Inspection·October 30, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/28/2024 at 10:05 AM, LVN C said that Resident #3 yells for help so they have her room located near the nurse's station so they can hear her when she needs them. During an observation on 10/28/2024 at 1:58 PM Resident #13 was lying in her bed asleep. The call light was located on her dresser out of reach of the resident. Residents Affected - Few During an interview on 10/28/2024 at 1:50 PM, CNA A came into the Resident #13's room and said that the call light should be attached to the resident's blanket so she could call for help. CNA A said the Hospice nurses had given her a bath and must not have put the call light on her blanket. CNA A said that the resident usually pounds on the wall when she needs help. CNA A said that the call light should have been near the resident . During on observation on 10/28/2024 at 1:53 PM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner. During an interview on 10/28/2024 at 5:30 PM, Resident #3's family member stated that Resident #3 was legally blind and was unable to hear well. Resident #3 said that if a call light was near Resident #3, she would use it to call for help. During on observation on 10/29/2024 at 8:29 AM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner. During an observation on 10/29/24 at 8:39 AM, Resident #13 was lying in her bed sleeping. The call light was out of reach of the resident located on her side dresser. The State Surveyor observed CNA B to be walking down the hall. The State Surveyor pounded on the wall but observed CNA B to walk by without acknowledging the noise. During an interview and observation on 10/29/2024 at 8:41 AM, CNA B stated she did not hear the pounding on the wall by the state surveyor. CNA B was observed putting the call light on Resident #13's blanket. CNA B said that she had observed Resident #13 using the call light and that it should have been on her blanket so she could call for help if needed. CNA B said that all staff were responsible for making sure call lights were near residents and a possible negative outcome for not having the call light in reach would be that the resident could fall out of bed. During an interview on 10/30/2024 at 9:14 AM the ADM said that a possible negative outcome for not having a call light near a resident would be that a resident would not be able to call for help. The ADM stated that nurses were responsible for ensuring call light placement. During an interview on 10/30/2024 at 10:45 AM, the DON said that a possible negative outcome for not having a call light near a resident would be a delay in care for that resident. During an interview on 10/30/2024 at 11:05 AM, the Corporate RN said that a possible negative outcome for not having a call light near a resident would be a delay in care and it was unacceptable. The Corporate RN said that staff were responsible for ensuring call lights were near residents. Record Review of Answering the Call light policy dated March 2021 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0558 When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility for 1 of 1 resident council. Residents Affected - Some The facility failed to ensure feedback and concerns expressed in the resident council meetings were addressed by the facility staff for the past seven months. This deficient practice could affect the residents who attended resident council meetings for the past seven months and place them at-risk to decrease quality of life and contribute to grievances not being resolved. The findings were: Record review of Resident Council Meetings from March 2024 to September 2024 revealed there was no complete feedback or response to the concerns made at the resident council meetings. Record review of Resident Council Minutes dated 03/27/2024 revealed concerns about missing clothes and not enough snacks for all residents. Record review of Resident Council Minutes dated 04/30/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 05/29/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 06/26/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 07/03/2024 revealed concerns about missing clothes and drinks at night. Record review of Resident Council Minutes dated 08/28/2024 revealed concerns about missing clothes. Record review of Resident Council Minutes dated 09/25/2024 revealed concerns about missing clothes and not enough snacks. During an interview on 10/28/2024 at 10:30 AM, an anonymous resident stated they do not get snacks daily and the only reason they were getting snacks was because the state was here. The resident also said that staff do not pass out snacks they sit at the counter. During an interview on 10/28/2024 at 11:00 AM, an anonymous resident said that some residents take 3 or 4 snacks at a time so there was not enough for everyone. During an interview on 10/28/2024 at 2:00 PM with residents in group, 10 of 13 residents revealed there had been concerns with missing clothes and they felt that the staff were not listening to their concerns. The, residents stated that nothing was getting done about the missing items. The residents stated that their clothing was being sent to the laundry and they would not get their clothing back or they would get clothes that did not belong to them. One resident during the group meeting stated that he wore large boxer underwear, and, on several occasions, he would get back small or medium underwear. During the meeting the group also stated that there were not enough snacks available for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some all residents. The group said that these concerns were brought up in the meetings but nothing changes. The resident's stated clothes were still coming up missing and