Health inspection·July 25, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Seroquel for Resident #6, but the consent for Seroquel was not dated or signed by the POA. She stated she was not able to find any other consents for psychoactive medications for Resident #6. She stated she had only been here at the facility for 2 weeks, so she checked with other staff who have been here longer, and their search resulted in no consents for Resident #6 being found. Further interview with DON revealed the DON or his/her designee were ultimately responsible for ensuring medication consents were obtained prior to giving the medications and did not know why the consents were not obtained and documented in the EHR. The DON stated that not obtaining a consent prior to the start of a medication may result in the medication being given without the resident or their representative party being aware of the risks, side effects and benefits of the medication being given. Record review of facility policy titled Antipsychotic Medication use revised July 2022 provided by DON when policy regarding need for obtaining consent for psychoactive medications was requested, revealed there was no information included in the policy regarding need to obtain consent for psychoactive medications. Event ID: Facility ID: 675124 If continuation sheet Page 2 of 15 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 07/25/2025 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 1 resident (Resident #6) reviewed for PASRR assessments. The facility did not refer Resident #6 to the appropriate state-designated mental health authority for review when she was admitted with diagnoses including: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). This failure could place residents at risk of not being evaluated and receiving needed PASRR services. Findings included: Record review of Resident #6's admission Record dated 07/23/2025 revealed an [AGE] year-old woman admitted on [DATE] with diagnoses which included: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #6's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 12, indicating moderate cognitive impairment. She was assessed with having active diagnoses of Anxiety Disorder, Depression and Psychotic Disorder and was taking antipsychotic, antianxiety and antidepressant medications. Record review of Resident #6's Care Plan initiated 6/17/2025 revealed a Focus area for Resident is on antipsychotic R/T delusional thinking, initiated 6/19/2025. Record review of Resident #6's PASRR Level 1 screening dated 6/16/2025 reflected she did not have a primary diagnosis of dementia and did not have a mental illness. During an interview on 07/25/2025 at 10:09 a.m., the MDS Nurse stated she was responsible for the PASRR reviews and stated Resident #6 was admitted from the hospital on a weekend, and she completed Resident #6's PASSR that following Monday, 6/16/2025. She stated she relied primarily on the hospital records when she completed the PASSR review for Resident #6, and the PASRR review from the hospital did not indicate any dementia or mental illness. After reviewing Resident #6's admission record and diagnoses, the MDS Nurse confirmed Resident #6 was admitted with diagnoses of Psychotic Disorder with Delusions, Major Depressive Disorder and Generalized Anxiety Disorder, and stated she used poor judgement when she did not revise the PASSR to reflect that Resident #6 had mental illness without a diagnosis of dementia as that would have prompted the Local Mental Health Authority to come to facility for a Level 2 PASSR screening to determine her eligibility for PASSR services. The MDS Nurse stated that Resident #6 was currently receiving mental health counseling and psychiatric services. Record review of Resident #6's EHR revealed she was seen by the mental health counselor on 6/18/2025, and by the psychiatric provider on 6/24/2025 for initial consult, and continued to be seen regularly by both. Interview with the DON on 07/25/2025 at 10:13 a.m. revealed she stated that Resident #6 did have diagnoses of mental illness and her PASRR should have reflected this upon her admission from the hospital. The DON stated that Resident #6 was seen by the mental health counselor within days after her admission and continues to receive regular mental health counseling and psychiatric services, but the result of not referring her for Level 2 PASRR screening was that these services were not coordinated through the local authority. The DON further stated they did not have a policy regarding PASRR services as they use the state guidelines. Event ID: Facility ID: 675124 If continuation sheet Page 3 of 15 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 07/25/2025 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment, for 3of 8 residents (Residents #1, #6, and #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1 had a care plan accessible in his current active record. 