Health inspection·April 21, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/18/2023 at 5:30 p.m. revealed the resident had been issued a new wheelchair that was clean with intact padding on both arms. During an interview with the Administrator on 04/18/2023 at 5:30 p.m., the Administrator confirmed that Resident #15 should have been issued a new wheelchair to replace the one which was soiled and in a state of disrepair. Record review of the facility policy, Quality of Life - Dignity, revised October 2009, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 2 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life or an inability to eat regular texture foods. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS assessment, dated 02/13/2023, revealed a BIMS score of 14 which indicated intact cognition. Further review revealed Section L: Oral Dental, Box B: No natural teeth or tooth fragments was not checked and Box Z: None of the above were present was checked indicating that the resident had no oral or dental concerns. Record review of Resident #35's care plan, dated 02/20/2023, revealed that it did not address her dental status. Observation on 04/18/2023 at 11:30 a.m. revealed Resident #35 appeared to have few or no natural teeth. During an interview with Resident #35 on 04/18/2023 at 11:30 a.m., Resident #35 confirmed she had no natural teeth and no dentures. During an interview with the ADON/MDS Coordinator on 04/21/2023 at 3:06 p.m., the ADON/MDS Coordinator confirmed Resident #35's MDS was inaccurate and should have indicated that the resident had no natural teeth or tooth fragments. The ADON/MDS Coordinator confirmed that the residents' plans of care were based on the MDS assessment and inaccurate assessments could lead to inadequate resident care. The ADON/MDS Coordinator stated that she was responsible for completing MDS assessments. Record review of the facility policy, Resident Assessment Instrument, revised October 2010, revealed The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 3 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0641 Ensure each resident receives an accurate assessment. 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 complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: Residents Affected - Few The facility failed to ensure that Resident #35's MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS assessment, dated 02/13/2023, revealed a BIMS score of 14 which indicated intact cognition. Further review revealed Section L: Oral Dental, Box B: No natural teeth or tooth fragments was not checked and Box Z: None of the above were present was checked indicating that the resident had no oral or dental concerns. Record review of Resident #35's care plan, dated 02/20/2023, revealed that it did not address her dental status. Observation on 04/18/2023 at 11:30 a.m. revealed Resident #35 appeared to have few or no natural teeth. During an interview with LVN C on 04/19/2023 at 11:25 a.m., LVN C stated resident had been offered a soft foods diet and had refused. During an interview with Resident #35 on 04/18/2023 at 11:30 a.m., Resident #35 confirmed she had no natural teeth and no dentures, was served a regular texture diet, and at times could not eat her food due to an inability to chew. Resident #35 stated she had not been offered a soft food diet, but added that she did request and receive alternate meals on the occasions that she was unable to chew her food. Record review of Resident #35's facility clinical record from time to admission until 04/21/2023 revealed the resident had gained weight while a resident of facility. During an interview with the ADON/MDS Coordinator on 04/21/2023 at 3:06 p.m., the ADON/MDS Coordinator confirmed Resident #35's care plan was inaccurate and should have indicated that the resident had no natural teeth or tooth fragments and that the resident at times could not eat her food due to an inability to chew. The ADON/MDS Coordinator confirmed that staff needed to know that Resident #35 had the need for an altered diet at times. The ADON/MDS Coordinator stated that she was responsible for completing MDS assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 4 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, Resident Assessment Instrument, revised October 2010, revealed The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 5 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

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 observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's care plan correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS assessment, dated 02/13/2023, revealed a BIMS score of 14 which indicated intact cognition. Further review revealed Section L: Oral Dental, Box B: No natural teeth or tooth fragments was not checked and Box Z: None of the above were present was checked indicating that the resident had no oral or dental concerns. Record review of Resident #35's care plan, dated 02/20/2023, revealed that it did not address her dental status. Observation on 04/18/2023 at 11:30 a.m. revealed Resident #35 appeared to have few or no natural teeth. During an interview with Resident #35 on 04/18/2023 at 11:30 a.m., Resident #35 confirmed