Inspection·April 4, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, and serve food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure pantry foods were properly labeled and dated. 3. The facility failed to ensure expired foods were not in the pantry and refrigerator. 4. The facility failed to ensure food service workers wore gloves. These failures could place residents at risk for food-borne illness. Findings include: Observation of the kitchen staff on 4/4/23 at 9:18 AM revealed the following: Two dietary service workers were not wearing gloves while preparing resident food. Observation of the refrigerator on 4/4/23 at 9:22 AM revealed the following: -Five gallons of milk with best by date 4/1/23. -75 4-ounce cartons of chocolate milk had no date. -Two heads of lettuce had no date. -4 large food service bags of cole slaw mix, had no date. -1 food service box of fresh tomatoes had no date. -3 gallons of maple syrup were open, with no date. -1 gallon of fruit punch had no date. -1 gallon of lemonade had no date. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 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)