2. The facility failed to ensure that Resident #6's diagnoses of anxiety and depression, including a past history of self-harm, were focus areas on the resident's comprehensive care plan. 3. The facility failed to develop and implement a care plan to reflect Resident #3's surgical removal of his kidneys. These deficient practices could place residents at risk for having their medical, nursing and psychosocial needs not being met and staff who provide direct care to the residents not having information needed The findings were: 1.Record review of Resident #1's admission Record revealed he was a [AGE] year-old man admitted [DATE], and re-admitted on [DATE], with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person can see at 20 feet what a person with normal vision can see at 200 feet), Borderline Intellectual Functioning (cognitive abilities that are below average, but not enough to be classified as intellectual disability), Major Depressive Disorder (mental health disorder characterized by persistent depressed mood or loss of interest causing impairment in life), and Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS score of 11, indicating moderate cognitive impairment and had an active diagnosis of legal blindness. Record review of Resident #1's EHR revealed there was no care plan available in Resident #1's Electronic Health Record (EHR). During an interview on [DATE] at 3:35 p.m., the DON checked Resident #1's EHR and confirmed that there was no care plan available in his record. The DON stated the care plan screen showed his care plan was last revised on [DATE] by the Regional Nurse Consultant (RNC) and stated it might have been deleted and she would check with the RNC. The DON stated it was important for staff to have access to the Resident's Care Plans so they could have all the information needed to provide individualized care to the Residents. During an interview with the MDS Nurse on [DATE] at 3:51 p.m., she stated that she also was unable to access Resident #1's Care Plan in the EHR, but knows he had one, and stated the facility switched EHR programs in late April, and Resident #1's Care Plan may not have transferred over yet. The MDS Nurse stated she still had access to the previous EHR system and accessed Resident #1's Care Plan from it, which showed an initiation date of [DATE]. The MDS Nurse stated that only she and a few other staff still had access to the old EHR system. Interview on [DATE] at 08:30 am. with the Regional Nurse Consultant (RNC) revealed she stated the former electronic medical record was not able to transfer everything over to the current EHR system, so they had to manually enter the Care Plans. She stated there were so many Care Plans to enter that she instructed her staff to manually enter the Care Plans at their quarterly reviews and stated that was most likely why Resident #1's Care Plan was not in the new EHR system yet. The Regional Training Nurse checked Resident #1's Care Plan schedule and stated his quarterly should have been done [DATE]. The RNC stated that staff could contact any of the Nursing or Administrative staff 24/7 if they had questions regarding Resident #1's care, but also stated that his Care Plan should have been available and accessible to staff who work with him in the current EHR system, so they had access to all needed care information for Resident #1. 2. Record review of Resident #6's admission Record dated [DATE] revealed an [AGE] year-old woman (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 4 of 15 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 07/25/2025 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted on [DATE] with diagnoses which included: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #6's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 12, indicating moderate cognitive impairment. She was assessed with having active diagnoses of Anxiety Disorder, Depression and Psychotic Disorder and was taking antipsychotic, antianxiety and antidepressant medications. Under section D0150 - Resident Mood Interview (PHQ-2 to 9), Resident #6 was assessed as having no symptoms for feeling bad about yourself and having thoughts that you would be better off dead or of hurting yourself in some way. Record review of Resident #6's Order Summary dated [DATE] revealed physician's orders which included:- Buspirone HCL oral tablet 7.5 mg - Give one tablet by mouth two times a day related to anxiety disorder.- Depakote oral tablet delayed release 125 mg (Divalproex Sodium) -Give 1 table by mouth two times a day related to psychotic disorder with delusions due to known physiological condition.- Quetiapine Fumarate [Seroquel] oral tablet 25 mg - Give 1 tablet by mouth at bedtime related to Psychotic Disorder with Delusions due to known physiological condition.- Sertraline HCL [Zoloft] oral tablet 100mg - Give 1 tablet by mouth one time a day for depression.