she had no natural teeth and no dentures, was served a regular texture diet, and at times could not eat her food due to an inability to chew. During an interview with the ADON/MDS Coordinator on 04/21/2023 at 3:06 p.m., the ADON/MDS Coordinator confirmed Resident #35's care plan was inaccurate and should have indicated that the resident had no natural teeth or tooth fragments and that the resident at times could not eat her food due to an inability to chew. The ADON/MDS Coordinator confirmed that staff needed to know that Resident #35 had the need for an altered diet at times. The ADON/MDS Coordinator stated that she was responsible for completing resident care plans. Record review of the facility policy, Resident Assessment Instrument, revised October 2010, revealed The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 6 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, Comprehensive Person-Centered Care Planning, revised 08/2017, revealed, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 7 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 16 residents (Residents #15, #35, and #43) reviewed for ADL's. Residents Affected - Some 1. Resident #15 did not receive his scheduled showers. 2. Resident #35 did not receive her scheduled showers. 3. Resident #43 did not receive his scheduled showers. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life. The findings were: 1. Record review of Resident #15's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: age-related cognitive decline, rhabdomyolysis, and muscle wasting and atrophy. Record review of Resident #15's comprehensive MDS, dated [DATE], revealed a BIMS score of 04 which indicated severe cognitive impairment. Further review revealed the resident required extensive assistance from facility staff to maintain personal hygiene. Record review of Resident #15's care plan, revised 04/20/2023, revealed a problem, Category: ADLs Functional Status/Rehabilitation Potential. Resident has impaired physical mobility r/t [related to] muscle wasting and an approach, staff will assist resident with adls. Record review of Resident #15's ADL shower documentation indicated from 04/1/2023 to 04/20/2023 the resident was scheduled for a shower every Wednesday and Saturday, totaling six opportunities. Further review revealed the resident only received a shower on 04/07/2023 and at no other time between 04/01/2023 and 04/20/2023. Observation on 04/18/2023 at 1:34 p.m. revealed Resident #15 ambulating in the hallway while pushing his wheelchair. Further observation revealed the resident's hair appeared greasy and the resident had body odor. During an interview with Resident #15 on 04/18/2023 at 1:34 p.m., Resident #15 stated he did not recall the last time he received a shower. When asked how he felt about not having received a shower, the resident declined to answer. 2. Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 8 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #35's comprehensive MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Further review revealed the resident was totally dependent upon staff for assistance with bathing. Record review of Resident #35's care plan, dated 02/20/2023, revealed a problem, Category: ADLs Functional Status/Rehabilitation Potential. Alteration in adl function: requires assist with adls and an approach, Provide/ assist with bath or shower as per schedule and as needed. Record review of Resident #35's ADL shower documentation indicated from 04/1/2023 to 04/20/2023 the resident was scheduled for a shower every Wednesday and Saturday, totaling six opportunities. Further review revealed the resident only received a shower on 04/17/2023 and at no other time between 04/01/2023 and 04/20/2023. During an interview with Resident #35 on 04/18/2023 at 11:30 a.m., Resident #35 stated she rarely receives a shower and feels anxious about being unclean. 3. Record review of Resident #43's face sheet dated 4/21/23 revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE]. The diagnoses included unspecified dementia with unspecified severity with other behavioral disturbance (when confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia), Huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die. The disease attacks areas of the brain that help to control voluntary (intentional) movement, as well as other areas), other abnormalities of gait and mobility (when a person is unable to walk in the usual way. This may be due to injuries, underlying conditions, or problems with the legs and feet), and other lack of coordination (Uncoordinated movement, coordination impairment, or loss of coordination). Record review of Resident #43's admission MDS assessment dated [DATE] indicated the resident had a BIMS score of 12 indicating the resident had a moderate cognitive impairment, no behaviors, and the resident required limited one person physical assistance in dressing, physical set up help in bathing, and also indicated the resident required partial/moderate assistance in showers/bathing, had impairment of functional limitation in range of motion to both upper extremities and both lower extremities. Record review of Resident #43's care plan dated 4/18/23 indicated the resident