Health inspection·January 3, 2026

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 grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to provide Resident #1 with assistance with the bathroom for more than 40 minutes following his second verbal request to CNA A on 1/02/2026. This failure could affect and diminish the resident's quality of life by potentially placing the resident at risk of infections, skin breakdown and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being. The findings include: Record review of Resident #1's admission record dated 1/03/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as an ischemic stroke, occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue) quadriplegia (a form of paralysis that affects all four limbs and the torso), and muscle wasting and atrophy (is the loss of muscle mass and strength). Record review of Resident #1's quarterly Minimum Data Set, dated [DATE] reflected a BIMS score 14, which indicated cognition to be intact. Section GG - Functional Abilities reflected Resident #1 required Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. The assistance of 2 or more helpers to provide total care is required for the resident to complete chair/bed-to-chair transfer, toilet transfer, shower transfer, sit to stand. Self-Care reflected Resident #1 required Dependent - Helper does All of the effort for activities of eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene. Resident #1 uses a wheelchair for mobility. Resident's urinary continence is always incontinent, and bowel continence is frequently incontinent. Record review of Resident #1's care plan dated 6/19/2025 and last revised 12/12/2025, reflected the following, Impaired Physical Mobility. Goal Resident Will Be Free of Complications of Immobility and Resident's Skin Will Remain Intact. Interventions Assist Resident in performing movements / tasks. Resident is at risk for pressure ulcer due to moisture. Goal Intact skin without evidence of redness, irritation, maceration, or open areas. Resident #1 is at Risk for Impaired Skin Integrity. Goal Resident's Skin Will Remain Intact and Identify Resident's Risk for Impaired Skin Integrity. Interventions Educate Resident / Representative about proper skin care to prevent skin breakdown. Further review of Resident #1's care plan dated 7/02/2025 and last revised on 12/12/2025, reflected the following, The resident has an ADL self-care performance deficit r/t. Goal The resident will maintain current level of function. Interventions TOILET USE: The resident is totally dependent on (X) staff for toilet use and TRANSFER: The resident requires Mechanical Lift (SPECIFY) with (X) staff assistance for transfers. Record review of Resident #1's progress note, dated 12/11/2025 and created by the ADON, Functional Limitations and Range of Motion: reflected the following: ADON documented, Significant Correction. Dates for 3-day window: 12/09-12/11 IDT Collaboration.Upper extremity (shoulder, elbow, wrist, hand): Impairment on Residents Affected - Few Page 1 of 4 675124 675124 01/03/2026 Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few one side. Lower extremity (hip, knee, ankle, foot): Impairment on one side. Wheelchair (manual or electric). Self-Care: Eating: Interim: Dependent. Oral hygiene: Interim: Dependent. Toileting hygiene: Interim: Dependent. Shower / bathe self: Interim: Dependent. Upper body dressing: Interim: Dependent. Lower body dressing: Interim: Dependent. Putting on/taking off footwear: Interim: Dependent. Personal hygiene: Interim: Dependent. Record review of Resident #1's quarterly Bowel and Bladder Program Screener dated 12/09/2025 reflected the following: a. Voids appropriately without incontinence3. Alwaysb. Incontinent of Stool3. Neverc. Ability to Get to the BR/transfer to toilet/commode/urinal, adjust to clothing and wipe etc0. Immobile, or 2 person assistd. Mental Status3. Alert and orientede. Mentally aware of need to toilet3. Always aware of need to toilet In an observation and interview on 1/02/2026 at 12:48 PM, Resident #1 was observed sitting in his wheelchair, he was dressed appropriately for the weather. He was observed to lower and raise his head numerous times. He was holding the call light. Resident #1 stated he was not having a good day, he was angry. He stated he has been wet for an hour now; CNA A doesn't want to change or bathe him. He stated he needs 2 staff to transfer him and all he wants was to be changed. He was observed pressing the call light for assistance. In an observation on 1/02/2026 at 12:50 PM, CNA A entered Resident #1's room to respond to his call light being on. CNA A turned off the call light and informed Resident #1 she was still waiting for additional nursing staff to help her change his brief and she will return once she has another