Health inspection·February 29, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the Resident's representative/legal guardian requiring intervention by legal guardian for one (Resident #5) of three residents reviewed for resident representative notification. The facility failed to immediately notify Resident #5's Legal Guardian regarding Resident #5 expiring at facility. The failure of the facility not notifying Resident #5's Legal Guardian of the incident led to a delay in arrangement for Resident #5's remains. Findings included: Record review of a Face sheet dated [DATE] reflected Resident #5 was a [AGE] year-old Female who was admitted to the facility on [DATE] with diagnoses of Metabolic encephalopathy (disease of the brain), Senile degeneration of brain (loss of intellectual ability), constipation, dementia (cognitive decline), aphasia (inability to speak), muscle wasting (loss of skeletal muscle mass), severe protein-calorie malnutrition. Resident #5 expired at the facility on [DATE]. Resident #5's contact list revealed Call Order #1 was the Legal Guardian. Record review of Resident #5's undated MDS section C assessment reflected Resident #5 with a BIMS score of 00. During an interview on [DATE] at 9:00 am the Administrator stated that the facility failed to contact the Legal Guardian when Resident #5 expired. The Administrator stated that Resident #5's family members were contacted , but nurse failed to contact the Legal Guardian who is listed in Resident #5's contact list as #1 to contact. Administrator stated this was an accident on part of the nurse. The Administrator stated an in-service for all staff was conducted on [DATE] on contacting Legal Guardians. The Administrator stated not contacting the Legal Guardian could cause delay in arrangements for Resident #5's final services. During an interview on [DATE] at 9:40 am the Legal Guardian stated he found out that Resident #5 had expired when the funeral home contacted him on [DATE] to ask what they needed to do with Resident #5's remains. The Legal Guardian stated this was 6 days after the resident expired. The Legal Page 1 of 3 675932 675932 02/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0580 Guardian stated that the facility had contacted him on concerns, Care Plans, and financial needs in the past, but he did not understand how they could neglect to contact him when Resident #5 expired. Level of Harm - Minimal harm or potential for actual harm Record review of the document titled Guardianship Guidelines: Residents Affected - Few GUARDIANSHIP GUIDELINES not dated. Guardianship staff is available 24 hours a day, 7 days a week. During business hours the office administrator will page the Case Manager. The answering service will give you prompts on how to leave a message for the Case Manager or to speak directly to the Case Manager on-call GENERAL GUARDIANSHIP INFORMATION o The Guardian must sign all documentation requiring the client's signature. o A guardian is the court appointed substitute decision maker. The Guardian is responsible for making all decisions set out in the Order Appointing Guardian. o In the event, a client is missing it is not necessary to wait 24 hours to file a Missing Person Report with the police since the client has been deemed legally incapacitated. EMERGENCIES 1) Follow your own facility emergency procedures (i.e. call 911) 2) Call - and speak directly to the Case Manager on call. 3) If a client is transferred to the hospital ER, you must provide hospital personnel with the Letter of Guardianship/Court Order and the contact information. Also, inform personnel that guardian must be contacted for all decisions/consents for treatment. WHEN TO CALL AND SPEAK DIRECTLY TO THE ON CALL CASE MANAGER o Elopement/Client missing. + Client is transitioning or has passed away. + Hospital transfer 675932 Page 2 of 3 675932 02/29/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0580 + Falls resulting in injury. Level of Harm - Minimal harm or potential for actual harm + Police involvement + Change of health and/or mental status Residents Affected - Few + Emergency evacuation (Always call the guardianship provider immediately in the event of an emergency.) WHEN TO CALL AND LEAVE A MESSAGE FOR THE ON CALL CASE MANAGER + Falls or incidents that do not result in an injury. + Medication changes INSTANCES REQUIRING GUARDIAN'S APPROVAL o Outings from the facility with family or friends + Change of Doctors oo Purchases beyond ordinary day-to-day needs + Insurance changes GUARDIAN MUST CONSENT TO ALL MEDICAL TREATMENT 675932 Page 3 of 3