Health inspection·December 18, 2025

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, serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.The facility failed to ensure hair restraints were used by all Kitchen staff when entering the kitchen.The facility failed to ensure foods were properly distributed with professional standards for food service safety.This failure could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include:Observation of the facility kitchen on 12/16/25 at 9:14 AM, revealed the DM was not wearing a hair restraint while testing the dishwasher temperature. Observation of the facility kitchen on 12/17/2025at 1:35 PM, revealed the DM was not wearing a hair restraint while in the kitchen, obtaining policy and logbooks.Interview on 12/17/2025 at 8:07 AM the DM stated her expectation was employees follow the company wide sanitation policy. She stated if hair restraints were not worn, hair could contaminate the food.Interview 12/17/25 at 12:34 PM, the [NAME] stated, everyone was required to wear a hair net that completely covers the hair on their heads. She stated this will prevent cross contamination and food borne illness.Interview on 12/18/2025 at 5:52 PM, the ADM stated kitchen staff and anyone who enters the kitchen should wear a hair net whenever they are in the kitchen. ADM stated all the kitchen staff have been trained by the DM about the expectations for food safety and kitchen sanitation.Findings include: During an observation of the dining room meal service on 12/16/25 at 11:29 AM, 4 staff members (CNA A, CNA B, LVN D, RN C) failed to perform hand sanitation prior to beginning drink and food service to 11 residents putting 11 residents at risk of cross contamination and food-borne illness During an observation of the dining room meal service on 12/17/25 at 11:39 AM, 3 staff members (RN C, LVN D, CNA F) failed to perform hand sanitation prior to beginning drink and food service to 13 residents putting 11 residents at risk of cross contamination and food-borne illness.During an observation of the dining room meal service on 12/18/25 at 7:30 AM, 5 staff members (ADM, LVN D, CNA H, CNA G, RN C) failed to perform hand sanitation prior to beginning drink and food service to 11 residents.During an interview on 12/17/2025 at 8:07 AM, DM stated that she has an expectation that all staff will sanitize hands before they begin food service. She stated, staff should use proper personal hand hygiene between serving every drink and every plate to a resident. DM stated that residents could get food born illnesses from improper personal hand hygiene.During an interview on 12/17/25 at 12:34 PM, the [NAME] stated, everyone is supposed to practice hand hygiene. She stated, staff are to wash hands anytime they touch their hair or their body. [NAME] stated a possible negative outcome for not using hand sanitizer could be food born illness. During an interview on 12/18/25 at 07:46 AM, CNA G stated she has been trained in proper hand hygiene. CNA G stated, you are supposed to wash your hands before walking into the dining room and you are to use hand sanitizer when leaving the dining room. CNA G stated, I have been taught that we are supposed to wash hands between tasks, so we don't pass germs.During an interview on Page 1 of 2 455522 455522 12/18/2025 Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12/18/2025 at 2:30 PM, CNA H stated that she has been trained in proper hand hygiene. She stated, it was the facility expectation that before we start serving the residents we are to sanitize our hands. She stated, I sanitize my hands between serving drinks and serving plates to residents. During an interview on 12/18/25 at 8:07 AM, LVN D stated, Service staff are to practice hand hygiene before and between servicing food or drinks to a resident. He stated residents could get a bacterial infection if staff do not practice proper hand hygiene. LVN D did not know why service staff did not use proper hand hygiene when serving drinks and meals to their residents.During an interview with ADON on 12/18/2025 at 2:14 PM, ADON stated she was the facilities Infection Preventionist and that her expectation was that all staff members will practice hand hygiene. She stated staff are expected to sanitize hands between passing each drink and each plate to a resident. She stated that hand hygiene training was mandatory during new employee on boarding and that in- services on hand hygiene was done on12/01/2025. During an interview with ADM on 12/18/2025 at 5:52 PM, the ADM stated it was his expectation that all staff will use proper hand hygiene before, during and after staff serve food to residents. Record review of dietary Orientation and Competency Checklist confirms all 8 kitchen staff members have been trained in Handwashing techniques and food safety.Record Review of In- Service Training Reports on Infection control, Food Safety completed 12/01/2025.Facility provided Policy & Procedure Manual, not dated: Employee Hygiene for Food Safety.Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.All employees will1. Wear hair restraints (hairnet, hat, and/ or beard restraint) to prevent hair from contacting exposed food. 2. All Employees: Hair restraints are required and should cover all hair on the head.4. All staff will be in good health, will practice good personal hygiene and will use safe food handling practices.Facility provided policy, titled, Handwashing/Hand Hygiene, dated 2001 revealed the following: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and ImplementationAdministrative Practices to Promote Hand Hygiene1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiened. after touching a resident.e. after touching the residents' environment. Applying Alcohol-Based Hand Rubs1. Apply generous amount of product to palm of hand and rub hands together.Facility provided Policy & Procedure Manual: Employee Hygiene for Food Safety.Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.All employees will1. Wash hands before handling food, using posted handwashing procedures. 2. All staff will be in good health, will practice good personal hygiene and will use safe food handling practices. 455522 Page 2 of 2