Inspection·December 22, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Observation and Interview on 12/20/23 11:01 AM revealed Resident # 34 was lying on his bed watching television. Resident #34 stated he did not want to do activities and preferred to stay in his room. Interview with Activities Director on 12/21/23 01:19 PM revealed Resident #34 did not like being social very often unless the activity is baking. Activity Director stated she did 1:1's 2 times a week. Residents Affected - Some Observation and Interview on 12/21/23 03:12 PM revealed Resident # 34 playing a casino game on his phone. He stated he likes watching tv, playing video games on his PlayStation 3 or casino games on his phone. He preferred to stay in his room, but the activities director did ask him if he would like to join activities one time a week. Interview on 12/22/23 09:52 AM with Activities Director said during her 1:1's 2 times a week, she will hang out with Resident #34 and talk with him or watch him play games. She said resident liked to watch tv and playing games in his room but will come to an activity if it is a baking activity. Activities Director and MDS coordinator work together to complete resident care plans. She plans on having gone through all the resident's care plans by mid-January. She does transports residents to doctor appointments and December is a busy month for transports. Interview on 12/22/23 10:46 AM with Activities Director revealed she did not have paperwork or a log to show for Resident #34's activities. She read the activities policy and did an in-service training that morning. Activities Director will have a checklist for all residents going forward. Activities Director stated she does activity assessments when they come due. The assessments are due at same time as MDS; within first two days of admission and then quarterly. She will participate in the care plans when she is available. Activities Director stated the younger residents like Western movies, baking parties and playing dominoes. She does 1:1's 2-3 times a week. She talks to residents about coming out more and making new friends. Activities Director stated she is working on getting more personalized assessments completed for all the residents. Record review of activity log revealed there was no activity log reflecting activities performed for resident #34. 2) Review of Resident #6 's face sheet, undated, revealed the resident was admitted to the facility on [DATE] with diagnoses of spastic diplegic cerebral palsy (Disorder that affects movement muscle tone, balance, and posture), dysphagia (difficulty chewing and swallowing), oropharyngeal phase (the first stage of swallowing) and neurotransmitter (device used to stimulate vagus nerve and brain signal to disrupt seizure) for seizure activity. Review of Resident #6's face sheet revealed Put wrist to left clavicle during seizure before calling 911. Resident has known seizure history and should not be sent to the ER unless neurotransmitter is faulty. Review of Resident #6's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status of 15 (cognitively intact). The MDS Assessment reflected Resident #6 requires supervision and set up when eating and drinking. MDS Assessment reflected Resident #6's eating support as Setup. Review of Resident #6's care plan revision date 08/06/2019 revealed Resident #6 did not want to use silverware during meals I want to use plastic utensils. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 2 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0656 Level of Harm - Minimal harm or potential for actual harm Observation on 12/20/23 at 2:04 pm revealed Resident #6 had magnet bracelet on left wrist. In an interview on 12/20/2023 at 2:04 p.m., Resident #6 stated she wore a magnet on her left wrist for seizures and had asked and begged for plastic utensils instead of silverware to kitchen staff and social worker but they don't do anything. Resident #6 stated that she was left-handed and when she used silverware it became stuck to her magnet on her wrist and it was difficult for her to unstick the silverware. Residents Affected - Some During observation on 12/21/23 12:21 PM Resident #6 was sitting in wheelchair at table with plate of food, green beans, steak fries, corn, and garlic bread. Observation revealed she was wearing magnet bracelet on left wrist. Observation revealed Resident #6 was using metal silverware and the spoon was stuck on magnet her on left wrist. Observation revealed Resident #6 was attempting to scoop food from plate but could not because spoon was stuck to her magnet bracelet. Resident #6 stated I hate this. Observation revealed the Resident #6 attempted 2 times to remove spoon from magnet on left wrist with her right hand. Resident #6 was able to eat once spoon was not attached to her wrist. Interview with Resident #6 revealed she needed plastic utensils and asks and asks but she continued to receive silverware. Observation of Resident #6 lunch meal ticket on tray revealed no note regarding resident need for plastic utensils. In interview on 12/21/23 at 12:46 pm with MDS Coordinator, revealed that Resident #6's request for plastic utensils was care planned with a problem start date of 08/06/19 and updated on 10/12/23 by MDS Coordinator. MDS Coordinator stated she did not remember updating the MDS for this particular issue and that Resident # 6 had not mentioned the issue to her. MDS Coordinator stated this is the first time I'm hearing of it. MDS Coordinator stated that staff should be reviewing resident care plan. In interview on 12/21/23 1:38 pm with CNA B, revealed that Resident #6 sometimes asked for plastic utensils but hardly ever. CNA B stated that she does give plastic utensils to Resident #6 if she asks for it and the last time she remembered Resident #6 asking for plastic utensils was about 3 weeks ago. CNA B stated she was not aware that plastic utensils were care planned for Resident #6. CNA B stated that the Speech Therapist should notify the kitchen and the kitchen should show the preference on the meal ticket. Interview on 12/22/23 at 1:00 pm with the DON revealed she was not aware of Resident #6 requiring plastic utensils and that she speaks with Resident #6 every day. Interview on 12/21/23 at 1:40 pm with Dietary Manager revealed she did not