Inspection·October 24, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #46) of 17 residents reviewed for range of motion. The facility failed to have interventions and monitoring in place to address Resident #46's left hand contracture. This failure could place residents with ROM issues at risk for decline in range of motion, decreased mobility, and worsening contractures. Findings included: Record review of Resident #46 admission face sheet dated 10/24/24 revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and recent admission from hospital on [DATE]. His diagnosis included (but not limited to) Parkinson's disease without dyskinesia and without mention of fluctuations (a neurodegenerative disease of mainly the central nervous system that affects both the motor and non-motor systems of the body); personal history of transient ischemic attack (a brief stroke-like attack) and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) without residual deficits. Record review of Resident #46's Quarterly MDS dated [DATE] Section C revealed BIMS Score 12 indicating moderate cognitive impairment. Record review of Resident #46's Quarterly MDS dated [DATE] Section GG 0130 A5 Eating is coded 02 indicating Substantial / Maximal assistance needed in eating; Section GG 0015 A revealed impairment to one side upper extremity and B. one side lower extremity. Quarterly MDS 07/22/24 & Quarterly MDS 06/21/24 Section G revealed Partial / Moderate assistance in eating. Quarterly MDS dated [DATE] & 02/11/24 revealed Supervision in eating. Record review of Resident #46 Occupational Therapy (OT) Discharge Summary 02/10/24 revealed Left upper extremity (LUE) palm protector to reduce risk of contracture and that resident required set-up or clean-up assistance with eating. OT Discharge Summary 06/24/24 revealed Minimal assistance with personal hygiene. Record review of Resident #46's Focused assessment dated [DATE] revealed contracture to LUE (Left upped extremity), LLE (Left lower extremity), RLE (Right lower extremity). Record review of Resident #46 OT evaluation dated 04/02/24 revealed resident required set-up assistance with self-feeding, LUE ROM impaired at shoulder, elbow, wrist, hand, thumb and fingers and that limitations were not related to contracture. Record review of Resident #46 OT Evaluation and Plan of Treatment dated 09/19/23 revealed goals to increase sitting balance, increase Right elbow/forearm flexion strength, to improve ability to safely and efficiently perform upper body dressing with partial / moderate assistance and to improve ability to safely and efficiently perform grooming and hygiene tasks with supervision or touching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 2 of 4 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0688 assistance. OT Evaluation and Plan of Treatment does not address left hand contracture. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #46 Care Plan dated 09/18/23 revealed use of divided plate and built-up utensils with all meals under nutritional status problem and ADL functional problem. Care plan does not identify left hand contracture. Residents Affected - Few Record review of the physician's orders (print/save date 10/24/24) revealed no orders in place for preventative measures to left hand contracture. Resident #46 observation 10/22/24 at 11:05 a.m. revealed resident sitting up in bed. Left hand was in fist position with no preventative measures in place. Resident #46 observation and staff interview with CNA A on 10/23/24 at 1:22 p.m.: CNA at bedside feeding resident with built up spoon. CNA A stated, I work night usually, but he does not try to hold the spoon with me, and his left hand is contracted, so I feed him. There were no preventative measures to his left hand. Interview with LVN B on 10/23/24 at 1:20 p.m. revealed Resident #46 will try to hold the utensils at times and that staff tend to help him with feeding. LVN B was asked if any assistive device was in place for his left hand to aid in contracture management. LVN B stated, I am part-time, and I have never seen any device for his left hand. Resident #46 observation and interview on 10/23/24 at 2:48 pm revealed Resident #46 sitting up in bed. Resident stated he was unable to open his left hand or lift his left hand and arm. Upon observation, left hand was in closed fist position with no preventative measures in place. Resident #46 observation and interview on 10/24/24 at 9:43 a.m. revealed resident sitting up in bed. The call light was attached to the bed sheet on left side. Resident was able to reach call light with his right hand and demonstrated ability to push call button. Resident stated he was unable to open his left hand and that, In a couple of days it will smell nasty, and that he will try to clean it myself because it smells nasty, and that he will have the girls clean is about every three days. There were no preventative measures in place to left hand. Interview with CNA C stated resident #46's shower is scheduled for today on the 2nd shift (after 6pm). When asked what type of care was provided to resident's left hand, she stated, I will put a towel inside, dry it down, apply lotion. Interview with the DON and DOR on 10/24/24 at 10:43 a.m.: DON stated, resident has been followed by Dermatology, Ortho and Neurology and contracture is addressed but no recommendations were made. DON stated resident had recent hospitalization (08/05/24-08/09/24 due to seizure activity with recommendations to follow up with neurology. Record review of Neurology progress note dated 08/19/24 revealed neurological condition to include spastic left hemiplegia, generalized weakness, no visible hypertrophy or atrophy to upper and lower extremities, and under Assessments #5. Hemiplegia following cerebral infarction affecting left non-dominant side. Record review of Ortho consult dated 10/10/24 revealed residual left hemiparesis with progressive low back pain, lumbosacral radiculitis with degenerative disc disease and facet arthropathy. Neurology progress note and Ortho consult note did not address contracture as stated by DON. Record review of the facility provided policy on Resident Examination and Assessment (Revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 3 of 4 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 676288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Cotulla 369 Mars Dr Cotulla, TX 78014 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 0688 Level of Harm - Minimal harm or potential for actual harm February 2014) revealed the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical assessment #4 Neurological d. strength and equality of the hand grasps; #5 Musculoskeletal b. mobility and range of motion of extremities & e. contractures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676288 If continuation sheet Page 4 of 4