- Trazodone HCL oral tablet 50 mg - Give 1 tablet by mouth at bedtime related Major Depressive Disorder, Single Episode. During an interview on [DATE] at 11:22 a.m., Resident #6 stated she shot herself several months ago, because her husband had died and she did not want to live after that. Resident #6 appeared calm and did not make any statements regarding wanting to harm herself or expressing feelings of depression or hopelessness. She stated the staff had been helping her and she felt safe. Record review of Resident #6's Progress Notes by the Nurse Practitioner (NP) on [DATE] revealed Resident #6's mental and emotional status was assessed and the NP found No indication she would harm herself at this time in the facility. Record review of Resident #6's EHR revealed her husband was alive and was a resident in the same facility but resided in a different room. Further review revealed Resident #6 had initial consult with the mental health counselor on [DATE] and had been receiving both psychiatric and psychotherapy counseling services since her admission. Record review of Resident #6's Care Plan initiated [DATE] revealed focus areas which included Resident is on antipsychotic R/T delusional thinking initiated [DATE]. The interventions for this focus area included: Mental Health to follow resident with counseling: Psychiatric NP to follow resident.; Pharmacy Consultant to follow and make recommendations for GDR/Changes; and Notify MD/RP of any concerns with resident being on antipsychotic. There were no care plan focus areas addressing her past history of or risk of self-harm, or her health diagnoses of anxiety disorder, major depressive disorder, and the medications she took as treatment for her mental health conditions. During a joint interview with the DON and MDS Nurse on [DATE] at 1:34 p.m., the MDS Nurse stated that Resident #6's family member #1, requested that the facility not mention Resident #6's attempted suicide in her documentation, as the family wished to keep it private, and therefore she did not put it explicitly in the care plan. The DON stated that the psychiatrist and mental health counselor and nursing staff assessed and monitored Resident #6's mental health status closely, and noted she has shown improvement since treatment has started. The DON stated that although the family requested her past attempt at self-harm not be included in her record, Resident #6's care plan should have included focus areas addressing her psychiatric diagnoses of Anxiety and Depression, monitoring for side effects of the psychoactive medications she takes to treat her Anxiety and Depression, including the past history of self-harm, so that staff could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 5 of 15 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 07/25/2025 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete be aware of what signs/symptoms of ineffective coping, that needed to be monitored for and reported, as well as any other interventions the team has put into place to meet her psychiatric needs into her care plan. 3. Record review of Resident #3's admission Record dated [DATE] revealed he was admitted on [DATE] with re-admit on [DATE] and had diagnoses which included: Dementia (general term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) , acquired absence of kidney (surgical removal of kidney) and nicotine dependence. Record review of Resident #3's 5-day MDS assessment dated [DATE] revealed he had a BIMS score of 3, indicating severe cognitive impairment and was assessed as having an active diagnosis of acquired absence of kidney. Review of Resident #3's Nursing Progress Note dated [DATE] revealed Resident arrived to facility via EMS.s/p RT radical nephrectomy [removal of kidney] for right adrenal mass [growth found on adrenal gland located on top of right kidney]. Mass diagnosed as adenocarcinoma [type of cancer that grows in glandular cells]. Record review of Resident #3's Comprehensive Care Plan initiated [DATE] revealed the resident's surgical removal of a kidney on [DATE] was not included in his care plan. During an interview with Resident #3 and his friend on [DATE] at 1:37 p.m., his friend stated that Resident #3 had a bad kidney and had it surgically removed recently. She stated that the doctors told him that if he did not stop smoking, he could severely damage his one remaining kidney, so he made the choice to stop smoking. She stated it was important to him to protect his remaining kidney. During a joint interview with the DON and MDS Nurse on [DATE] at 1:34 p.m. the DON stated that the surgical removal of Resident #3's right kidney should have been included in his care plan, as it would have been important to include interventions such as educational needs, and health monitoring into his plan. The DON stated the care plan provided information to the staff on the personalized care needs of each resident, and not having information regarding his acquired absence of a kidney in his care plan could result in Resident #3 not receiving the individualized care he needs. The DON stated she only recently started working at the facility, after he had already had the surgery, so she did not know why it was not included in his plan. The MDS Nurse noted that revision and updating of care plans was a group effort between herself and the DON and noted Resident #3's surgical removal of his kidney occurred when the previous DON was leaving and before the new DON started work, and believes that was the reason they missed updating his care plan to reflect the surgical removal of his kidney. