the staff got him out of bed using the mechanical lift due to his inability to bear weight related to the amputation of his left foot and his size. Resident #20Review of Resident #20's Resident Face Sheet dated 07/24/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of heart failure, high blood pressure, obesity, anxiety, major depressive disorder, atrial fibrillation, enlarged heart, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), gastrointestinal (stomach and intestine) bleeding, chronic pulmonary embolism (blood clot in the lung), nerve pain, difficulty with coordination, and respiratory failure. Review of Resident #20's admission MDS Assessment, dated 05/05/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #20 scored 15 out of 15 indicating intact cognition. Section GG Functional Abilities, subsection GG0110 Prior Device Use C. Mechanical Lift was not selected. Record review of Resident #20's Comprehensive Care Plan reviewed/revised 06/09/2025 did not include use of a mechanical lift for transfers as a focus of care or intervention. During an interview on 07/23/2025 at 6:34 AM, Resident Page 1 of 3 455744 455744 07/24/2025 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #20 stated the staffed used a mechanical lift to transfer her from the bed to a chair and back again. Resident #53Review of Resident #53's electronic face sheet dated 07/24/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] and to hospice services on 07/01/2025 with diagnoses to include: Alzheimer's, kidney disease, and urinary tract infection. Review of Resident #53's Quarterly MDS dated [DATE], revealed a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Review of Section O - Special Treatments, Procedures, and Programs, subsection O0110, item K1 Hospice Care, column b. While a Resident was selected. Review of Resident #53's electronic Physicians Orders dated 07/01/2025 revealed: Resident has hospice services for diagnoses of Alzheimer's Disease. Review of Resident #53's Comprehensive Care Plan last review completed 03/07/2025, revealed no evidence of resident being on hospice services. During an interview on 07/24/2025 at 12:50 PM, the DON stated use of a mechanical lift to transfer residents should be on the comprehensive resident centered care plan. She stated the facility did not have a policy that she was aware of that specifically addressed requiring a physician's order for a mechanical lift or for inclusion of the mechanical lift on the care plan. The DON stated one possible reason for the failure to include use of a mechanical lift on care plan was due to all the changes the facility had been going through. She stated creation of the care plans was a joint effort that included the medical director, MDS Coordinator and DON. She stated her expectations were for an order to be obtained and the residents care plans updated. The DON stated training was a work in progress with the newly hired leadership team. She stated possible consequences of failing to include use of a mechanical lift on a care plan was that she felt care planning provided residents with a list of expectations, gave residents a voice to convey their concerns, needs and wants. Failing to include the use of a mechanical lift did not give residents a complete list of the care they should expect to receive from the facility or an opportunity to state their preferences. During an interview on 07/24/2025 at 1:00 PM, the RNC stated the reason for the failure to include the use of mechanical lifts on resident care plans was due to the recent turnover in the facility. She stated she did not consider the lack of a physician's order of any consequence to the residents. She stated the care plan was a communication tool but was rarely utilized by the staff. The RNC stated she felt there would be no repercussions related to the failure to care plan the use of a mechanical lift. The facility provided policies titled Activities of Daily Living (ADL), Supporting and Lifting Machine, Using a Mechanical. These policies did not address obtaining a physician's order to use a mechanical lift or including the use of a mechanical lift on the care plan. 455744 Page 2 of 3 455744 07/24/2025 Avir at Stephenville 1670 Lingleville Rd Stephenville, TX 76401

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #53) of 4 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included:*the certificate of terminal illness and the hospice election form; *how the communication will be documented between the facility and the hospice provider; and *the physician certification and recertification of the terminal illness. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Review of Resident #53's electronic face sheet dated 07/24/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] and to hospice services on 07/01/2025 with diagnoses to include: Alzheimer's, kidney disease, and urinary tract infection. Review of Resident #53's Quarterly MDS dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. Review of Section O: revealed Resident #53 was on hospice care. Review of Resident #53's Comprehensive Care Plan last review completed 03/07/2025, revealed no evidence of resident being on hospice services. Review of Resident #53's electronic Physicians Orders revealed: Resident has hospice services for diagnoses of Alzheimer's Disease, dated 07/01/2025. Review of Resident #53's clinical records from 02/24/2025 to 07/24/2025, revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness, hospice election form, or any form of communication between the facility and the hospice provider for Resident #53. During an interview on 07/24/2025 at 12:21 PM, the DON stated communication between hospice staff and facility staff was done verbally. She stated communication forms should be filled out daily to ensure that everyone was aware and the residents' status and care concerns. She stated the communication sheet should be filled out and she did not know why this was not being done. She stated the facility should have a copy of the election form and the certification of terminal illness. She stated it was her responsibility to ensure that the required documents were in the facility. Review of facility policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident. 455744 Page 3 of 3