know Resident #6 required plastic utensils. Dietary Manager obtained Resident #6's 12/21/23 lunch meal ticket and stated that it did not note Resident #6's need for plastic utensils on ticket. In interview with Dietary Manager revealed she would not know if Resident #6's needed plastic utensils unless indicated on the resident's meal ticket. In interview with Dietary Manager she stated she would fix the ticket to ensure Resident #6 receives plastic utensils. Review of facility's Assistance with Meals Policy, dated March 2022, revealed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. Review of facility's Accommodation of Needs Policy, dated March 2021, revealed Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 3 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some achieving safe independent functioning, dignity and well-being .1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Record review of facility's activity policy revealed Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who can maintain an independent program will have supplies available to them. Record review of the Care Plan policy revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally- competent and trauma-informed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 4 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. Residents Affected - Many The facility failed to provide RN coverage for 8 consecutive hours daily for 10 of 16 weekends (09/02/23, 09/03/23, 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/14/23, 10/15/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/17/23, 11/18/23, 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/16/23 and 12/17/23) from September to December 2023. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities. Findings included: Review of facility's staffing schedules for September to December 2023 revealed the following: 09/02/23 and 09/03/23 RN Supervisor was the DON. 09/16/23 and 09/17/23 RN Supervisor was the DON 09/30/23 and 10/01/23 RN Supervisor was the DON 10/14/23 and 10/15/23 RN Supervisor was the DON with phone number 10/28/23 and 10/29/23 RN Supervisor was the DON with phone number 11/11/23 and 11/12/23 RN Supervisor was the DON with phone number 11/17/23 and 11/18/23 RN Supervisor was the DON with phone number (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 5 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0727 12/02/23 and 12/03/23 RN Supervisor was the DON with phone number Level of Harm - Minimal harm or potential for actual harm 12/09/23 and 12/10/23 RN Supervisor was the DON with phone number Residents Affected - Many 12/16/23 and 12/17/23 RN Supervisor was the DON with phone number Interview on 12/22/23 at 4:22 PM and 4:35 PM with the Administrator revealed he was aware of requirement of RN coverage but currently the DON was the only RN that worked at the facility. He stated when ADON worked at the facility she was RN so they took turns on the weekends providing RN coverage for the facility. He stated after ADON quit in October 2023, and the DON was not at the facility each weekend for RN coverage. He reviewed staffing sheets with surveyor revealing on the weekends of 09/02/23, 09/03/23, 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/14/23, 10/15/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/17/23 and 11/18/23 the DON was only available by phone not at the facility for RN coverage. He stated the last time DON was onsite for RN coverage was the last weekend of November (11/25/23 and 11/26/23) and he stated in December they had no RN coverage for Saturdays and Sundays. The Administrator stated the LVNs could contact the DON by phone on the weekends. He stated the DON did not provide RN coverage starting in December 2023 on the weekends since she needed to be at the facility during the week for survey preparation. He stated the facility did not use any agency staff for nursing. He stated the DON did not have to fill out any timesheets for DON so all he had was the staffing sheets. Interview on 12/22/23 at 4:29 PM with LVN D revealed since the ADON quit the DON would be available by phone if needed but did not come to the facility on the weekends. She stated the DON came on some of the weekends but was not consistently at the facility every weekend since ADON quit. Interview on 12/22/23 at 4:32 PM with LVN E revealed DON did provide some RN coverage on the weekends by coming to the facility but if DON was not in facility they could reach out to DON by phone on the weekends. Interview on 12/22/23 at 4:35 PM with Administrator revealed the facility did not have a waiver for RN coverage. He stated the risk for the lack of RN coverage on the weekends could place residents at risk for not getting the services they require from RNs. Interview on 12/22/23 at 4:50 PM with DON revealed she was not able to provide RN coverage each weekend since there was no weekend RN supervisor. Review of ADON's employee file revealed the ADON resigned on 10/10/23 and her last day of employment at the facility was on 10/09/23. Review of CMS PBJ staffing reports reflected facility triggered for no RN coverage for all quarters since the last re-licensure survey. Review of facility's policy Staffing dated 09/28/23 reflected the facility provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 6 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0727 Level of Harm - Minimal harm or potential for actual harm psychosocial well-being of each resident in accordance with resident care pans and the facility assessment .4. The facility utilizes the services of a registered nurse for at least 8 hours consecutive hours a day, 7 days a week. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 7 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.for 1 of 1 medication carts reviewed for pharmacy services. The facility failed to ensure Resident #31 did not have expired medication of Zofran in the nurse medication cart. These failures could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications. The findings include: Observation on 12/21/23 at 10:57 AM revealed in the medication cart there was Resident #31's opened Zofran 4 mg pill bottle with received date of 03/07/22 and expired date of 03/07/23. Interview on 12/23/23 at 10:59 AM with LVN A revealed she did not have a current order for Zofran and this medication was expired. She stated she would dispose of the medication and should not have been in the medication cart. She stated she checked the medication cart weekly to ensure no expired medication. She stated the risk of residents having expired medications in the medication cart could be less effective use or adverse reaction of medications for residents. Review of Resident #31's current physician orders for December 2023 reflected no current physician order for Zofran. Review of Resident #31's inactive medication orders revealed Zofran 4 mg prn every 4 hours for nausea with vomiting was started on 04/07/21 and discontinued on 08/31/22. Interview on 12/22/23 at 8;30 AM with the DON revealed she and nursing went through the medication carts weekly to ensure all discontinued and expired medications were taken out and disposed of. She stated there was not a high risk of Resident #31 receiving the medication since it was discontinued. She stated the expired and discontinued medication should have been removed of and disposed of properly. She stated the consultant pharmacist looked at the medication carts monthly and had not seen any issues with pharmacy storage. Review of facility's policy Storage of Medications last revised November 2020 reflected The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 8 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication carts reviewed for pharmacy services. 1. The facility failed to ensure 2 unidentified pills were stored properly in nurse medication cart. 2. The facility failed to ensure nurse medication cart was free of cracks and in good working condition to ensure proper storage for resident medications. These failures could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications. The findings include: 1. Observation on 12/21/23 at 10:55 AM revealed when LVN A picked up medication blister packages, 2 pills (1 small white and 1 small round tan pill) fell out and were in bottom of medication drawer. Observation and Interview with LVN A revealed she was not sure what pills those were specifically, but she needed to throw them out. She disposed of them in trash can. 2. Observation on 12/21/23 at 11:01 AM revealed the 2nd drawer of the medication cart had a crack and piece of medication cart was gone revealing an opening of about ½ inch wide by 4.5 inches where you could see medication blister packs. Interview on 12/21/23 at 11:02 AM with LVN A revealed she had noticed the crack and opening about a couple of months ago but had not reported it to anyone. She stated she thought the facility had more medication carts they could use but was not sure. Interview on 12/22/23 at 8;30 AM with the DON revealed she and nursing went through the medication carts weekly to ensure resident medications were stored properly in the nurse medication cart. She stated she looked at the crack in the medication cart yesterday when she was notified but stated the opening was too small to get medications out of. She stated the medication cart would need to be repaired. The DON stated the pills should not have been loose and should have disposed of. She stated the consultant pharmacist looked at the medication carts monthly and had not seen any issues with pharmacy storage. Review of facility's policy Storage of Medications last revised November 2020 reflected The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 9 of 10 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 455970 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at River Valley 1907 Refinery Rd Gainesville, TX 76240 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and record review, the facility failed to maintain oven equipment in safe operating condition in facility's only kitchen reviewed for physical environment. Residents Affected - Some The facility failed to ensure the stove and oven were in good working condition with no missing control knobs or loose handles. This failure places residents at risk of injury due to fire or foodborne illness. Findings included: Observation on 12/20/23 at 10:15 am revealed oven door handle not attached on one end, hanging down on left side. Observation on 12/20/23 at 10:15 am revealed Dietary Manager looking at oven handle hanging off oven door. Interview with Dietary Manager on 12/20/23 at 10:15 am revealed Dietary Manager was unsure how long the handle has been hanging off of oven door and stated it happened not very long ago, and that it just happened. Observation on 12/20/23 at 10:15 am revealed stove control knobs were missing for 2 of 9 control knobs. Observation on 12/20/23 at 10:15 am revealed Dietary Manager looked at missing control knobs. Interview with Dietary Manager on 12/20/23 at 10:15 am revealed she was not sure what happened to control knobs. Observation on 12/21/2023 at 10:58 am in kitchen revealed oven handle reattached to oven door and 1 of 9 control knobs missing with exposed metal turning shaft. Surveyor asked about missing knob and Dietary Manager stated that they fall off pretty often because they are slippery and looked around the kitchen floor for the missing control knob but did not see it. Dietary Manager demonstrated how she uses stove when control knobs are missing by using the exposed metal shaft and pushed in and turned burner on, then turned it off. Dietary Manager stated she can put in a request verbally or electronically for maintenance issues and just hasn't gotten around to it yet. Interview on 12/22/23 at 10:13 am with the Maintenance Director revealed he was informed on 12/21/23 of the oven handle and oven control knobs and completed repairs. Interview on 12/22/23 at 10:39 am with Administrator revealed expectation on maintenance repairs was for any issues to be reported immediately via written work order, verbally to Maintenance Director, or over TELS (Electronic Maintenance Application). Record review of Maintenance Work Orders for 11/7/23-12/20/23 showed no work orders for oven control knobs or handle. Record review of the facility's Equipment policy, dated October 2019, revealed It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order . 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/ or Maintenance Director as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455970 If continuation sheet Page 10 of 10