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised [DATE] revealed in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Event ID: Facility ID: 675124 If continuation sheet Page 6 of 15 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 07/25/2025 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)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 for 1 of 1 facility reviewed for nursing services. The facility failed to use the services of an RN as required for 13 days during the period between 3/1/2025 through 7/20/2025. This could result in residents 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: Review of the facility's RN hours revealed there were no RN coverage hours on the following dates: 4/13/2025; 4/26/2025; 5/10/2025; 5/11/2025; 5/24/2025; 5/25/2025; 6/15/2025; 6/21/2025; 6/28/2025; 6/29/2025; 7/4/2025; 7/5/2025; 7/6/2025. During an interview on 07/24/2025 at 3:17 p.m., the Administrator reviewed the time sheets for RN hours and confirmed there was no RN coverage on the listed dates. The Administrator stated they didn't have enough RNs to cover all the weekend slots, and stated it was very tough hiring enough RNs in rural settings. During an interview with the DON on 07/25/2025 at 3:30 p.m., the DON stated they did not have a nursing policy which addressed RN coverage for 8 hours per day as that was a CMS standard. Event ID: Facility ID: 675124 If continuation sheet Page 7 of 15 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 07/25/2025 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 (Residents #1 and #11) of 4 residents reviewed for medication errors, in that: 1. Medication aide-B (MA-B) administered Resident #11 his medication Omeprazole (a medication used to reduce the amount of acid produced by the stomach and recommended to be taken on a empty stomach before a meal) late by 1 hour and 48 minutes. 2. MA-B administered Resident #1's Refresh Optive Mega-3 eyedrops (a medication to relieve eye dryness), late by 4.5 hours. 3. MA-B administered Resident #1's Refresh Optive Mega-3 eyedrops, one drop to each eye on 07/24/2025 at 12:28 p.m., but the physician order indicated REFRESH OPTIVE ADVANCED DROPS Instill 1 drop in both eyes one time a day related to LEGAL BLINDNESS. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders. Findings include: 1.Record review of Resident #11's admission Record, dated 07/25/2025 revealed he was a [AGE] year-old man admitted on [DATE] with readmission on [DATE], and with diagnoses which included: Gastro-esophageal Reflux Disease (a digestive disease in which stomach acid irritates the esophagus lining, causing heartburn). Record review of Resident #11's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated the resident's cognition was intact. Record review of Resident #11's Order Summary, dated 07/25/2025, revealed the resident had a Physician Order for OMEPRAZOLE DR 20MG TABLET Give 1 tablet orally one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS. Record review of Resident #11's MAR for July 2025 reflected an administration time of 7:00 a.m. for the Omeprazole. Record review of website for Drugs.com at https://www.drugs.com revealed it is usually best to take Omeprazole 1 hour before meals and When omeprazole is taken with food, it reduces the amount of omeprazole that reaches the bloodstream. Observation and interview with MA-B on 07/24/2025 at 8:48 a.m., revealed MA-B preparing medications to administer to Resident #11. MA-B's computer electronic medical record display showed a display of Resident's #11 medications, all of which were highlighted in yellow, except for one, which was highlighted in red. The medication highlighted in red was his Omeprazole. MA-B stated the red highlighted medication meant the medication was late in being administered. MA-B administered 10 medications to Resident #11, all of which were on time, except for the Omeprazole which was administered 1 hour and 48 minutes late. During further interview with MA-B on 07/24/2025 at 12:30 p.m., she stated she was late giving Resident #11 his medications that morning, because she arrived late to work, and arrived too late to administer Resident #11's Omeprazole on time. She stated she was supposed to start work at 7:00a.m., but that does not give her enough time to give everyone scheduled for 7:00 a.m. their medications within the hour window (a one-hour medication administration window, created by giving healthcare professionals 30 minutes before and after a medication is scheduled to be given to administer the medication). Medication Aide-B stated she thought medications likes Omeprazole should be given at 6:00 a.m. by the night shift. 