Health inspection·April 30, 2025

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 ensure the comprehensive assessment accurately reflected the resident's status for 1 of 5 Residents (Resident #1) whose assessment records were reviewed. Residents Affected - Few The facility failed when nursing staff did not code on Section GG of MDS Comprehensive assessment dated [DATE] that Resident #1 had functional limitation in range of motion to her upper extremity. This deficient practice could affect residents and contribute to residents not receiving care and services as needed. The findings included: Review of Resident #1's face sheet, printed 04/29/25, revealed the resident was admitted to the facility on [DATE]/24 with a primary diagnoses of myopathy (a disease of the muscle in which muscle fibers do not function properly), Rheumatoid Arthritis (an autoimmune disorder where the immune system attacks to joints, causing inflammation, pain and potential joint damage), Osteoarthritis (a degenerative joint disease characterized by the breakdown of joint tissues over time), Osteoporosis a condition that causes bone loss and increases the risk of fractures), Osteopenia (a condition characterized by lower than normal bone density which makes bones weaker and more susceptible to fractures), contractures of multiple sites (structural changes to soft and connective tissues that cause them to stiffen, tighten and contract that causes tissues to lose their former elasticity and range of motion), chronic pain, hypermetropia (far sightedness), Hypertension, anxiety, insomnia, and muscle atrophy (wasting or thinning of muscle mass). Record review of Resident #1's MDS, dated [DATE], revealed it was noted that the resident had no impairment to upper extremity (should, elbow, wrist, hand). Interview and observation on 04/29/2025 at 11:20 AM with Resident #1 revealed she had suffered with hand contractures from Rheumatoid Arthritis for many years. Resident #1 presented with left hand contractures and no assistive device was in place. Interview on 04/29/2025 at 1:08 PM with MDS Coordinator LVN A revealed Resident #1's MDS Comprehensive assessment, dated 02/13/2025, did not capture that Resident #1 has limited range of motion secondary to contractures. LVN A stated it was important to accurately reflect Resident #1's status so staff would provide the necessary care and services needed. Record review of Resident #1's Care Plan problem, dated 2/14/24, revealed Resident #1 required assistance of staff to transfer and that resident has contractures. (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: 675124 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 04/30/2025 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)