Health inspection·September 20, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 (Resident #205) of 6 residents reviewed for advanced directives. The facility failed to ensure Resident #205's code status was updated and documented in his physician's orders. This failure placed residents at risk of not having their end of life wishes honored. Findings included: Review of the electronic admission Record reflected Resident #205's POA was her friend [NAME]. Review of Resident #205's electronic admission Record, latest admission date of [DATE], reflected she was a [AGE] year-old female. Record reflected a medical diagnoses including Dementia-Dementia is the result of changes in certain brain regions that cause neurons (nerve cells) and their connections to stop in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance(Primary, Admission), Pruritus- Pruritus is the medical term for itchy skin. Normally, itchy skin isn't serious, but it can make you uncomfortable. Sometimes, itchy skin is caused by a serious medical condition, unspecified, Local infection of the skin and subcutaneous tissue, unspecified, Pain, unspecified, Disorder of mineral metabolism-Mineral metabolism disorders are abnormal levels of minerals - either too much or too little - in the blood, unspecified, Polyneuropathy-Polyneuropathy is the most common form of peripheral neuropathy, a condition involving damage to the peripheral nerves - which are outside the brain and spinal cord - and the symptoms that result from that damage. In this form of neuropathy, multiple nerves are affected, and frequently, nerves throughout the body will be affected simultaneously, unspecified, wheezing- breathing with a whistling or rattling sound in the chest, Schizoaffective disorder-a mental disorder characterized by abnormal thought processes and an unstable mood, bipolar type, Depression-Depressive disorder (also known as depression) is a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. Depression is different from regular mood changes and feelings about everyday life. It can affect all aspects of life, including relationships with family, friends, and community. It can result from or lead to problems at school and at work, unspecified, anxiety disorder-involves persistent and excessive worry that interferes with daily activities, unspecified, Acute hematogenous osteomyelitis- the diagnosis of bone infection within 4 weeks after the onset of clinical manifestations (symptoms or signs) in a previously uninfected bone, unspecified site. Review of Resident #205's care plan, dated with a start date of [DATE] reflected Do Not Resuscitate (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 675809 Printed: 05/15/2026 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 675809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lancaster 1241 Westridge Ave Lancaster, TX 75146 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)