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, interview and record review, the facility failed to store, prepare, distribute, and serve
food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.
Residents Affected - Some
The facility failed to ensure:
- items in the reach in cooler had a label and an open date.
-items on the prep table had been opened and not labeled with the open date.
These failures could place residents who ate food from the kitchen at risk of foodborne illness.
Findings included:
During observations, interviews and record reviews on 05/027/25 of the kitchen the following was noted:
On 05/27/25 at 10:16 AM in the 3-door cooler
1-46 oz honey thick Orange Juice was not dated when opened. It had a truck delivery date on the container
of 05/07/2025.
1-46 oz. nectar thick Orange Juice was not dated when opened. It had a truck delivery date on the
container of 05/14/2025.
The packaging on the container reads: After opening may be kept up to 7 days under refrigeration.
1 small white bowl of white substance plastic covering dated 05/20/25.
1 small square plastic covered container with no label or date contained a small brown square of some
substance.
During an observation on 05/27/2025 at 10:40 AM on the prep table opposite the dish machine the
following was noted:
1-46 oz honey thick sweet tea was not dated when opened. It had a truck delivery date on the container of
5/14/25.
(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 3
Event ID:
675320
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
675320
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Bradburn
520 Bradburn Rd
Grand Saline, TX 75140
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
1-46 oz. nectar thick sweet tea was not dated when opened. It had a truck delivery date on the container of
5/21/25.
The packaging on the container reads: After opening may be kept up to 7 days under refrigeration.
During an interview and observation on 05/27/2025 at 10:27 AM the DM removed all four thickened liquid
cartons that were open and discarded them. She said the date marked on the box was the date the truck
delivered the item and was to help with product rotation. She said items were to be marked when opened.
She said leftovers in the refrigerator should be used within 3 days or discarded. She said the white
substance was a bowl of icing and should have been discarded. She said the item in the small square
container was a piece of fudge that belonged to a resident. She discarded the icing and fudge.
Record review the facility's Food Receiving and Storage policy, revised November 2022, indicated the
following: .Refrigerated /Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled
and dated (use by date) .7. Refrigerated foods are labeled, dated and monitored so they are used by their
use-by date, frozen, or discarded.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675320
If continuation sheet
Page 2 of 3
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
675320
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Bradburn
520 Bradburn Rd
Grand Saline, TX 75140
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 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure resident rooms measured at least 80
square feet per resident in multiple rooms and at least 100 square feet in single resident rooms for 2 of 10
resident rooms (Resident room [ROOM NUMBER] and 311) reviewed for square footage.
The facility failed to provide 80 square feet per resident for a room certified for 4 residents and provide 100
square feet for a room certified as a private room.
These failures could place residents at risk of not having adequate space to meet their needs.
Findings included:
During an observation on initial tour on 05/27/2025 at 10:40 AM, it was observed that no residents were
residing in room [ROOM NUMBER] and no residents were residing in room [ROOM NUMBER].
During an interview on 05/28/2025 at 9:45 AM, the Administrator said resident rooms [ROOM NUMBERS]
still required room waivers. She said room [ROOM NUMBER] was certified for 4 residents and measured
74 square feet per resident and room [ROOM NUMBER] was certified as a private room and measured 81
feet instead of 100 square feet. She said room [ROOM NUMBER] was used as a staff break room. She said
she filed for the waiver after the life safety code inspection on 05/27/2025.
Record review of the bed classification form dated 05/27/2025 indicated room [ROOM NUMBER] was
certified for 4 residents and room [ROOM NUMBER] was certified for 1 resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675320
If continuation sheet
Page 3 of 3