was a fall risk, required assistance with ADL's and interventions included were to provide assistance with baths or showers as scheduled and as needed. Record review of Resident #43's ADL shower documentation indicated from 3/1/23 to 4/20/23 the resident was scheduled for a shower every Wednesday and Saturday and had a shower on 3/1/23, 3/11/23, 3/15/23, 3/18/23, 3/22/23, 3/25/23, and 3/29/23. Further review revealed the resident refused a shower on 3/13/23. On 3/4/23, and 3/8/23 was 8-Activity did not occur. All showers for April 2023 (4/1/23, 4/5/23, 4/8/23, 4/12/23, and 4/15/23) were documented as 8-Activity did not occur. In an interview on 4/18/23 at 1:15 pm, Resident #43 stated showers were an on-going problem, and he did not get his showers as scheduled had not had a shower since last Monday. In an interview on 4/21/23 at 3:45 pm CNA B stated, I do my showers. In an interview on 04/21/2023 at 4:00 p.m., LVN D confirmed that residents did not always receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 9 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete showers on scheduled days or in a timely manner. LVN D stated she did not know why residents did not always receive showers on scheduled days or in a timely manner, and confirmed nursing staff were responsible for ensuring residents received assistance with activities of daily living. Review of facility policy titled Shower/Tub Bath revised October 2010 indicated The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin.The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed . 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken . Event ID: Facility ID: 675124 If continuation sheet Page 10 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care to include but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs for 1 of 5 facility nurses (GVN) evaluated for licensed nurses. The facility failed to ensure the GVN (Graduate Vocational Nurse) did not continue to work as a GVN after her permit to practice was expired from [DATE] to [DATE]. This failure could place residents at risk of not receiving appropriate care and services to meet their needs by qualified, competent nurses. The findings were: Review of staff qualifications and training revealed the GVN was hired on [DATE]. Review of an email report from the Texas BON on [DATE] at 9:58 pm indicated the GVN was issued a graduate permit (pre-exam) for a LVN permit to practice on [DATE] with an expiration date of [DATE] and listed the permit as inactive. Under messages in the report was This Permit is issued until the applicant meets all of the licensure requirements for a permanent license. (The 75th day after issuance was [DATE] and would have expired on that date if not already tested). Review of the facility's time sheets for the GVN indicated she worked past her permit expiration as a GVN on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], for a total of 27 shifts. Observation on [DATE] at 12:20 pm revealed the GVN was seated at the nurses station and was documenting notes in a resident's record in the computer. In an interview on [DATE] at 12:20 pm the GVN stated she had not taken her test yet but had her permit to practice and could show her permit once she was done charting. (The permit to practice as the GVN was not viewed due to the GVN leaving shortly after the request due to a personal medical emergency). Observation on [DATE] at 9:24 am revealed the ABOM came to the conference room with the Texas BON on speaker phone and gave the Texas BON the GVN's date of birth and the representative from the Texas BON stated regarding the GVN should have stopped practicing in February when license expired, no waiver, failed test in February, cannot practice nursing. In an interview on [DATE] at 9:24 am, the ABOM stated she did not know the GVN had failed her NCLEX-PN test and did not ask the GVN if she had taken the test. The ABOM stated she had checked the GVN's license when she was hired in January and had not followed up since. In an interview on [DATE] at 10:11 am with the Administrator and the ADON. The Administrator stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 11 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it was HR's responsibility to verify licensure status of staff and HR verified licensure status upon hire. The Administrator and ADON denied knowledge of the GVN already testing or failing the NCLEX-PN. The Administrator and the ADON both stated they had asked the GVN when she was scheduled to test, and both reported the GVN stated to both of them she was scheduled to test on [DATE]. The Administrator and ADON both stated they were not aware of a timeframe for testing or expiration of the GVN permit to practice. The ADON stated she had contacted the GVN and had not heard back from her regarding her permit to practice being expired according to the Texas BON. In an interview on [DATE] at 11:33 am, with the GVN on speaker phone, the GVN stated she had not tested previously but was scheduled to test in February but did not test and she did have to pay for another test and was scheduled to test on [DATE]. The GVN further stated she did not know that her permit was expired, and she had not been checking