not enough snacks were being offered for the entire resident population. One resident in the group was a diabetic and she stated that the snacks that were left out were full of sugar and she was not able to eat them due to her diabetes. Another resident stated that he had gone to bed hungry before because he did not have a good meal at dinner and the snacks that were left out were gone by the time, he got to the nurse's station where the snacks were located. During an interview at 10/29/2024 at 10:35 AM, an anonymous resident said if you were in bed and can't get up, you don't get a snack because the staff will not pass the snacks out. During an interview at 10/30/2024 at 8:35 AM, an anonymous resident said she had lost several clothing items and she felt staff were not listening to her concerns related to the missing items. The resident said she had to sleep in her sweats one night because she had three pair of pajamas that were still missing. The resident said she had informed the staff during resident council but had not received any feedback about her missing items. During an interview with the AD on 10/30/2024 at 8:39 AM, the AD stated she took notes for the meeting. The AD said she did not feel that missing clothes were a big concern because the facility gets donations.; If a resident had anything missing, they can get items from the donations pile. The AD said the residents have valid concerns regarding the lack of snacks and was unsure if their concerns were being heard because some residents take more snacks than they should. The AD said she did not think there was a negative outcome for missing clothing or not enough snacks for residents because of the donations that were given to the facility and that nurses have a key to the kitchen if a resident wanted food. During an observation on 10/30/2024 at 10:05 AM the State Surveyor observed the snack cart being unattended at the nurse's station. During an interview on 10/30/2024 at 10:10 AM, LVN D stated that the snacks were left at the nurse's station for residents to get a snack and some residents take more than their share of snacks. During an interview with the LS on 10/30/2024 at 10:18 AM, the LS said that she was also filling in as the dietary supervisor until the new one starts. The LS said the donated clothing was put in with the resident's lost and found laundry. The LS said that a possible negative outcome for mixing the lost and found laundry and the donations was that a resident may see their lost item on another resident and become angry thinking their items were stolen. The LS said that no one had discussed or implemented any changes in the way laundry was handled or stored. The LS said the snacks were left at the nurse's station and not passed out to residents; it was a first come first serve type situation. The LS said it was common for residents to hoard snacks causing other residents not to get one. The LS said that she believed that snacks should be passed out to each resident, so everyone had a chance to get a snack. The LS stated that she informed Administration that leaving the snack cart unattended at the nurse's station was causing issues with residents not receiving snacks because some residents were taking more than their share, but nothing had been done. During an observation on 10/30/2024 at 10:18 AM the State Surveyor observed a stack of donated clothing and the lost and found clothing in same the area stacked together in the laundry room. During an interview with the DON on 10/30/2024 at 10:45 AM, the DON said that possible negative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some outcome for not listening to the residents about their concerns with the laundry or snacks could be a dignity issue as they feel they were not being heard. During an interview with the ADM on 10/30/2024 at 11:00 AM, the ADM said that he was responsible for the grievances and the AD tells him of any issues with the group meetings. The ADM said that a possible negative outcome for not listening to the residents about their concerns with laundry or snacks was they may feel that their concerns do not matter. During an interview with the DON on 10/30/2024 at 1:15 PM revealed that she acknowledged that there had been issues with the not having enough snacks. Record review of facility's policy on grievances dated 1/12/2023 revealed the following: The resident has a right to organize and participate in resident groups in the facility. The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendation of such groups concerning issues of resident care and life in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (RN F) of 13 staff reviewed for abuse policies. Residents Affected - Few The facility failed to make sure that a potential employee who would be working with residents directly was free of criminal charges. This failure could place residents of the facility at risk of abuse or neglect at the hands of an employee with a documented history of these types of behaviors. Findings Included: Record review of RN F's employee file revealed a hire date of 7/4/2024 and an Employee Misconduct Registry (EMR) with a date of 7/9/2024. During an interview on 10/30/24 at 11:21AM, HRD stated that RN F was supposed to start later in the month but started on July 4, 2024. The HRD stated the negative outcome for hiring staff without running their record first would be putting residents at risk for abuse. Record review of the facilities ANE policy dated 10/2023 stated the following: 1. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 2. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews, and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 33 days in the months of April, May, June July and October, 2024. The facility did not have an RN in the facility for 8 consecutive hours on the following dates: April 4, 5, 6, 7, 10, 13, 14, 20, 21, 27, and 28th of 2024. May 4, 5, 11, 12, 18, 19, 25, 2 6, and 27th of 2024. June 1, 2, 8, .9. 15, 16., 22, .23, .29. and 30th of 2024. July 13 and 14 of 2024. The date of October 11, 2024 only had RN coverage for 5.63 hours. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care. Findings include: During an interview on 10/29/24 at 10: 20 pm, the DON stated she did not have RN coverage for June. She stated it just fell through the cracks. When asked about RN coverage for April and May as listed on the facility PBJ report, she had no answer. She stated she had been actively looking for an RN. She stated an RN was not hired until July. The DON stated the consequences of not having an RN in the building would be There needs to be someone here to report incidents to. There was no one to report incidents to. Record reviews of the facility's last 5 months of time sheets for RN coverage revealed that the facility did not have an RN in the facility on the following dates: April 4,5, 6, 7, 10, 13, 14, 20, 21, 27, and 28 th of 2024 May 4, 5, 11, 12, 18, 19, 25, 26, and 27th of 2024 June 1, 2, 8, .9, 15. 16., 22., 23, .29. and 30th of 2024 July 13 and 14 th, 2024 The date of October 11, 2024, only had RN coverage for 5.63 hours. Record review of the CMS PBJ Staffing Data Report dated 11/1/24 revealed the facility infraction dates listed the following dates as not having RN hours for: April 4,5, 6, 7, 10, 13, 14, 20, 21, 27, and 28, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0727 May 4, 5, 11, 12, 18, 19, 25, 26, and 27 ,2024 Level of Harm - Minimal harm or potential for actual harm June 1, 2, 8. 9. 15. 16., 22, .23., 29. and 30, 2024 Residents Affected - Some Record review of facility presented Time Clock Punch In Hours revealed there were no RN clock in hours prior to 7/4/24. A policy for RN coverage was requested from the DON on 10/29/24 at 1:30 pm but never received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: Residents Affected - Some A. Ensure facility staff wore a hair restraint while in the kitchen. B. Ensure stored food was properly labeled, dated and covered. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 10/28/24 at 9:25 am of the walk-in cooler the following was found: 1. A pan of cooked chicken, covered with foil that was torn allowing air into the pan, no label or date 2. A plastic container of strawberries, no label or date 3. A tray of individual glasses of milk, no label or date 4. A glass of milk, no cover, label or date Observations of the freezer on 10/28/24 at 9:40 AM revealed the following: A. An opened box of beef fritters, open to air and unsecured. In an observation on 10/28/24 at 11:30 am, revealed Housekeeper E was in the kitchen without a hairnet, talking to one of the kitchen staff. When asked if she was aware she did not have a hairnet on, she stated she was not aware she needed to have a hairnet on. She stated the consequences of not wearing a hairnet would be a sanitary issue. In an interview and an observation of the kitchen prep table on 10/28/24 from 11:30 am to 11:50 am revealed a tray with individual bowls of chocolate pudding with no covering. [NAME] G stated the pudding was for the noon meal for residents who eat in the dining room. She stated the nursing staff did not want foods served in the dining room to be covered. She stated that was why the glass of milk was also uncovered. She stated not covering the puddings could cause cross contamination of the foods and residents could get sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 10/29/24 at 1:30 pm, the HS stated she was supervising the kitchen until another manager is hired. She stated she had worked very hard to make sure the kitchen was in order. She stated she expected the staff to wear hairnets while in the kitchen and Housekeeper E had been counseled about not wearing a hairnet in the kitchen. She stated the housekeeper should not have been in the kitchen at all. She stated all food items should be covered labeled and dated. She stated the reason the pudding and drinks were not covered were because the nursing staff did not want the foods covered if the residents were eating in the dining room. The HS stated the consequences of all the issues in the kitchen could cause cross contamination and possibly make the residents sick. Record review of the facility policy titled ' Employee Sanitation' dated 2018 documented hairnets must be worn to keep hair from food and food contact surfaces. Record review of the facility's policy titled, 'Food Storage' dated June 1, 2019, documented: Date, label and tightly seal all refrigerator foods using clean nonabsorbent covered containers that are approved for food storage. To ensure freshness , store opened items in tightly covered containers. All containers must be labeled and dated. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3201.11 Compliance with Food Law (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under §§ 3-202.17 and 3-202.18. Pf Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 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 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 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)

F 0812 3-302.12 Food Storage Containers, Identified with Common Name of Food. Level of Harm - Minimal harm or potential for actual harm Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall Residents Affected - Some 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) , preparation, holding, and display by: (a) Using separate EQUIPMENT for each type, P or (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 If continuation sheet Page 12 of 12