Health inspection·January 29, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and ensured the services that were to be furnished attained and maintained the residents' physical, mental, and psychosocial well-being for 1 of 4 residents (Resident#32) reviewed for care plans.The facility failed to implement a person-centered care plan for Resident #32 by monitoring his thyroid function with lab tests as ordered by the physician.This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include:Record review of Resident #32's, undated, face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included paralytic syndrome (a serious condition defined by the rapid onset of flaccid muscle weakness or paralysis, often affecting limbs, breathing, and swallowing, commonly triggered by neurotoxins, infections like polio, traumatic brain injury (a disruption in brain function caused by an external physical force, such as a blow to the head, jolt, or penetrating object, often resulting from falls, vehicle crashes, or assaults), and hypothyroidism (the thyroid gland doesn't make enough thyroid hormone). Record review of Resident #32's quarterly MDS assessment, dated 11/03/2025, revealed Resident #32 had a BIMS of 03, which indicated severe cognitive impairment. He required dependent assistance with all ADLS. He had a diagnosis of hypothyroidism. Record review of Resident #32's comprehensive care plan, dated 06/12/2025, revealed Resident #32 had hypothyroidism and an intervention, dated 06/12/2025, stated: Monitor thyroid function test per MD order. Notify MD of abnormal lab values. Record review of Resident #32's physician orders, dated 09/21/2024, revealed an order for a TSH (thyroid stimulating hormone) lab to be drawn every 6 months. Record review of Resident #32's laboratory results revealed the last drawn TSH lab was on 03/17/2025. No laboratory results were noted in the EHR, dated after 03/17/2025. During an interview on 01/29/2026 at 3:20 p.m., the DON stated Resident #32 should have had a TSH lab drawn in September of 2025 and it had not been drawn. She stated the facility changed lab services and the transcription of the order must not have been put in correctly. She stated she called the MD and Resident #32 was scheduled to have a TSH drawn in March of 2026. The DON stated failing to follow the interventions on a care plan could lead to poor care results for the residents. She stated it was her responsibility to ensure the labs were put in correctly.During an interview on 01/29/2026 at 3:30 p.m., MD A stated he was made aware on 01/29/2026 of the missing lab and changed the resident to have yearly TSH labs. He stated that yearly labs are the practice for people like Resident #32 because his medication was managing his thyroid condition.During an interview on 01/29/2026 at 3:45 p.m., the Administrator stated it was her expectation all interventions on care plans be followed as listed on the Page 1 of 2 455963 455963 01/29/2026 Avir at Carthage 701 S Market St Carthage, TX 75633

F 0656 Level of Harm - Minimal harm or potential for actual harm care plan. She stated not following the care plan could lead to lack of individualized care. She stated she expected the MD to be notified if a lab was missed and the MD was notified.Record review of the facility's, undated, policy titled ‘Comprehensive Care Planning revealed The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life. Residents Affected - Few 455963 Page 2 of 2