Health inspection·October 20, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 10/19/2023 at 3:34 p.m., the DON confirmed the window curtain should have been closed to protect the privacy of the resident. She confirmed the staff were trained in resident rights 2. Record review of Resident #56's face sheet, dated 10/23/2023, revealed an admission date of 05/13/2015 and, a readmission date of 09/20/2015, with diagnoses which included: Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypothyroidism (under active thyroid) and, Dementia (decline in cognitive abilities) Record review of Resident #56's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 0, indicating she was severely impaired. Resident #56 required extensive assistance to total care and was always incontinent of bladder and bowel. Record of Resident #56's care plan, dated 07/10/2023, revealed a problem of My skin is fragile and I am at risk for skin injury--new or worsening skin condition. 0/10/23 pressure ulcer to Sacrum. with an intervention of Apply treatment as ordered. Observation on 10/20/2023 at 9:03 a.m. revealed LVN M provided wound care for Resident #56, exposing the end of the resident's bed which could be seen from the door if someone had entered the room during care. Further observation revealed LVN M did not pull the curtains completely around Resident #56's bed to offer privacy to the resident during care because the privacy curtain was not long enough During an interview with LVN M on 10/20/2023 at 9:16 a.m., LVN M confirmed the privacy curtain was not completely closed while she provided care for Resident #56, but it should have been. She confirmed receiving training for residents' rights within the year. During an interview with the DON on 10/20/2023 at 12:52 p.m., the DON confirmed the privacy curtain should have been closed to protect the privacy of the residents. She confirmed the staff was trained in resident rights The DON revealed The ADON would annually check the skills and knowledge of the staff and sport check were done if a concern was noted. Review of facility policy, titled Standards for clinical procedures, dated January 2022, revealed [ .] g. Pull the privacy curtain between the residents, even if the roommate is not present. close windows blinds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 2 of 12 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 10/20/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report alleged violations related to neglect or abuse, including injuries of unknown source, are reported immediately, but not later than 24 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency), for 1 of 39 residents (Resident #9) reviewed for abuse and neglect, in that: The facility failed to report to the State Survey agency (HHSC) when Resident #9 alleged a dietary cook hit her on the arm on 08/16/2023. This failure could place residents at risk for abuse and neglect. The findings were: Record review of Resident #9's face sheet, dated 10/19/2023, revealed the resident was re-admitted on [DATE] (original admission on [DATE]) with diagnoses that included: major depressive disorder, age-related physical debility, and muscle weakness. Record review of Resident #9's quarterly MDS assessment, dated 03/11/2023, revealed the resident had a BIMS score of 15, which indicated intact cognitive impairment. Record review of the Grievance/Concern Report - Residents and Families, dated 08/21/2023, revealed Room Name: Resident Council. [ .] Concern/Details: Resident #9 claimed [name of Dietary [NAME] C] from kitchen hit her on the arm. Resident did speak to [name of Administrator] about incident. [ .] Action Taken: on 8/16/23 resident approached this writer [Administrator] in hallway & stated [name of Dietary [NAME] C] in the kitchen hit her on the arm. Resident [#9] stated she got me my food & then hit me on the arm. I [Administrator] asked if she did it to be mean or like she was patting her to say here you go. She [Resident #9] stated she didn't know. I [Administrator] asked her [Resident #9] if she believed she [Dietary [NAME] C] was trying to hurt her, if so I [Administrator] would call the police & notify the state & her family. Resident [#9] started laughing & stated no she [Resident #9] just didn't want her [Dietary [NAME] C] to do that anymore. I [Administrator] assured resident [#9] that I [Administrator] would speak with [name of Dietary [NAME] C] & this wouldn't happen again. Conversation held with [name of Dietary [NAME] C] & documented. [name of Dietary [NAME] C] is aware that Resident [#9] does not want to be touched. Record review of Tulip, on 10/19/2023, revealed no incident report for Resident #9, during 08/2023, of Resident #9's alleged staff complaint. During an interview on 10/18/2023 at 2:25 p.m., Resident #9 stated she told an unknown staff member that she wanted cottage cheese and then Dietary [NAME] C came to her and hit her on her arm, while motioning to her upper left arm. She stated she believed it was last month. She stated she felt bad because all she did was ask for something and then was hit by staff. Resident #9 stated she told the Administrator and he had told her he would contact the police and correct it but she never saw anything done. Resident #9 stated that Dietary [NAME] C didn't even come apologize to her or anything. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 10:55 a.m., Activity Assistant stated she remembered the incident and that Resident #9 first brought up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 3 of 12 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 10/20/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the incident during resident council on 08/16/2023. She stated that Resident #9 told her that she had asked someone for something (believed it was cottage cheese but couldn't remember) and that Dietary [NAME] C had swatted her on the arm. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 11:00 a.m., the Administrator stated he remembered the incident. He stated he contacted Resident #9's family about this incident and he said they laughed and stated Resident #9 was not a touchy feely person and did not like to be touched. The Administrator stated he believed it was not abuse and therefore was not reported because the resident stated she was not wanting it reported and that the resident stated she believed the staff was not being hurtful. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 11:21 a.m., Dietary [NAME] C stated Resident #9 asked for cottage cheese and she placed it on the table and then tapped the resident on the shoulder to say here you go. She stated Resident #9 had no response afterward. Dietary [NAME] C stated the Administrator spoke with her about the incident and asked her what happened and for her not to touch Resident #9 anymore. She stated that she was not aware of what should be reported but if a resident was claimed abuse, then maybe it should be reported. During an interview and record review, of written grievance dated 08/21/2023,on 10/20/2023 at 12:31 p.m., the DON stated she believed she was on PTO at the time and only recalled the incident upon her return to work. She stated she believed it was not a reportable because of the resident's statements and it was probably just a tap [instead of a hit]. Record review of facility's Abuse Guidance: Preventing, Identifying, and Reporting, dated 02/2017, revealed Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. [ .] Report any alleged or suspicions of abuse to HHSC by telephone reporting or via TULIP reporting with the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18)[a] are reported immediately, [b] but not later than 2 hours after the allegation is made, if the events cause the allegation involve abuse or result in serious bodily injury; [c] or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, [ .]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 4 of 12 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 10/20/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 27 residents (Resident #81) whose assessments were reviewed, in that: Residents Affected - Few Resident #81's Annual MDS incorrectly documented the resident as receiving an insulin injection. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #81's face sheet, dated 10/18/2023, revealed an admission date of 08/17/2022, with diagnoses that included: Hemiplegia(Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) and, Cerebral infarction (Stroke). Record review of Resident #81's Physician orders and Medication administration record for August 2023 revealed orders for: Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Peninjector 2 MG/3ML (Semaglutide) Inject 1 milliliter subcutaneously one time a day every Mon related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Wipe pen prior to applying needle Record review of Resident #81's Annual MDS, dated [DATE], revealed the assessment indicated Resident #81 received an injection of insulin. During an interview with MDS nurse D on 10/20/23 at 12:05 p.m., the MDS nurse confirmed she had completed the MDS. The MDS nurse confirmed Resident #81's Annual MDS was coded as the resident having received an insulin injection when Resident #81 had only received Ozempic (medication used for the treatment of type 2 diabetes in combination with diet and exercise) . The MDS nurse revealed she did not know why she had coded Ozempic as an insulin. She confirmed Ozempic was a non-insulin injection pen and should not have been coded as an insulin injection. