Health inspection·December 11, 2024

F 0550 recently trained on dignity by the DON. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/11/24 at 5:08 p.m., the ADON stated her and the DON most recently in-serviced staff on dignity last month. The ADON stated her and the DON most recently trained staff on using appropriate terminology, such as clothing protector instead of bibs last month. The ADON explained the training was about giving dignity to residents and respecting residents' rights. The ADON stated she knew it was important not to use bibs and said, Because I don't want residents to feel like babies or kids, and adults use clothing protectors. Residents Affected - Some During an interview on 12/11/24 at 5:12 p.m., the RNC stated she worked with facility for 1 month. The RNC stated she had not trained the facility staff on dignity. The RNC stated the facility staff were expected to use word, clothing protector instead of bibs. The RNC stated she knew it was important to use clothing protector instead of bibs and said, I would not want the residents to feel childish or childlike. The RNC stated using bibs had the potential to bother residents. During an interview on 12/11/24 at 5:28 p.m., the SW stated she worked at the facility for 7 years. The SW stated she had not received any concerns or issues from residents and responsible parties about dignity. The SW stated she knew it was important not to use bibs and said, Residents were adults and grown and that is a dignity issue. Residents might be offended if they heard 'bibs' instead of 'clothing protector' and it would make residents feel childlike. The SW stated facility staff were most recently in-serviced on dignity during the all staff meeting on 11/21/24. The SW explained dignity and resident courtesy was reviewed again with the facility staff. During an interview on 12/11/24 at 5:33 p.m., the ADM stated facility staff were most recently in-serviced on dignity during the all staff meeting held on 11/21/24. The ADM stated he knew it was important to use the correct terminology of clothing protectors instead of bibs and said, Because one is used to refer to children and people could feel some type of way about that. It's important to be mindful and talk to adults as if they're adults. During an interview on 12/11/24 at 6:02 p.m., the DON stated she most recently in-serviced the staff the previous month on dignity. The DON stated she in-serviced the staff about the dignity policy and procedures and using the correct terminology, such as using clothing protectors instead of bibs. The DON stated she expected the staff to use clothing protectors instead of bibs when referring to the clothing protectant a resident wore to prevent food from spilling on their clothes. The DON stated she knew it was important to use clothing protector and said To honor the residents' dignity. 'Bibs' is used for children. That's a dignity issue. We're here to honor the residents, their rights, and their dignity. Record review of the facility's in-services, from 10/01/24 through 12/11/24, reflected staff were most recently in-serviced on the facility's dignity policy and procedure on 10/23/24. Record review of the facility's Dignity policy and procedure, revised February 2021, reflected the following, Each resident shall be cared for in a manner that promotes and enhance his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 2 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 0550 .5. When assisting with care, residents are supported in exercising their rights. For example, residents are: Level of Harm - Minimal harm or potential for actual harm e. provided with a dignified dining experience. Residents Affected - Some 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. Record review of the facility's Resident Rights policy and procedure, revised February 2021, reflected the following, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 3 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interviews and record reviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (MA C) of 3 staff reviewed for authorized drug destruction personnel. The facility failed to ensure a licensed professional was a witness to the drug destruction. MA C witnessed and handled controlled and non-controlled medications during the drug destruction process with the DON. This failure could place residents at risk of drug diversion. Findings included: Record review of the facility's staff roster, dated 12/11/24, reflected MA C was a medication aide. Record review of the facility's controlled and non-controlled drug destruction forms, from 06/01/24 through 12/11/24, reflected the following: -MA C signed as a witness and the DON signed as a nurse to the non-controlled and over the counter drug destruction process on 10/08/24. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process on 10/10/24. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process on 10/16/24. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process on 13 undated forms. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process on 11/06/24. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process on 11/12/24, 11/20/24 and 11/22/24. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process on 11/26/24 and 12/04/24. There was no signature from the Pharmacist. -MA C signed as a witness, the DON signed as a nurse, and the Pharmacist signed as a Pharmacist to the controlled drug destruction process in June 2024. -MA C signed as a witness, the DON signed as a nurse, and the Pharmacist signed as a Pharmacist to the unknown type of drug destruction process on 08/31/24. -MA C signed as a witness, the DON signed as a nurse, and the Pharmacist signed as a Pharmacist to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 4 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 the controlled drug destruction process on 12/03/24. Level of Harm - Minimal harm or potential for actual harm During a confidential interview on 12/11/24 at 9:06 a.m., CE stated MA C did the medication destruction. CE stated MA C was a medication aide and not a nurse. Residents Affected - Some During an interview on 12/11/24 at 10:33 a.m., the DON stated she was responsible for residents' medication drug destruction. The DON explained the drug destruction process occurred in the Pharmacist's presence. During an interview on 12/11/24 at 12:20 p.m., MA C stated she worked at the facility for approximately 7 months. MA C stated she helped the DON with drug destruction. MA C stated she helped destroy residents' narcotic and non-narcotic medications with the DON and pharmacist. MA C explained her and the DON popped the medications out of the blister packs and the pharmacist checked out the forms to ensure the correct resident and medication was being destroyed and then the Pharmacist destroyed the medications with a chemical, closed the box, sealed the box, and took the box. MA C stated she had been helping the DON with the process for a few months and said, Maybe since August or September 2024. MA C stated she wasn't trained on how to destroy the medications by the DON. MA C stated she was the only medication aide who helped the DON with the drug destruction process. MA C stated she was not aware that she was not authorized to destroy medications with the DON. MA C stated she knew it was important for authorized staff to conduct the drug destruction process and said, It's to make sure everything was accounted for. During an interview on 12/11/24 at 12:54 p.m., the ADM stated he was aware that the facility's pharmacist was aware that MA C was helping the DON with destroying narcotic and non-narcotic medications and never mentioned MA C helping with the drug destruction process as an issue. The ADM stated based on the facility's policy, he believed MA C was not an authorized staff member to assist the DON with the drug destruction process. The ADM stated he was not aware, prior to surveyor showing him the facility's policy, that MA C was not an authorized staff member. The ADM stated he knew it was important to follow policies and procedures and said, I understand there was a policy. The policy was important for guideline purposes and to protect us, but in my view, it's just a guideline. During an interview on 12/11/24 at 1:00 p.m., the DON stated the facility's pharmacist was a healthcare professional and she was a healthcare professional who conducted the drug destruction process. The DON explained the nurses brought the narcotic and non-narcotic medications to be destroyed to her and she destroyed the medications. The DON stated the facility's pharmacist looked at the drug destruction log, she looked at the log to verify, and then she destroyed the medications. The DON stated the only staff who helped her with the drug destruction process was [MA C], nurses, if they have time, and the ADON if she had time. The DON explained MAs could log during the drug destruction process. The DON stated MA C had been and signed as a witness during the narcotic and non-narcotic drug destruction process. The DON stated MA C helped her with the non-narcotic medications destruction process and said, Per policy, there's nothing wrong with her (MA C) logging non-narcotic medications to be destroyed. The DON stated she didn't know how long MA C had been witnessing the drug destruction process. The DON explained MA C also helped her pop out non-narcotic medications from the blister packs during the drug destruction process and said, The pharmacy consultant told me that she (MA C) could do it. During an interview on 12/11/24 at 1:13 p.m., LVN A stated she never participated in the facility's drug destruction process and said, We (nurses) had a sheet that we filled out. Say if I had narcotics, the DON and I have to log the medications to be destroyed, then we sign confirming the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 5 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 - Some medications to be destroyed and then the DON destroys it. MAs were not allowed to witness the drug destruction process as far as I know. LVN A stated she knew it was important for authorized staff to participate in the drug destruction process and said, Because nine out of ten times, the drugs are narcotics. LVN A explained that her understanding was that there must be 2 RNs who participated in the drug destruction process. LVN A stated she didn't know who witnessed and destroyed medications at the facility and only knew her process of logging and disposing the medications in boxes. LVN A said, Two nurses sign off on the narcotics to be destroyed and hand it to the DON. During an interview on 12/11/24 at 2:00 p.m., the