Health inspection·November 26, 2025

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 observation, interview, and record review, the facility failed to ensure RN coverage of eight (8) hrs daily and a full time DON for eight days (11/1/25, 11/2/25,11/6/25,11/9/25,11/12/25, 11/13/25,11/17/25, and 11/18/25) in November 2025 for 1 of 1 facility. The facility failed to ensure RN 8 hour daily coverage and a full time DON in the facility for eight days in November 2025. This deficient practice could place residents at-risk of not having their care needs assessed by a licensed RN on a daily basis.The findings included: Record review of the facility's daily nursing staffing for the time period of 10/31/25 through 11/24/25 revealed there were eight days in the month of November 2025 in which there was not an RN or DON working at the facility during the 24 hour time period for the following days (11/1/25,11/2/25,11/6/25, 11/9/25, 11/12/25,11/13/25, 11/17/25, and 11/18/25). During an interview on 11/26/25 at 9:00 a.m. with the Corporate RN-A she advised that she had visited the facility as much as possible since the DON position became vacant in order to provide the required RN coverage. The RN Corporate Nurse stated that her visits to the facility were not made on a daily basis. During an interview on 11/26/25 at 9:20am with the Human Resources (HR) Director she advised that the previous DON who provided the daily 8 hours of RN coverage at the facility was last employed at the facility on 10/31/25.The HR Director stated that there was not an RN or DON working at the facility during the 24 hour time period on the following days (11/1/25, 11/2/25, 11/6/25, 11/9/25, 11/12/25. 11/13/25. 11/17/25, and 11/18/25). During an interview on 11/26/25 at 11:00am with the Administrator and ADON-B they advised that having a DON/RN at the facility was necessary to provide a licensed nursing assessment of resident care needs and behaviors on a daily basis. Record review of the facility policy titled Staffing, Sufficient and Competent Nursing revealed A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week. Page 1 of 2 675124 675124 11/26/2025 Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 an adequate communication system to allow residents to call for staff assistance for 3 of 9 rooms (Rooms# 108,109, and 206) reviewed on the three resident hallways for an operating call light system. The facility failed to ensure Resident rooms # 108, 109, and 206 had a fully functional call light notification system. This deficient practice could place residents at-risk of not being able to call for staff assistance to meet care needs.The findings included: Record review of the facility floor plan revealed there were three resident hallways (hallway #'s 100, 200, and 300). Record review of the facility's maintenance repair log from 01/25 through 10/25 revealed maintenance repairs on all of the three resident hallways included call light notification repairs which had been completed. Observation rounds on 11/25/25 from 2:55 p.m. through 3:15 p.m with the Maintenance Director and Activity Director., revealed that the room dome lights outside the entrance to rooms #108 and 109 did not come on when the call light was engaged inside the room and the room dome light apparatus outside of room [ROOM NUMBER] was missing from the room's door entrance. During an interview on 11/25/25 at 3:20 p.m., with the Maintenance Director and Activity Director , the Maintenance Director stated that he was not aware of how long the dome lights in the rooms [ROOM NUMBER] had been in need of repair. The Maintenance Director stated that he had been in the Maintenance Director position for approximately one month. The Maintenance Director stated he had checked the hallway call lights as needed but had not kept a written log of the room call light checks which were completed. The Maintenance Director and Activity Director stated that having an operating dome light would have assisted staff by providing visual notification that the resident had care needs. During an interview on 11/26/25 at 8:30am with the Administrator she stated that all of the resident hallway room call lights had been re-checked and were functioning properly. The Administrator stated that the Residents had to have a complete functional alarm notification system to ensure notification of their care needs. Record review of the facility's policy titled Call System Residents dated 2001 revealed The resident call system remains functional at all times. Residents Affected - Some 675124 Page 2 of 2