2. Record review of Resident #1's admission Record dated 07/22/2025 revealed he was a [AGE] year-old man initially admitted on [DATE] with re-admission on [DATE] and with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person can see at 20 feet what a person with normal vision can see at 200 feet) and Dry Eye Syndrome (condition where tears produced aren't able to provide adequate lubrication for the eyes). Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS score of 11, indicating moderate cognitive impairment and had an active diagnosis of legal blindness. Record review of Resident #1's Order Summary dated 07/24/2024 revealed a Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 8 of 15 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 07/25/2025 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete physician order for REFRESH OPTIVE ADVANCED DROPS Instill 1 drop in both eyes one time a day related to LEGAL BLINDNESS. Record review of Resident #1's July Medication Administration Record (MAR) revealed an administration time of 0700 for Resident #1's Refresh Optive Advanced Drops. During an observation on 07/24/2025 at 12:28 p.m. of medication administration of an antibiotic oral pill for Resident #1 by MA-B, Resident #1 told MA-B that she did not give him his eye drops that morning. MA-B told him she had not given him his eyedrops this morning because she had been running late, but she would give him his eyedrops now. Further observation revealed MA-B then prepared and administered Resident #1's Refresh Optive eye drops, one drop in each eye. During an interview on 07/24/2025 at 12:30 p.m., MA-B stated that because she was running late that morning, she was trying to hurry and was going to give Resident #1's eye drops later in the day. MA-B stated that when medications are not given at the time listed on the MAR, it could result in medications being given too close together. 3. Observation of medication administration on 07/24/2024 at 12:28 p.m., for Resident #1 by MA-B, revealed MA-B administered one drop of Refresh Optive Mega-3 eye drops, one drop into each eye, but the physician order indicated REFRESH OPTIVE ADVANCED DROPS Instill 1 drop in both eyes one time a day related to LEGAL BLINDNESS. During an interview on 07/24/2025 at 12:30 p.m., MA-B stated she was aware the eyedrops she administered to Resident #1 did not exactly match the name of the medication on the MAR, but stated this is what the pharmacy delivered so she assumed it was just a substitute for the ordered medication and okay to give. During a joint interview on 07/24/2025 at 12:45 p.m. with the Administrator and DON, the DON stated medications administered to the Residents needed to be administered within the one-hour window for medication administration, and that if it was not given at the correct time, it could affect how medications are absorbed, noting some medications such as Omeprazole should be taken on an empty stomach. The DON further stated that the right medication needed to be given and that meant it matched what was listed on the MAR. The DON stated that if the wrong type of eyedrop was given it could result in possible adverse reaction or decreased therapeutic effect. Record review of facility policy titled Administering Medications revised April 2019 revealed Medications are administered in accordance with prescriber orders, including any required time frame. Further review revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Event ID: Facility ID: 675124 If continuation sheet Page 9 of 15 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 07/25/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility, were labeled and stored in accordance with professional standards for 1 (Hall 300 Nurse's medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure one controlled medication Morphine Sulfate 20mg/5ml oral suspension for Resident #8 was removed from the medication cart when it had expired on 12/28/2024. This failure could place residents at risk of not receiving the therapeutic benefit of medications.Findings included: Record review of Resident #8's admission Record dated 07/22/2025 revealed she was an [AGE] year-old woman admitted [DATE] with re-admission on [DATE] and with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow and makes it difficult to breathe). Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 2, indicating severe cognitive impairment. Record review of Resident #8's Order Summary dated 07/22/2025 revealed a physician order for Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 1 ml by mouth every 4 hours as needed for pain or shortness of breath. During an observation of the Hall 300 Nurse's medication cart with LVN-A present on 7/24/2025 at 8:00 a.m., a box of Morphine Sulphate 20mg/5ml oral suspension prescribed for Resident #8 with an expiration date of 12/28/2024 was found in the back of the locked controlled medication storage inside the Hall 300 Nurse's medication cart. Interview on 07/24/2025 at 8:04 a.m. with LVN-A revealed she had only been working at the facility for 3 weeks. LVN-A stated that the date on the pharmacy label for the Morphine Sulfate showed that the medication was expired. LVN-A stated