her emails. The GVN stated she was not aware that her permit was only good for 75 days from the date of issuance and would have expired regardless on [DATE]. In an interview on [DATE] at 2:46 pm, the ADON stated there was no harm to residents from the GVN continuing to work past expiration as a licensed nurse supervised her. Review of Texas Administrative Code, Texas Board of Nursing Rule 217.3 indicated . A new graduate who completes an accredited basic nursing education program within the United States, its Territories, or Possessions and who applies for initial licensure by examination in Texas may be temporarily authorized to practice nursing as a graduate nurse (GN) or graduate vocational nurse (GVN) pending the results of the licensing examination. This temporary authorization is not renewable and will expire the earliest date of any of the following: (1) when the candidate passes the NCLEX-PN® or NCLEX-RN® test; (2) when the candidate fails the NCLEX-PN® or NCLEX-RN® test; (3) or on the 75th day following the effective date of the temporary authorization [217.3(2)] . (2) The temporary authorization to practice as a GN or GVN, which is not renewable, is valid for 75 days from the date of eligibility, receipt of permanent license, or upon receipt of a notice of failing the examination from the Board, whichever date is the earliest. The GN or GVN must immediately inform employers of receipt of notification of failing the examination and cease nursing practice (4) The nurse administrator of facilities that employ Graduate Nurses or Graduate Vocational Nurses must ensure that the GN or GVN has a valid temporary authorization to practice as a GN or GVN pending the results of the licensing examination, has scheduled a date to take the NCLEX-PN or NCLEX-RN, and does not continue to practice after expiration of the 75 days of eligibility or receipt of a notice of failing the examination from the Board, whichever date is earlier. Review on [DATE] at https://www.bon.texas.gov/practice_guidelines.asp.html#RG_GoverningGraduate_Vocational indicated . Verification of Temporary Permission to Practice - Effective [DATE], a licensure candidate (GVN or GN) who meets Board requirements will be issued a temporary permission to practice via the Board's web site at www.bon.state.tx.us. Potential employers must verify that a licensure candidate has current temporary permission to practice via the web page or by phoning the Board at (512) [PHONE NUMBER]. Hard-copy (paper) temporary permits are no longer issued. Under Expired or Invalid Permission to Practice New graduates may not continue to practice as GVNs or GNs after failing the NCLEX-RN® or NCLEX-PN®, even if the expiration date of the temporary permission to practice has not expired. Employers must follow-up on the results of the new graduate's test results, either by asking to see the new graduate's test results, monitoring the issuance of a license using the automated phone line (512/305-7400), or utilizing the on-line licensure verification process on the Board's web page. If the new graduate is allowed to continue to practice after receiving notice of failing the NCLEX-RN® or NCLEX-PN®, both the nurse manager and the new graduate may be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 12 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some subject to disciplinary action by the Board .If the new graduate does not test in time to receive a nursing license before the date that the permission to practice expires, the GVN or GN must cease practicing as a graduate nurse. There are no extensions for the temporary permission to practice as a GVN or GN based on failure to schedule the licensing examination. Review of Texas BON (board of nursing) website at //txbn.boardsofnursing.org/licenselookup on [DATE] at 9:00 am revealed the GVN was issued a graduate permit (pre-exam) for LVN permit to practice on [DATE] with an expiration date of [DATE] and lists the permit as inactive. The facility policy on GVN's working in the facility, sufficient and competent staff, staff qualifications, and qualified persons was requested in an email sent to the Administrator on [DATE] at 4:30pm. In an interview on [DATE] at 6:05 pm, the ADON stated the facility did not have policies for the above requested policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 13 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week and failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services. 1. The facility failed to designate a full time DON from 4/4/23 to 4/21/23. 2. The facility failed to use the services of an RN as required for 9 days. This could result in resident's not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care. The findings were: 1. Review of the facility's staff list revealed no DON was listed for the facility. Review of staffing records revealed the DON's last day at the facility was 4/4/23. In an interview on 4/18/23 at 2:30pm, the ADON stated the facility had two RN's that worked different shifts and the facility was utilizing them when an RN was needed. In an interview on 4/21/23 at 1:27pm the Administrator stated the DON's last day was 4/4/23 and a new DON had been hired and would start on 5/1/23. 