staff. She walked out of resident's room rushed and didn't allow Resident #1 to explain why he pressed the call light. In an observation and interview on 1/02/2026 at 1:06 PM, Resident #1 stated he was still waiting for the nursing staff, and he had yet to be changed. CNA A entered Resident #1's room and put down wipes, gloves, and changing pads on his bed near him and walked out quickly saying she would return and state, resident is so impatient, I'm trying to help him, but I need another staff to help me. In an observation on 1/02/2026 at 1:19 PM, CNA A was observed asking Med Tech if she would be able to assist her with a 2-person brief change and she responded she would help her. In an observation on 1/02/2026 at 1:21 PM, Med Tech and CNA A were observed entering Resident #1's room to provide resident with incontinent care. The two staff exited the room quickly. In an observation and interview on 1/02/2026 at 1:24 PM, CNA A was observed entering Resident #1's room and wheeling Resident #1 to the shower area. She passed surveyor and stated for the second time, Resident #1 is so impatient, and I keep explaining to him that I need another staff to help me clean and change him or bathe him. In an observation on 1/02/2026 at 1:28 PM, Med Tech was observed entering the shower area to assist CNA A with toileting hygiene and showering Resident #1. In an interview on 1/02/2026 at 5:35 PM, CNA B stated she has received training in ANE and resident rights during onboarding to full-time staff on 12/09/2025. CNA B was knowledgeable of ANE and resident rights and provided examples. She stated call lights responses are within 5-10 minutes. She stated the residents can wait up to 30 minutes at most for care as there was one charge nurse and one CNA for each hallway. She stated the wait time can be longer for residents that require 2-person assistance. She stated residents waiting more than 30 minutes for toileting hygiene was outside of facility protocol and can be seen as neglectful and could affect a resident in that they can distrust staff and think that all staff were the same. In an interview on 1/03/2026 at 11:20 AM, CNA A stated she received in-service on ANE and resident rights during monthly meetings. She was knowledgeable of ANE and resident rights and provided examples. She stated call light responses are within 5 minutes, but no more than 10 minutes. She stated anything after 15 minutes was not okay but sometimes it can go past 30 minutes if staff were too busy or cannot find a 2nd staff member to help with 2-person transfer. She stated rounds for brief change should be made every 2 hours. She stated Resident #1 was a 2-person transfer, she asked other 675124 Page 2 of 4 675124 01/03/2026 Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing staff for help, and she was not getting it. She stated she was able to get help from Med Tech after more than 30 minutes waiting for toileting hygiene. She stated she believes several staff members do not care for her and refuse to help her. She stated that a waiting time of 40 minutes was excessive and can make a resident feel like they were not important and make them feel bad and feel like they were not getting proper hygiene. CNA A stated 100 hallway had heavy male residents who were heavy wetters and require frequent changes with 2-person and hoyer lift. She stated it was difficult to transfer residents as she has carpal tunnel, she was too stressed, very tired, and frustrated she doesn't get help quickly. CNA A was unable to recall when she informed management of these concerns, and she would not provide information as to which management staff she approached directly with these concerns. CNA A stated she couldn't recall what time Resident #1 requested assistance with brief change and that she was doing her best to assist him. In an interview on 1/03/2026 at 12:02 PM, CNA C stated she received in-service on ANE and resident rights during mandatory monthly meetings. She was knowledgeable of ANE and resident rights and provided examples. She stated effects of ANE on a resident would be loss of trust in staff and would not want staff to work or provide them with care. She stated call lights responses were within 5 minutes, but no more than 10 minutes and rounding every two hours. She stated there were challenges with meeting the call light response and rounding expectation of the facility and sometimes can go a little longer than 5-10 minutes. She stated assisting a resident was everybody's job. She stated providing brief change for a resident can exceed the 5-10 minutes wait time, but more than 30 minutes for call light response for brief change would be considered excessive and can make a resident upset to stay soiled for long periods of time. She was not familiar with Resident #1's care other than