Health inspection·August 31, 2022

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 CNAs 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 for 1 of 2 CNAs (CNA A) observed for incontinent care, in that: CNA A failed to use appropriate techniques while cleaning Resident #144's rectal area during wound/incontinent care. This deficient practice place residents identified for incontinent care at risk for cross contamination resulting in infections. The findings include: Record review of Resident #144's face sheet, dated 08/31/2022 revealed an admission date of 08/27/2022 with diagnoses which included: acute respiratory failure with hypoxia (hypoxemic respiratory failure means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), sepsis (the body's extreme response to an infection), pneumonia (an infection that inflames the air sacs in one or both lungs), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), atrial Fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), acute kidney failure (when your kidneys stop working suddenly) and pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung). Record review of Resident #144's most recent admission MDS assessment, dated 08/23/2022, revealed the resident was incontinent of both bowel and bladder and was totally dependent upon 1 staff member to provide incontinent care. Observation on 08/31/2022 at 11:05 a.m., during wound care for Resident #144, revealed the resident was incontinent of bowel movement (BM), resulting in CNA A, needing to provide incontinent care. As CNA A was cleaning the rectal area, CNA A took a wet wipe and wiped back and forth without changing the surface of the wet wipe or obtaining a clean wet wipe X 2 to on Resident #144. Further observation revealed as LVN A and CNA A began to turn Resident #144 on his left side, he became incontinent of BM again. Again, CNA A began to provide incontinent care to Resident #144 and as she was cleaning the rectal area, CNA A took a wet wipe and wiped back and forth without changing the surface of the wet wipe or obtaining a clean wet wipe X 2. During an interview on 08/31/2022 at 11:09 a.m., CNA A confirmed she had wiped Resident #144's rectal area X2 each time with a wet wipe and wiped back and forth without changing the surface of the wet wipe or obtaining a clean wet wipe During an interview on 08/31/2022 at 11:40 p.m., the ADON stated CNA A had performed incontinent care before. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 2 of 6 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 676138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Gonzales 701 N Sarah Dewitt 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 - Few Record review of CNA A's Personnel Files revealed CNA A was hired on 09/13/2021 and review of CNA A's training record CNA Skills Checklist dated 11/24 (no year), revealed on the second page, Personal Care: Pericare/Incontinent Male and was checked off by the instructor, the initials of the employee and date completed (11-24). During an interview with the DON on 08/31/2022, the DON stated the facility used [NAME] and [NAME] as their policy and procedure for perineal care. Record review of the Facility Procedural Guideline #21 for Perineal Care/Incontinent Care-Male (no date) used to train CNA A and the [NAME] & [NAME] on Perineal Care (also used by the facility) stated in part: 12. After cleansing genital area, turn to side, then wash and rinse the rectal area moving from front to back using a clean area of washcloth for each stroke . (Facility uses wet wipes instead of a washcloth). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 3 of 6 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 676138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Gonzales 701 N Sarah Dewitt 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications, in that: The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings include: During an interview on 8/28/2022 at 4:05 p.m., Dietary Aide A stated the Dietary Manager was not available as she was out on leave. During an interview on 8/29/2022 at 8:30 a.m., the Administrator explained the facility did not have a Certified Dietary Manager employed at this time and further stated the staff currently identified by kitchen staff as the current Dietary Manager was not certified. Record review of employee records and licensure revealed the Dietary Manger was hired 12/12/2017 as an employee with the facility. No documentation provided by the facility revealed the date the current Dietary Manager assumed that role in the facility. Record review of the USDA Food Code 2017 indicated the following: Based on the risks inherent to the Food Operation, during inspections and upon request the Person in Charge shall demonstrate to the Regulatory Authority knowledge of food borne disease prevention application of the Hazard Analysis of foodborne disease prevention, application of the Hazard Analysis and Critical Control Point principles, and the requirements of this Code. The Person in Charge shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of priority items during the current inspection; (B) Being a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program; Record review of Texas Food Establishment Rules 228.33 Certified Food Protection Manager and Food Handler Requirements 228.33(a) states: At least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 4 of 6 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 676138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Gonzales 701 N Sarah Dewitt 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 - Some 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 in 1 of 1 kitchen reviewed for sanitation and storage, in that: 1. The facility failed to properly store food in the walk-in refrigerator. 2. The facility failed to properly store food in the walk-in freezer. 3. The ceiling in the dry storage area had water stains and water was leaking on a box. These deficient practices could place residents who eat food from the kitchen at-risk of foodborne illness. Observation of the walk-in refrigerator on 8/28/2022 at 4:10 p.m., with Dietary Aide C, revealed the following: - One 3-pound container or sour cream opened and approximately 75 percent used was not labeled with an open date, - Cheese removed from the manufacturer's packaging was not labeled or dated, - One quarter silver pan of what was identified by kitchen staff as possibly beef stew was not labeled, - One quarter silver pan of what was identified by kitchen staff as possibly eggs was not labeled, - One quarter silver pan of what was identified by kitchen staff as possibly sausage and bacon was not identified, - One quarter pan of an unknown substance tan in color was not labeled in the walk- in refrigerator, - and One full sheet carrot cake was partially used and stored in the walk- in freezer with no open date. Observation of the walk-in freezer on 08/28/2022 at 4:13 p.m., with Dietary Aide C, revealed the following: - One 3-gallon container of ice cream had a torn lid exposing the ice cream to other possible containments, - One package of an unknown substance identified as possibly some type of meat in the freezer with no date or label, - One item wrapped in foil, approximately the size of standard house brick, was unlabeled or dated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 5 of 6 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 676138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Gonzales 701 N Sarah Dewitt 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 - One 2.5 pound fully cooked sliced ham with no manufacturers date visible on the packaging, Level of Harm - Minimal harm or potential for actual harm - and two 40-ounce bags of frozen green peas with no manufacturer's date visible on the packaging. Residents Affected - Some Observation on 08/29/2022 at 4:15 p.m., with Dietary Aide C, revealed the ceiling in the dry storage area was peeling and appeared to have a small hole in it and to be leaking, there was a brown closed cardboard box labeled store in a cool dry area beneath the hole which appeared to be wet. During an interview with Dietary Aide C on 8/28/2022 at 4:20 p.m., Dietary Aide C stated the items in the walk-in refrigerator and walk in freezer should have been labeled and were supposed to be labeled and dated so staff knew which items were able to be used. Dietary Aide C further stated the kitchen staff was supposed to make sure the food was good before it was served to the residents, and dating and labeling were important to keep residents from getting items they were not supposed to be served. Dietary Aide C stated she was not aware if the cardboard box of food items in the dry storage area was wet prior to the observation on 08/29/2022. During an interview with the Administrator on 8/28/2022 at 5:20 p.m., the Administrator stated he was unaware there were unlabeled and undated items anywhere in the kitchen. The Administrator further stated he was unaware there was an area in the ceiling possibly leaking onto items in the dry storage area prior to today, and further stated the facility's Dietary Manager was on leave. Record review of the facility's policy titled, Food Storage Policy, dated 2018, revealed, 1. Dry Storage Rooms: Keep the storage room well-ventilated with humidity controls to prevent mold growth. 2. Refrigerators: (d) Date, label and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezer: (e) Store frozen foods in moisture-proof wrap or containers that are labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 6 of 6