she did not know whose responsibility it was to check the medication carts and remove expired medications, but she would ask her supervisor. During an interview on 07/24/2025 at 08:10 a.m., the DON reviewed the pharmacy label on the Morphine Sulfate for Resident #8 and confirmed that it was expired and should not be stored in the medication cart. The DON stated that it was the responsibility of the Nurse using the medication cart to remove any expired medications. She stated expired medications may lose some of their therapeutic effect, and not removing expired medications from the medication cart may result in expired medications being administered to residents. Record review of Competency Checklist for LVN-A dated 7/10/2025, revealed LVN-A had been checked as showing competency in pharmacy to include: expiration of medications, ordering medications, House stock and Documentation. Record review of the facility policy titled Medication Labeling and Storage revised February 2023 revealed If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Event ID: Facility ID: 675124 If continuation sheet Page 10 of 15 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 07/25/2025 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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 of 3 residents (Residents #4 and #15) reviewed for personal food policy, in that: 1.Resident # 4's personal refrigerator located in her room revealed food item of a glass jar of Picante Sauce which had been opened with a Best Use By Date of February 9,2025. There was no label or date of when the jar had been opened. 2.Resident # 15's personal refrigerator located in his room revealed food item of a Styrofoam cup covered with clear plastic wrap with white liquid inside it. There was no label or date identifying the name or date. These failures could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #4's face sheet, dated 07/24/2025, reflected the resident was an [AGE] year old female and was initially admitted to the facility on [DATE] with diagnoses that included: Fracture of the Left Femur (Broken leg), Hemiplegia and Hemiparesis affecting Left non-dominant side (Unable to move left side of body) Unspecified Dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life) Record review of Resident #4's quarterly MDS assessment, dated 07/07/2025, reflected the resident's BIMS score was 4 out of 15 which indicated the resident had severe cognitive impairment. Record review of Resident # 15's face sheet, dated 07/24/2025, reflected the resident was an [AGE] year-old male and was initially admitted to the facility on [DATE] with diagnoses that included: Muscle Wasting and Atrophy (loss of muscle tissue and strength), Chronic Kidney Disease Stage 3 (kidneys are not filtering correctly), Type 2 Diabetes (body does not produce enough insulin). Record review of Resident #15's quarterly MDS assessment, dated 05/01/2025, reflected the resident's BIMS score was 13 out of 15 which indicated the resident had mild cognitive impairment. Observation on 07/22/2025 at 11:00 a.m. revealed Resident #4 was not in her room. There was a personal refrigerator in the room, and inside the refrigerator was a glass jar of Picante Sauce which had been opened with a Best Use by Date of February 9,2025. There was no label or date of when the jar had been opened. Observation on 07/22/2025 at 11:30 a.m. revealed Resident #15 was not in his room. There was a personal refrigerator in the room, and inside the refrigerator was a Styrofoam cup covered with clear plastic wrap with white liquid inside it. There was no label or date identifying the name or date. Interview and observation on 07/24/2025 beginning at 11:00 a.m. the DON and the Administrator went to both residents' room and showed them the food items. I asked what the white liquid was in the Styrofoam cup. They thought it might be milk. I asked them how long it had been in the refrigerator. The DON and Administrator were unable to answer since there was no date on the cup I talked to them about the expired picante sauce jar. I asked the DON and Administrator what could happen if food or drink that is consumed that is outdated, and both replied that the residents could become ill. The DON and Administrator confirmed that outdated food should be thrown away. I asked who is responsible for checking items in refrigerator. The Administrator told me it is the nursing staff, and the housekeeping keeps track of the temperature logs. Record review of the facility policy titled Foods Brought by Family/Visitors, revised March 2022, revealed .5. Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that is clearly distinguishable from facility-prepped food. 6. The nursing staff will discard perishable foods on or before the use by or expiration date. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 11 of 15 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 07/25/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete and accurately documented, for 1 of 8 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's application of TED hose was accurately documented on his Medication Administration Record (MAR) for 23 of 23 daily entries in July 2025. This failure could place the residents at risk of not receiving the care and services needed due to inaccessible and inaccurate clinical records. Findings included: Record review of Resident #1's admission Record revealed he was a [AGE] year-old man admitted [DATE], and re-admitted on [DATE], with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person an see at 20 feet what a person with normal vision can see at 200 feet), Borderline Intellectual Functioning (cognitive abilities that are below average, but not enough to be classified as intellectual disability), Major Depressive Disorder (mental health disorder characterized by persistent depressed mood or loss of interest causing impairment in life), and Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS score of 11, indicating moderate cognitive impairment and had an active diagnosis of legal blindness. Record review of Resident #1's Order Summary dated 07/24/2025 revealed an order for TED Hose -On in AM, off at HS at bedtime for edema (swelling). Record review of Resident #1's July 2025 MAR revealed every daily entry at 0700 from 07/01/2025 through 07/23/2025 was checked and initialed for TED Hose - On in AM. indicating that TED hose were placed on Resident #1 every morning. Further review revealed 20 of 22 daily entries at 1900 (7:00p.m.) were documented with a 9 indicating see progress note. The two remaining daily entries at 1900 were documented as off and N/A (non-applicable). Observation and Interview with Resident #1 and family member #1 on 07/23/2025 at 2:53 p.m. revealed Resident #1 was sitting on the edge of his bed, wearing black compression knee-hi socks on his feet. Resident #1 stated staff have never put TED hose on him, and he always wears the type of socks he was currently wearing, and he puts them on himself every day. Resident #1's family member stated she has never seen staff put TED hose on Resident #1, and he always puts on the black knee-high compression socks he was wearing currently. Interview on 07/23/2025 at 6:36 p.m. with LVN C revealed she has never seen Resident #9 wear TED hose, so she documents 9 on his MAR, which she stated meant to check the progress record, and stated she usually writes in note that Resident #1 was not wearing TED hose at 7:00p.m. LVN-C stated she thought his primary doctor was going to discontinue the TED hose order, because he does not experience leg swelling anymore and does not need them. During an observation of Resident #1, and interview with the Unit Manager on 07/24/2025 at 8:03 a.m. the Unit Manager stated that Resident #1 wears his black compression socks every day, and stated that the day Nurse's were documenting the use of the compression socks in place of the TED hose on his MAR. The Unit Manager noted Resident #1's ankle/feet/legs were not swollen at this time. Observation of Resident #1 during this interview revealed Resident #1's ankle/feet/legs were not swollen. During an interview on 07/24/2025 at 4:50 p.m., the DON stated that compression socks and TED Hose were not the same thing and should not be substituted one for the other. TED hose are used to treat edema and are used primarily for bed bound residents, and compression stockings are used for residents who are more ambulatory. The DON stated she will contact Resident #1's primary physician for clarification of the TED hose order, and also stated the discrepancy on Resident #1's (day shift documenting TED hose were placed on in mornings and night shift documenting the TED hose were not on at 7:00p.m.) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 12 of 15 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 07/25/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm inaccurate documentation and she would address. Record review of facility policy titled Charting and Documentation undated revealed The following information is to be documented in the resident medical record:.treatments or services performed. and Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 13 of 15 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 07/25/2025 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)

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 disease and infection for 2 of 6 residents (Residents #4 and #24) reviewed for infection control: 1.The facility failed to maintain proper infection control procedures when LVN-A place Resident #4's open left heel wound directly onto the Resident's bedspread to during wound care treatment. 2.The facility failed to ensure MA-B sanitized the blood pressure cuff per facility protocol before and after checking Resident #24's blood pressure. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1.Record review of Resident #4's admission Record dated 07/25/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: Venous insufficiency-peripheral (condition where veins in leg become damaged and struggle to send blood back up to the heart), and hemiplegia and hemiparesis following cerebral infarction (partial paralysis on one side of body resulting from a stroke) affecting left non-dominant side. Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and was assessed as having a pressure ulcer/injury over bony prominence requiring application of dressings to feet. Record review of Resident #4's Order Summary dated 07/25/2025 revealed an order for Left heel wound: Cleanse with wound cleanser, apply betadine, wrap with kerlix every day shift for wound care related to VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL). Record review of Resident #4's Care Plan revealed a focus area for Pressure ulcer to left heel-stage 3 initiated 06/19/2025, with interventions which included treatments as ordered. Observation on 07/24/2025 at 2:09 p.m. of wound care for Resident #4 by LVN-A revealed that after removing the old dressing from Resident #4's left heel, LVN-A placed Resident #4's heel/foot on top of the bedspread on her bed to rest while LVN-A sanitized her hands and changed her gloves. After sanitizing her hands and changing her gloves, LVN-A picked up Resident #4's left foot and proceeded to clean and change the dressing per physician orders. During an interview on 07/24/2025 at 2:28 p.m. - LVN-A stated she was having trouble holding up Resident #4's foot and trying to clean/dress the wound at the same time. LVN-A stated she should not have placed Resident #4's heel down on the bedspread as it was not a sanitized surface, which could result in transfer of germs into the heel wound, and the transfer of germs onto the bedspread. LVN-A stated she had only been working at the facility a few weeks but had received training in infection control and wound care. Interview on 07/25/2025 at 9:50 a.m. with the DON revealed the DON stated that LVN-A should not have placed Resident #4's heel wound directly onto a surface that was not clean, as this could result in spread of infection. The DON stated LVN-A had received training in wound care and infection control, but they will educate and re-do her competency checklist for infection control. 2.Record review of Resident #24's admission Record dated 07/25/2025 revealed he was a [AGE] year-old man admitted [DATE] with diagnoses which included Essential Hypertension (high-blood pressure). Record review of Resident #24's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment and had an active diagnosis of hypertension. Record review of Resident #24's Medication Administration Record (MAR) for July 2025 revealed an order for AMLODIPINE BESYLATE 10MG TAB Give 1 tablet orally one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION with space on the MAR to document Resident #24's blood pressure. During an observation of medication administration for Resident #24 on 07/24/2025 at 8:16 a.m., MA-B was observed to clean the blood pressure cuff before and after checking Resident #24's blood pressure by taking a tissue, pumping 1-2 pumps of gel from the hand Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675124 If continuation sheet Page 14 of 15 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 07/25/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sanitizer dispenser onto the tissue, and cleaning the blood pressure cuff with the tissue. During an interview with MA-B on 07/24/2025 at 12:30 p.m., MA-B stated that cleaning the blood pressure cuff with a tissue that had hand sanitizer gel on it was not the proper way to sanitize the cuff. She opened one of the drawers on the medication cart to reveal a blue top disinfecting wipes container labeled Micro-Kill Bleach and stated that is what they are supposed to use to sanitize the blood pressure cuffs in between uses, however she is allergic to bleach so she cannot use it. She further stated she had seen other staff clean the blood pressure cuffs using tissue and hand-sanitizing gel, so thought it would be okay, noting if it could sanitize hands it should be enough to sanitize the blood pressure cuffs. During an interview with the ADM and DON on 07/24/2025 at 12:45 p.m., the DON stated that using a tissue with hand sanitizer gel on it was not an acceptable method to sanitize a blood pressure cuff and could result in the spread of infection. The DON stated that Medication Aides and Nurses are taught to sanitize blood pressure cuffs using the purple top disinfecting wipes (Super Sani-Cloth) which do not contain bleach, and to wear gloves when they were disinfecting the blood pressure cuffs, and that they will be in-servicing MA-B regarding infection control and device sanitation. Interview on 07/25/2025 at 9:50 a.m. with the DON revealed the DON stated that they do not have a policy which specifically addresses how to sanitize blood pressure cuffs. Record review of facility policy titled Standard Precautions revised September 2022, revealed under policy statement Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. and Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. Event ID: Facility ID: 675124 If continuation sheet Page 15 of 15