he requires 2-person assistance with hoyer lift. In an interview on 1/03/2026 at 12:25 PM, LVN stated she was agency staff, and this was her 2nd shift at this facility. She stated there were enough staff to meet the needs of the residents. She stated call lights were expected to be answered ASAP, and rounding was expected every 2 hours. She stated she believes more than 30-minute wait time for brief change would be excessive for a resident and could cause them to become upset and would not be happy about it and would feel helpless. She stated she was not familiar with Resident #1's care. In an interview on 1/03/2026 at 1:00 PM, the Regional Nurse Consultant stated that she received ANE and resident rights training 2 weeks back at a sister facility of the company. She stated the facility has annual training on procedures and policies that were conducted by the DON at the other facility. She stated the response of call lights was in a timely manner and this was within 5 minutes. She stated nursing staff may not be able to provide care for the residents immediately but were required to communicate with the residents during the waiting time. She stated she wouldn't want a resident to wait more than 10 minutes for brief changes. She stated that rounding and call light response in-service was conducted about 3 weeks back. The Regional Nurse Consultant stated it was a team at this facility, and everyone should help. She stated it would be excessive for a resident to wait more than 30 minutes for a brief change. She stated if a resident was soiled and in brief for more than 30 minutes it could make the residents angry, especially if alerted. She stated Resident #1 was total care and he was alert. She stated more than 35-minute wait time to have his brief changed was unacceptable and that staff not helping each other after asking one another was not acceptable and will look into this incident. In an interview on 1/03/2026 at 3:31 PM, the Administrator stated she completed ANE and resident rights training online in the last week. She was knowledgeable of ANE and resident rights and provided examples. She stated she was the abuse coordinator for the facility. She stated that the call light response time follows the Texas Administration code and rounding of 2 hours. She stated all staff can answer a call light and if 675124 Page 3 of 4 675124 01/03/2026 Avir at Gonzales 3428 Moulton Rd Gonzales, TX 78629

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few something out of the scope of practice would need to notify the nurse aid or charge nurse. She stated a recent in-service on call lights was conducted and it conveyed to staff check on call lights quickly when it is seen. She stated if an aide needs additional staff for a 2-person transfer, let the resident know that they were going to go get help. The Administrator stated residents were not aware of time or believe they have been waiting longer if staff are not communicating or feel they have been neglected if not responded to. She stated if staff were not rounding or responding to call lights in a timely manner, the resident may want to go to the restroom, and they could get up on their own and hurt themselves. She stated rounding protocol was every 2 hours to ensure residents are cared for, clean, safe, and not neglected. The Administrator stated residents who are total care would require 2-person assistance for toileting hygiene. She stated if the aide was working with another resident the aide can then request help from a charge nurse. She stated that residents should not wait longer than 30 minutes for brief change. She stated Resident #1 was total care and he was alert. She stated more than 35-minute wait time to have his brief changed was unacceptable and that staff not helping each other after asking one another was not acceptable and will look into this incident. Record review of facility In-Service Training Report, dated 11/07/2025 revealed: Content: Respect & dignity, communication, compassion & patience, teamwork & attitude, service recovery. Record review of the facility's policy, Resident Rights, dated 02/2021 revealed: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity Record review of the facility's policy, Activities of Daily Living (ADL), Supporting, dated 2001 revealed: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care);b. mobility (transfer and ambulation, including walking);c. elimination (toileting);5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD) and the following MDS definitions:f. Dependent: If the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity. Record review of the facility's policy, Call System, Residents, dated 01/2025 revealed: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.6. Calls for assistance are answered timely. 675124 Page 4 of 4