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed, Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 5 of 12 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 10/20/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan to reflect the current condition for 1 of 20 residents (Resident #86) reviewed for care plan revisions The facility failed to update Resident #86's care plan to reflect his risk for elopement This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #86's face sheet, dated 10/20/2023, revealed he was admitted to the facility on [DATE] with diagnoses which included: Dementia (decline in cognitive abilities), Heart disease, Insomnia (Sleep disorder), Dysarthria (Speech sound disorder) and, Ataxic gait (lack of voluntary coordination of muscle movement) Review of Resident's 86 quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8 which indicated moderate cognitive impairement. Resident #86 was coded as no behavior for the look back period. Record review of Resident #86's care plan with a review date of 09/14/2023 revealed there was no risk for elopement care plan. Review of Resident #86's nurse's progress note, dated 08/09/2023, revealed Resident ambulating again by pushing his wheelchair towards middle of building -and trying to go outside again-- voicing he was going outside to sit down-- three staff members redirecting him back to his room and he did. Review of Residnet #86's nurse's progress note, dated 09/28/2023, revealed Resident has been redirected back to room from nearest exit doors X 3 by CNA. Resident is having hallucinations. States someone is coming to pick him up. Offered snack and a drink. Redirected resident back to room. No questions or concerns at this time During an interview on 10/20/23 at 12:52 p.m., the DON confirmed Resident #86 was trying to exit the building and confirmed that no care plan for elopement or exit seeking had been created. The DON Confirmed a care plan should have been created and that they had apparently forgotten to create a care plan. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, Version 1.18.11, October 2023 revealed Therefore, facilities are responsible for assessing and addressing all care issues that are relevant to individual residents, regardless of whether or not they are covered by the RAI (42 CFR 483.20(b)), including monitoring each resident ' s condition and responding with appropriate intervention FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 6 of 12 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 10/20/2023 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 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 interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for 1 of 39 Residents (Resident #302) reviewed for medical records, in that: The facility failed to ensure Resident #302's Full Code status was included in his physician orders. This failures could place residents at risk for improper care due to inaccurate records. The findings were: Record review of Resident #302's face sheet, dated 10/19/2023, revealed the resident was admitted [DATE] with diagnoses that included: dementia, fracture of left femur, vitamin deficiency, and history of falling. Record review of Resident #302's MDS assessment, dated 10/13/2023, revealed the resident had a BIMS score of 01, which indicated severe cognitive impairment. Record review of Resident #302's care plan, dated 10/19/2023, revealed Resident/Family/RP does not have advance directives and elects Full Code status. Record review of Resident #302's physician orders, dated 10/19/2023, revealed no mention of resident's code status. During an interview and record review, of Resident #302's physician orders, on 10/20/2023 at 10:40 a.m., MDS D confirmed resident's code status was not included in his orders. MDS D was not able to state why his code status was not included. She stated the potential harm to the resident was staff would not know his code status. During an interview and record review, of Resident #302's physician orders, on 02/2017 at 11:50 a.m., the DON confirmed there was not a code status entered in his physician orders. She was not able to state why there was not a code status in his orders. The DON stated she believed there was not a potential harm to the resident because he would automatically be considered full code, being there was nothing specified. Record review of facility policy titled Medical Records, revised 04/2008, which read A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 7 of 12 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 10/20/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 (Resident #47) reviewed for hospice services, in that: The facility failed to obtain Resident #47's most recent hospice Plan of Care, Hospice Election Form and Physician Certification of Terminal Illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: Record review of Resident #47's face sheet, dated 10/19/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: neurocognitive disorder with Lewy bodies, dementia, dysphagia, and Parkinson's disease with dyskinesia. Record review of Resident #47's admission MDS, dated [DATE], revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #47's Care Plan last review completed 10/06/2023, revealed a focus area, Advanced care planning choices for end-of-life: Lewy Body Dementia-no weight monitoring. Further review revealed interventions with visit frequencies for nurse and CNA, coordinate care with all hospice team members and name of hospice agency and contact information. Record review of Resident #47's electronic medical record Order Summary Report of Active Orders as of 10/19/2023, revealed an order on 09/19/2023 for: Admit to [Hospice] DX- Lewy body Dementia: Please contact at [phone number] for any changes in condition. Record review