Health inspection·January 8, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #1. #2 and #3) reviewed for infection control in that: The facility failed to ensure the Activity Director utilized hand hygiene during meal service between resident contact for Residents #1, #2 and #3. This deficient practice could affect all residents and place them at risk for infection. The findings were:Record review of Resident #1's face sheet dated 1/08/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: moderate dementia with mood disturbance (a person with dementia who also experiences depression, anxiety and aggression), type 2 diabetes mellitus with diabetic neurological complication (diabetes that also affects the nervous system) and generalized muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated a moderate impairment. Her functional ability for eating included set-up/clean-up assistance. Record review of Resident #1's Care Plan dated 7/31/2024 indicated the resident was able to eat with meal tray set up and supervision. Record review of Resident #2's face sheet dated 1/08/2026 revealed a [AGE] year-old-male admitted on [DATE] with diagnoses which included: acute kidney failure, type 2 diabetes mellitus without complications and blindness in one eye. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. His functional ability was listed as independent. Record review of Resident #2's Care Plan dated 7//31/2025 indicated the resident was able to eat his meal tray with set-up assistance. Record review of Resident #3's face sheet dated 1/08/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: speech and language deficits following cerebrovascular disease (a group of disorders that affects blood flow to the brain), type 2 diabetes mellitus without complications and pain in the joint. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated he was cognitively intact. His functional abilities indicated he was independent with eating. Record review of Resident #3's Care Plan dated 7/31/2024 indicated the resident was able to eat with meal tray set up and supervision. During an observation on 1/08/2025 at 12:08 p.m., the Activity Director was observed holding an unknown female residents spoon and offering her bites of food off the spoon. The Activity Director then helped push the residents wheelchair closer to the table, handed her the spoon, encouraging the resident to feed herself and walked to the open kitchen door where hall trays were being prepped. The Activity Director did not wash or sanitize her hands after contact with the unknown female resident. After a couple of minutes of talking to other staff, she grabbed a hallway meal cart and headed down the hallway with the food trays. During an observation on 1/08/2025 at 12:15 p.m. the Activity Director delivered Resident #1's lunch meal tray to the resident in her room. She assisted with setting up the meal tray on the bedside table and then Residents Affected - Some (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 2 Event ID: 455941 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 455941 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Enchanted Rock 210 West Windcrest St Fredericksburg, TX 78624 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)