2. Review of the facility's RN hours revealed there were no RN coverage hours on 4/5/23, 4/6/23, 4/7/23, 4/10/23, 4/11/23, and 4/14/23. Further review revealed on 4/17/23 there were 4 hours of RN coverage, on 4/18/23 there were 3.75 hours of RN coverage, and on 4/19/23 there were 3.75 hours of RN coverage. In an interview on 4/21/23 at 1:27 pm, the Administrator stated the DON quit on 4/4/23, and the facility had not had an RN every day since that time, and the facility did not have one that day. Review of the facility policy titled Director of Nursing Services revised August 2006 indicated The Nursing Services department is under the direct supervision of a Registered Nurse. 1. The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by the state . 2. The Director is employed full time (40-hours per week) . Review of Nursing policies provided did not address RN coverage for 8 hours per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 14 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to assure drugs and biologicals were secured properly in 1 of 2 nurses' stations (Station 1) observed, in that: Three unsecured medications were found inside Resident #35's clinical record binder at nursing station #1. This deficient practice could place residents at-risk for harm due to ingesting medications not prescribed to them, and possible drug diversion. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Further review revealed the resident was dependent upon staff for assistance with activities of daily living. Record review of Resident #35's physician orders as of 04/21/2023 revealed the resident's physician had prescribed furosemide 40 mg, KCL (potassium) 20 meq and gabapentin 300 mg on 04/21/2023. Record review of Resident #35's care plan, dated 02/20/2023, revealed a problem, Category: ADLs Functional Status/Rehabilitation Potential. Alteration in adl function: requires assist with adls. Observation on 04/21/2023 at 9:15 a.m. revealed three individually wrapped tablets were found inside Resident #35's clinical record. Further observation revealed the clinical record consisted of a three-ring binder with the resident's name written in the outside and that the binder was found lying in front of the computer located at the facility nursing station. Further observation revealed the tablets were: furosemide 40mg, KCL (potassium) 20 meq and gabapentin 300mg. During an interview with LVN C on 04/19/2023 at 9:16 a.m., LVN C confirmed the presence of three individually wrapped tablets of prescription medication inside Resident #35's clinical record binder. LVN C further confirmed the medications should have been secured in case they fell in the wrong hands and were accidently ingested by a resident who may be harmed by ingesting medications not prescribed to them. During an interview with the ADON/MDS Coordinator on 04/21/2023 at 3:06 p.m., the ADON/MDS Coordinator confirmed that medications should have been secured. Record review of the Facility's policy titled Storage of Medications, dated 11/2022, stated Policy Heading: The facility stores all drugs and biologics in a safe, secure, and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 15 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen, in that: Residents Affected - Few 1. Individual packets of whipped spread were not refrigerated and not placed in an ice bath during preparation for the breakfast meal. 2. The top and sides of the dish sanitizing unit were soiled with a substance resembling sand. These deficient practices could lead to diminished quality of life due to foodborne illness. The findings were: Observation on 04/20/2023 at 7:24 a.m. revealed individual packets of whipped spread had been removed from the refrigerator and placed on a serving cart in preparation for the morning meal service. Further observation revealed the packets of whipped spread had not been placed in an ice bath. During an interview with Dietary Aide A on 04/20/2023 at 7:25 a.m., Dietary Aide A confirmed that this was the usual procedure, and that packets of whipped spread or butter were not placed in an ice bath routinely. During an interview with the DM on 04/20/2023 at 7:26 a.m., the DM confirmed that this was the usual procedure, and that packets of whipped spread or butter were not placed in an ice bath routinely. When asked by the Surveyor if residents could potentially become ill from consuming unrefrigerated dairy products, the DM confirmed this was a possibility. 2. Observation on 04/20/2023 at 12:35 p.m. revealed the top and sides of the dish sanitizing unit were soiled with dust and a substance resembling sand. Further observation revealed the sanitizing unit's doors opened upward and closed downward and when this motion occurred, the dust and sand-like substance clung to the door and was smeared down to the area holding clean dishware. During an interview with the DM on 04/20/2023 at 12:35 p.m., the DM confirmed the presence of dust and a sand-like substance on the dish sanitizer machine and stated it was soap residue. The DM confirmed that the dust and residue could reach clean dishware and soil it. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-501.16, revealed, Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5ºC (41ºF) or less. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 16 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 3-305.1, revealed, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of facility policy Food Receiving and Storage revised December 2008 revealed, 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 7. All foods stored in the refrigerator or freezer will covered, labeled, and dated. Event ID: Facility ID: 675124 If continuation sheet Page 17 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, 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 of 3 resident (Resident #33) reviewed for hospice services, in that: The facility did not have Resident #33's most recent hospice Plan of Care, Hospice Consent and Election Form, and Physician Certification of Terminal Illness. This deficient practice could place 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 were: Record review of Resident #33's facesheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia without behavioral disturbance, major depressive disorder, and chronic kidney disease stage 3 unspecified. Record review of Resident #49's quarterly MDS assessment, dated 03/10/2023, revealed the resident was rarely or never understood and a staff assessment for mental status was performed which indicated the resident had short-term and long-term memory problems. Record review of Resident #33's care plan, revised 04/14/2023, revealed a focus, Psychosocial Wellbeing: I am at risk for psychosocial decline r/t [related to] long term admission to skilled nursing facility, COVID-19 protocols, and admission to Hospice for terminal care, a goal, I will experience no loss of self, autonomy, or dignity through my end-of-life process, and interventions, Provide support and allow resident to express feeling, fears and concerns. Record review of Resident #33's physician orders revealed an order dated 11/16/2021 admitting the resident to hospice services. Record review of Resident #33's facility clinical record from the time of admission to 04/21/2023 revealed the record did not include the resident's most recent hospice Plan of Care, Hospice Consent and Election Form, or Physician Certification of Terminal Illness. During an interview with the Administrator on 04/21/2023 at 3:42 p.m., the Administrator stated no one staff member had been designated as hospice liaison and confirmed Resident #33's facility clinical record did not include the resident's most recent hospice Plan of Care, Hospice Consent and Election Form, or Physician Certification of Terminal Illness, and confirmed these documents were necessary to facilitate communication and coordination of care between the facility care team and the hospice care team. Record review of the facility policy, Hospice Program, revised July 2017, revealed, .to coordinate care provided to the resident by our facility staff and the hospice staff .d. Obtaining the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 18 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0849 Level of Harm - Minimal harm or potential for actual harm following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election forms; (3) Physician certification and recertification of the terminal illness specific to each resident . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 19 of 20 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 675124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 public restroom on the 300 Hall, in that: The public restroom utilized by residents, staff, and visitors on the facility's 300 Hall had a sink which was loosely affixed to the wall, a toilet with stained and missing caulking and loosely affixed to the floor, dark gray and black stains in the toilet, and a stained washcloth on the floor. This deficient practice could lead to residents living in, staff working in, and residents visiting in an environment that is not safe, functional, sanitary, and comfortable. The findings were: Observation on 04/18/2023 at 12:19 p.m., revealed the public restroom utilized by residents, staff, and visitors on the facility's 300 Hall had a sink which was loosely affixed to the wall, a toilet with stained and missing caulking and loosely affixed to the floor, dark gray and black stains in the toilet, and a stained washcloth on the floor. During an interview with the Administrator on 04/18/2023 at 12:21 p.m., the Administrator confirmed the public restroom utilized by residents, staff, and visitors on the facility's 300 Hall had a sink which was loosely affixed to the wall, a toilet with stained and missing caulking and loosely affixed to the floor, dark gray and black stains in the toilet, and a stained washcloth on the floor. The Administrator stated is was the responsibility of the Housekeeping and Maintenance Departments to ensure the facility was clean and operational. The Administrator further confirmed that the loose sink and loose toilet were potentially hazardous to residents if the sink fell from the wall, or the toilet moved while a resident utilized it. Record review of the facility's policy, Quality of Life - Homelike Environment, revised February 2014, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 20 of 20