of Resident #47's electronic medical record, miscellaneous documents, revealed no Hospice Election of Benefits form, Certificate of Terminal Illness, or Plan of Care. In an interview with the MR staff on 10/19/2023 at 2:35 p.m., the MR staff confirmed there were no paper charts kept at the facility. She stated all records were in the facility's electronic system. The MR staff revealed the DON had access to the portal for [Hospice Company B] for any information not found in the electronic system. The MR staff was not sure if portal access for [Hospice Company A] records were available. In an interview with the DON on 10/19/2023 at 3:10 p.m., the DON stated she had access to both hospices currently used for all needed information. However, at the time of interview the DON was unable to access the portal for [Hospice Company A] and revealed the Election form, Certificate of Terminal Illness, and Plan of Care would be in Resident #47's hospice binder at the nurse's station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 8 of 12 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 10/20/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation and interview with the DON on 10/19/2023 at 3:23 p.m., revealed the DON was unable to locate Resident #47's hospice binder at the nurse's station. The DON stated the SW was responsible for making referrals for hospice services for families. The DON further revealed that as the DON she was the designated staff responsible to coordinate services after a resident was on hospice services to ensure all documentation was in place and that the resident's hospice plan of care is coordinated with the facility plan of care. During an interview and record review with the MR staff on 10/19/2023 at 5:08 p.m., the MR staff provided a white binder with [Hospice Company A] and Resident #47's name on the front cover. Further review of the binder revealed a hospice admission consent, election of Medicare hospice benefits, Certificate of Terminal Illness with Recertification, and physician orders. The MR staff stated the hospice binder was found in a drawer in the secure unit. Further review of the binder revealed the documents were printed on 10/19/2023 between 3:46 p.m. and 4:52 p.m. In an interview with the DON on 10/19/2023 at 5:14 p.m., the DON stated she did not know when the hospice binder had arrived at the facility however stated she had been coordinating with [Hospice Company A] earlier that day to ensure all documentation was in place. Record review of the facility's hospice services agreement with [Hospice Company A], with effective date May 14, 2021, revealed, in Agreements: 2. Responsibilities of Facility, (e) Coordination of Care, (v) Designated Facility Member; Facility shall designate a member of Facility's interdisciplinary team who is responsible for working with Hospice representatives to coordinate care to each Hospice Patient provided by Facility and Hospice. Facility's designated interdisciplinary team member shall be responsible for: (iv) obtaining patient specific information from Hospice as required by applicable laws and regulations. 3. Responsibilities of Hospice. (e) Provision of Information; At a minimum, Hospice shall provide the following information to Facility's designated interdisciplinary team member for each Hospice Patient residing at Facility: (i) Hospice Plan of Care, Medications and Orders, (ii) Election Form, (iii) Certifications, (iv) Contact Information, and (v) On-Call System. Record review of the facility's policy titled, End of Life Hospice Type Care & Coordination, date implemented 3/13/19, revealed, To provide supportive care for residents and their families during the end stages of life by enabling them to participate in interactions of their choice in a supportive environment with the assistance of compassionate caregivers and interdisciplinary teams. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 9 of 12 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 10/20/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 3 of 10 residents (Residents #81, #93 and, #31) reviewed for infection control, in that: Residents Affected - Some 1. Medication Aide F did not sanitize the blood pressure cuff between Resident #81 and Resident #93 2. While providing incontinent care for Resident #31, CNA G did not wash her hands after touching the trash can and, LVN H did not change her gloves or wash her hands before touching a pair of clean briefs These failures could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #81's face sheet, dated 10/18/2023, revealed an admission date of 08/17/2022, with diagnoses that included: Hemiplegia (Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Cerebral infarction (Stroke). Record review of Resident #81's physician orders for October 2023 revealed an order for amlodipiine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE (I11.9) hold if sbp (Systolic blood pressure) under 100, or dbp (Diastolic blood pressure) under 60, or pulse under 60 Record review of Resident #93's face sheet, dated 10/19/2023, revealed an admission date of 09/01/2022 with diagnoses