Inspection·June 6, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were held monthly in the dining room. The Administrator stated the Activity Director was present during the meetings because she was the one who hosted the meetings. The Administrator stated usually there were 10-15 residents that attended, and the dining room was the largest space the facility had to hold the meetings. The Administrator stated prior to the meeting, the Activity Director alerted staff not to enter the area unless there was an emergency. The Administrator stated if there were any issues or concerns discussed at the meeting, the Activity Director told her about them, and they were addressed immediately. The Administrator stated it had never been brought to her attention that the location or staff being present was an issue with residents. Record review of the resident council minutes for January 2023, February 2023, and March 2023, April 2023, May 2023 revealed no requests for a private area. Request for facility policy concerning Resident Council was requested. The Administrator stated the facility did not have a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675270 If continuation sheet Page 2 of 5 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 675270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060 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 observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. Residents Affected - Some The facility failed to ensure: - the dishmachine was working properly and did not have to been run mulitple times to reach 120 degrees F; - the Dietary Manager was aware of the dishmachine was a sanitizing dishmachine and not a high temperature dishmachine; - Dishwasher Aide B was documenting actual dishmachine tempteratures; and - food stored in the pantry was properly stored, labeled and dated. This failure could place residents at risk for food contamination and food borne illness. Findings included: Observation and interview in the kitchen pantry on 06/04/23 at 9:08 AM revealed a bag of chocolate cake mix was not properly sealed, with a date of 04/20 written on the outside of the manufacturer's bag. The cake mix was open sitting on the top shelf. In the freezer, there was a box labeled fully cooked sausage patties in open plastic, not properly sealed, with a date of 06/03/23. In the refrigerator at the bottom was a gray tub with three bags of yellow liquid. The bags were not labeled or dated. Two bags had dark yellow liquid; the third bag had a lighter yellow liquid with chunks of substances. When asked about the third bag, it was revealed by [NAME] A that the bag contained eggs that she placed in boiling water to cook for breakfast. [NAME] A stated she forgot today was a cold food breakfast day (only serving cereal, milk, toast) and would not be using the eggs. [NAME] A stated she forgot to label and date the eggs so they could be used the following day. [NAME] A stated it was her responsibility to ensure any food that was stored should be properly sealed, labeled and dated to prevent food born illnesses. Interview with the Dietary Manager on 06/04/23 at 9:15 AM revealed she monitored the kitchen and staff to ensure facility policies are being followed. The Dietary Manager stated she completed a walk through daily behind staff to make sure food items are labeled, dated, and sealed. The Dietary Manager stated she did not do a walk through today because she was scheduled off. The Dietary Manager stated she was not aware of the opened items in the pantry or the freezer. The Dietary Manager stated she was not aware of the partially cooked eggs in the refrigerator. The Dietary Manager stated [NAME] A was responsible to ensure opened food items were properly stored after used. The Dietary Manager stated the eggs should have been labeled and dated properly so they could have been used the following day. The Dietary Manager stated not having food items properly sealed, labeled, and stored could put residents at risk for illness. During observation, interview, and record review on 06/04/23 at 9:30 AM revealed the dishmachine temperature/chemical log was completely filled out for the day. The log reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675270 If continuation sheet Page 3 of 5 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 675270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060 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 - Breakfast: wash 100/rinse 110/ppm 50, initialed by Dishwasher Aide B Level of Harm - Minimal harm or potential for actual harm - Lunch: wash 115/rinse 120/ppm 50, initialed by Dishwasher Aide B Residents Affected - Some - Dinner: wash 120/rinse 140/ppm 150, initialed by Dishwasher Aide B (which were the exact same numbers from the previous days beginning with 06/01/23). When reviewing the dishwasher log, Dishwasher Aide B stated she completed the log for the day by mistake and knew the log should be completed after each meal when cleaning the dishes. Observation of the dishmachine temperature reached between 80 degrees during the dishmachine run. Observation of the dishmachine revealed it ran at least 5 times before reaching manufacturer's minimum of 120 degrees. According to Dishwasher Aide B the dishmachine should reach temperatures of at least 120 degrees to clean dishes. Dishwasher Aide B stated not reaching proper temperatures could result in residents getting sick. Interview on 06/04/23 at 9:40 AM with the Dietary Manager revealed the dishmachine machine is a high temperature machine and should reach temperatures of 130 degrees during wash cycle. After pointing out the manufacture template. The Dietary Manager stated she was not aware of the proper wash and rinse temperatures of minimum of 120 degrees. The Dietary Manager stated she expected staff to monitor the machine and to ensure dishes are cleaned by using proper water temperatures and checking sanitation levels. The Dietary Manager stated a couple of weeks ago the facility had water issues and stated the dishmachine had to run several times to reach proper water temperatures. The Dietary Manager stated staff should be monitoring the machine to ensure temperatures are reached before unloading dishes. The Dietary Manager stated the temperature log should be completed after each meal while cleaning dishes. The Dietary Manager stated breakfast dishes should be re-ran to ensure cleanliness and sanitation. Observation of the dishwasher on 06/04/23 at 12:30 PM revealed Dishwasher Aide B running the dishmachine, Dishwasher Aide B was not observed monitoring the temperature of the dishmachine to ensure proper temperatures are being reached prior to unloading lunch dishes. Observation of Dishwasher Aide B running the machine several times revealed the dishmachine running at minimum 120 degrees for both wash and rinse cycles. Dishwasher Aide B stated she did have an in-service about the dishmachine, she stated she was aware to keep eyes on the temperature guage for minimum temperatures of 120 degrees. Observation and interview of the dishmachine on 06/05/23 at 9:14 AM revealed Dishwasher Aide C running the dishmachine after breakfast, Dishwasher Aide C was observed not monitoring the dishmachine to reach minimum of 120 degrees. Observation of the first run revealed wash 80 degrees rinse at 127, second run revealed wash 105 degrees rinsed at 130, third run revealed was at 125 rinse at 140 with 50 ppm for the sanitizer. According to Dishwasher Aide C she completed in-service to ensure the dishmachine was reaching minimum of 120-degree temperatures. Dishwasher Aide C stated the dishmachine was very sensitive and with any break the temperature will go low, and the machine had to be run several times to get the temperature back to 120 degrees. Interview on 06/06/23 at 4:50 PM with the Administrator revealed she was informed by the Dietary Manager that the dishmachine was having issues keeping at minimum of 120-degree temperature and staff was having to run the machine several times to ensure the machine was running properly. The Administrator stated the machine was serviced monthly and there had not been any issues or concerns noted prior to survey. The Administrator stated staff had been in serviced, and the Dietary Manager would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675270 If continuation sheet Page 4 of 5 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 675270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060 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 responsible for continued monitoring of both staff and the dishmachine to ensure dishes were being thoroughly cleaned. The Administrator stated not storing food properly in the kitchen could allow staff to used outdated foods. The Administrator stated not ensuring the dish machine was running at correct temperatures could put residents at risk of illnesses. Record review of facility policy revised 06/01/19 titled Food Storage reflected: .to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes .to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Store raw meets and eggs on the bottom shelf to prevent contamination of other foods. Date, label and tightly seal all refrigerated foods . Record review of facility policy dated 10/01/18 titled Mechanical cleaning and Sanitizing of Utensils and Portable Equipment reflected: .The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes to ensure thorough cleaning and sanitization to minimize the risk of food hazards. Operate the dish machine as instructed in the manufacturer's directions. a. The temperature of the wash water must be at lease 120-degree F FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675270 If continuation sheet Page 5 of 5