which included: Dementia (decline in cognitive abilities), Atrial fibrillation (Abnormal heart rhythm), Insomnia (Sleep disorder), Malignant neoplasm of female breast (Breast cancer) Record review of Resident #93's physician orders for October 2023 revealed an order for amlodipiine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if sbp (Systolic blood pressure) under 100, or dbp (Diastolic blood pressure) under 60, or pulse under 60 Observation on 10/19/23 at 8:52 a.m revealed, while administering medications, Medication Aide F took the blood pressure and pulse of Resident #81. Further observation at 8:58 a.m. revealed, Medication Aide F took the blood pressure and pulse of Resident #93 with the same blood pressure/pulse cuff that was used for Resident #81. Medication aide F did not sanitize the blood pressure/pulse cuff between the two residents. During an interview with Medication aide F on 10/19/2023 at 9:15 a.m. the medication aide confirmed she forgot to use a wipe to clean the blood pressure/pulse cuff between use. She revealed it was causing a risk of cross contamination. She received infection control training within the year. During an interview on 10/19/2023 at 3:34 p.m., the DON confirmed the medication aide should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 10 of 12 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 10/20/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sanitized the blood pressure/pulse cuff in between resident to avoid cross contamination. She revealed infection control training was provided to the staff multiple times a year. She revealed the staff's skills were checked annually. She also stated the ADON and herself would do spot check of the staff for skills and infection control knowledge. Review of the facility's policy, titled Infection prevention and control program, dated 10/2022, revealed 10 Disinfecting multi-patient use equipment or supplies after each use and stored appropriately 2. Record review of Resident #31's face sheet, dated 10/19/2023, revealed an admission date of 11/27/2019 and, a readmission date of 01/02/2020, with diagnoses which included: Chronic atrial fibrillation (heart rhythm disorder), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Chronic kidney disease (gradual loss of kidney function), Hemiplegia (Paralysis of one side of the body) and, Urinary tract infection (an infection in any part of the urinary system). Record review of Resident #31's MDS quarterly assessment, dated 07/27/2023, revealed the resident had a BIMS score of 7, indicating moderate cognitive impairment. Resident #31 required extensive assistance and was always incontinent of bowel and bladder. Record review of Resident #31's care plan revealed a care plan revised 08/30/2023 with a problem of I am at risk for significant infections and/or recurrent infections r/t compromised medical condition: Actual Infections: UTI (urinary tract infection) and a goal of I will not experience any complications to include distress throughout the course of my treatment of infection until resolved and/or next revision Observation on 10/19/23 10:20 a.m., revealed while providing incontinent care for Resident # 31 CNA G, after washing her hands, touched the trash can with her gloved hands. She did not change her gloves or wash her hands, then, started providing care for Resident #31. LVN H touched the door and privacy curtain to close them and without changing her gloves or washing her hands, touched the resident to position her and the clean brief and fasten it on the resident, During an Interview on 10/19/2023 at 10:30 a.m., CNA G confirmed she touched the trash can after washing her hands and putting her gloves one. She did not realize the trash can was considered contaminated and that she should have changed her gloves and clean her hands. She confirmed receiving infection control training within the year. During an interview on 10/19/2023 at 10:30 a.m., LVN H confirmed not changing her gloves and cleaning her hands after touching the door and privacy curtain. She confirmed she needed to clean her hands and change gloves, but she forgot. She confirmed receiving infection control training within the year. During an interview with the DON on 10/19/2023 at 3:34 p.m., the DON confirmed the staff should change gloves and wash their hands after touching the environment directly around the resident She confirmed the staff was trained in infection control within the year. She revealed the staff's skills were checked annually by the ADON and they would spot check skills in case of concerns with infection control. Review of the facility's policy, titled Infection prevention and control program, dated 10/2022, revealed Educating staff and ensuring that they adhere to proper infection prevention and control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 11 of 12 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 10/20/2023 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 0880 practices when performing resident care activities Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676138 If continuation sheet Page 12 of 12