Pharmacist stated she visited the facility once a month to participate in the drug destruction process. The Pharmacist explained she checked to make sure that the number of medications matched the medication sheet and drug destruction form. The Pharmacist said, There has to be 2 other people, typically nurses or the ADM. The DON always helps. For witnesses, typically, it was the ADM, a nurse on floor or the DON. When asked if an MA could participate in the drug destruction process, the Pharmacist said, I honestly don't know, I never had a medication aide help me before. The Pharmacist stated she been at the facility for all the drug destructions conducted, but she was always told that a nurse was with her and the DON. The Pharmacist said, If it was a medication aide, I assumed it was nurse. I always say I want the DON, ADON and another nurse. So, if she brings someone else in, I assumed it was a nurse. I don't really know who [MA C] was. I just know it was a Black female who helped the DON. The Pharmacist said, It's important for authorized staff to handle narcotics to avoid drug diversion. I always preferred a nurse. I don't prefer a medication aide. I don't use medication aides during the drug destruction process. I want someone authorized to do it and sign off on it to perform the drug destruction. I know it must be authorized personnel and that it must be nurses. I always asked for nurses for this process. I'm concerned on my part about medication aides participating and witnessing this process. I always asked for the DON and another nurse. I'm wondering if the DON knew something I didn't know? The Pharmacist stated she was unsure if MAs could conduct and witness the non-narcotic drug destruction process because she wasn't there for that process. During an interview on 12/11/24 at 2:55 p.m., CNA D stated nurses were responsible for destroying narcotic and non-narcotic medications. CNA D explained two nurses performed the drug destruction process and said, I'm not sure if a medication aide could discard medications, but if so, it would be medication aide with a nurse. CNA D stated she knew it was important for authorized staff to conduct the drug destruction process and said, Because medications could come up missing, but when having people with licenses do it, it gets done correctly. Anybody can't just do it, you can't trust everybody, it has to be people with licenses. During an interview on 12/11/24 at 3:16 p.m., RN E stated she never participated in the drug destruction process, but she was familiar with the process. RN E said, The facility's policy said that a licensed person can be a witness, which can be a doctor, MA, LVN, RN, and MD. I believe MAs were licensed people because they had to pass an exam to be able to pass out medications. The policy doesn't specify who was licensed, but only said licensed people. When asked who could conduct the drug destruction process, RN E said, I believe an RN, pharmacy technician and a witness for narcotics, and for non-narcotics, I will defer to what the policy says. The policy says it has to be the pharmacist, a nurse, and licensed witness. RN E stated she knew it was important for authorized staff to conduct the drug destruction process and said, To ensure appropriate disposition of medications. If they are not authorized, it is illegal to do it. During an interview on 12/11/24 at 3:44 p.m., the ADON stated she never participated in the facility's drug destruction process. The ADON stated she witnessed the drug destruction process. The ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 6 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 - Some said, Licensed staff, which were MAs, LVNs, and RNs can witness the drug destruction process. MAs were licensed because they had to take a state test to become an MA. If a staff member was working with residents, they more than likely must be certified. MAs were more than just passing out medications. They have to be aware of the medication administration process. The ADON also stated she didn't know the facility's protocol for who were authorized drug destruction personnel. The ADON stated she knew it was important for authorized staff to conduct the drug destruction process and said, To make sure the drugs were destroyed and someone was not taking and using them for their own good. The ADON said, With narcotics, the drug destruction process was performed with the pharmacist. With non-narcotics, I was in the office with [MA C] when she was physically handling medications. If you and someone else is destroying them, MAs can witness the process. There has to be nurse with the MA to destroy the medication if a medication is dropped because it must have 2 signatures. Record review of the facility's Disposal of medications and medication-related supplies for controlled medications policy, revised January 2018, reflected the following, Controlled Substance Disposal Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures: A. The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. B. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of (two licensed nurses), and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason. C. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: I) In the facility by the (administrator), director of nursing and/or consultant pharmacist (or others as allowed by state law); .E. The [administrator], nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the (individual controlled substance accountability record/book): .6) Signatures of witnesses. Record review of the facility's Disposal of medications and medication-related supplies for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 7 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 non-controlled medications policy, revised January 2018, reflected the following, Level of Harm - Minimal harm or potential for actual harm Medication Destruction For Non-Controlled Medications Residents Affected - Some Policy: Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, or are donated are destroyed (See IEl: CONTROLLED SUBSTANCE DISPOSAL). Destruction methods comply with federal and state laws and regulations for medication destruction. Procedures: .E. Medication destruction occurs only in the presence of at least two licensed healthcare professionals or according to regulation and applicable law. F. The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the [medication disposition form): .6) Signatures of witnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 8 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for kitchen sanitation. Residents Affected - Few The facility failed to ensure dietary staff stored disposable plates and cups away from chemicals and cleaning supplies. This failure could place residents at risk of cross-contamination, food contamination, and foodborne illness. Findings included: An observation of the kitchen's cleaning supply room on 12/11/24 at 10:35 a.m., revealed there was an open box of Styrofoam cups next to a rack that had cleaning supplies stocked on each shelf. The room door was propped wide open with 1 gallon-sized bottle of concentrated alkaline degreaser and 1 gallon-sized bottle of concentrated alkaline floor cleanser. There was no dietary staff in or near the cleaning supply room. From top to bottom, the first shelf had 1 quart spray bottle of heavy duty degreaser and 1 quart spray bottle of bio-enzymatic odor eliminator hanging on the edge of the shelf. The second shelf had 1 open and half empty gallon-sized bottle of concentrated alkaline degreaser, 1 quart-sized bottle of all-purpose cleaner with bleach, and 8 .95 liters of concentrated hi-alkaline degreaser. The third shelf had 2 gallon-sized bottles of bleach, 3 2.5 liters of sanitizer, 3 2.5 liters of dish liquid, and 2 2.5 liters of presoak. During an interview on 12/11/24 at 10:39 a.m., DA F stated she did not know how long the disposable plates and cups were stored next to the cleaning supplies in the kitchen's cleaning supply room. When asked who was responsible for storing away disposable cups and plates, DA F said, It depended on who unloaded truck. We don't have room to put the disposable plates and cups anywhere else. I guess you could put it in the shed outside the kitchen. DA F stated she was usually trained to store the disposable plates and cups in the outside kitchen shed, pantry or underneath the counter in the kitchen. DA F stated the DM was responsible for storing away the disposable plates and cups weekly. DA F stated she knew it was important to store the disposable plates and cups away from and not near the cleaning supplies and said, It was a cross contamination issue. DA F stated she knew storing disposable plates and cups near cleaning supplies could place residents at risk and said, The chemicals could spill on the box and cause residents to get sick if they used the plates and cups. During an interview on 12/11/24 at 10:44 a.m., the [NAME] stated she did not know how long the disposable plates and cups had been stored next to the cleaning supplies in the kitchen's cleaning supply room. The [NAME] stated she was not trained to store the disposable plates and cups next to the cleaning supplies. The [NAME] stated she knew that there should not be anything stored near the cleaning supply chemicals. The [NAME] stated she knew it was important to store the disposable plates and cups away from the cleaning supplies and said, So the plates and cups don't get exposed to the chemicals. The [NAME] stated she knew storing disposable plates and cups near cleaning supplies could place residents at risk and said, Residents could get sick, if the disposable plates and cups were exposed or cross-contaminated with the cleaning supply chemicals they were stored next to. The [NAME] stated she was usually trained to store the disposable plates and cups in the outside kitchen shed, pantry, or underneath the counter in the kitchen. The [NAME] stated the DAs and the DM were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 9 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 responsible for storing away the disposable plates and cups weekly. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/11/24 at 10:52 a.m., the DM stated all dietary staff were responsible for storing the disposable plates and cups away from the cleaning supplies. The DM stated she expected her dietary staff to store the disposable plates and cups in the storage shed outside the kitchen. The DM said, The staff set the disposable cups and plates in the cleaning supply room after it rained during the week. It's not a regular thing. Usually, they put it (disposable plates and cups) in a particular box under the countertop in the kitchen, when asked why the disposable plates and cups were in the cleaning supply room. The DM stated she most recently trained staff 6 months ago about proper kitchen supply storage. The DM stated she was responsible for training the dietary staff on proper kitchen supply storage and said, The Dietician also trained the dietary staff on proper kitchen supply storage. The DM stated she knew it was important to store the disposable plates and cups away from the cleaning supplies and said, Just in case there's a spill and the plates and cups were used. Residents could get sick if the disposable cups and plates stored next to the cleaning chemicals were used. Residents Affected - Few An observation of the kitchen's cleaning supply room on 12/11/24 at 11:25 a.m. revealed the disposable plates and cups were no longer in the cleaning supply room. The room door was propped wide open with 1 gallon-sized bottle of concentrated alkaline degreaser and 1 gallon-sized bottle of concentrated alkaline floor cleanser. There was no dietary staff in or near the cleaning supply room. During an interview on 12/11/24 at 11:26 a.m., the DM stated the cleaning supply room was allowed to stay open when in use. The DM stated the cleaning supply room was not currently in use at the time of the interview. During an interview on 12/11/24 at 11:34 a.m., the DON said, Residents could potentially have an upset stomach if the disposable plates and cups were stored in the same room as the cleaning supply chemicals. If the cleaning supply chemicals got on the plastic cups and plates, residents could become sick. The DON stated the facility was not using the disposable plates and cups at the time of the interview. During an interview on 12/11/24 at 11:42 a.m., the DC stated she trained the dietary staff whenever there was an issue. The DC stated she was unsure if she trained the dietary staff on proper kitchen supply storage. The DC stated the DM was responsible for training the dietary staff on proper kitchen supply storage techniques. The DC said, The cleaning supply room could be open, but it was usually closed when not in use. Disposable plates and cups are supposed to be stored separately. I was told by the dietary staff that there was no room in the storage room outside the kitchen and they haven't gotten to clearing the shed yet. The DC stated she didn't know when the disposable plates and cups were put there. The DC stated she knew it was important to store the disposable plates and cups away from the cleaning supply chemicals and said, To avoid any potential likelihood of cross contamination of paper goods used to serve food. It was against our policy, but obviously you don't want a resident to consume chemicals. During an interview on 12/11/24 at 3:16 p.m., RN E stated she knew it was important to store disposable plates and cups away from cleaning supply chemicals and said, It's chemicals, it's dangerous, it should be separate. Residents could get sick from being served disposable plates and cups stored next to cleaning supply chemicals. RN E stated the facility was not serving residents disposable plates and cups at the time of the interview. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 10 of 11 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 675587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Adams 3011 W Adams Ave Temple, TX 76504 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 During an interview on 12/11/24 at 3:44 p.m., the ADON stated she knew it was important to store disposable plates and cups away from cleaning supply chemicals and said, Residents could inhale cleaning supply chemicals in the Styrofoam because Styrofoam absorbs that type of stuff. The ADON stated the facility used regular plates unless a resident asked for salads, then the dietary staff would provide them with the salads in a disposable takeout container. Residents Affected - Few During an interview on 12/11/24 at 4:04 p.m., CNA B stated she knew it was important to store disposable plates and cups away from cleaning supply chemicals and said, Residents could get sick. During an interview on 12/11/24 at 4:10 p.m., CNA G stated she knew it was important to store disposable plates and cups away from cleaning supply chemicals and said, Residents could get sick if served disposable plates and cups next to cleaning supply chemicals. Cleaning supply chemicals must be away from plates and cups to prevent sickness. During an interview on 12/11/24 at 4:21 p.m., LVN H stated he knew it was important to store disposable plates and cups away from cleaning supply chemicals and said, To keep the plates from being contaminated by the cleaning supply chemicals. If the cleaning supply chemicals got on the plates, residents could ingest the cleaning supply chemicals. Review of the facility's Food Storage policy, revised 06/01/19, reflected the following: Policy: 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 and HACCP guidelines. Procedure: 1. Dry storage rooms .h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination. .i. Do not use or store cleaning materials or other chemicals where they might contaminate foods. Label and store them in their original containers when possible. Store in a locked area away from any food products. Review of the facility's Kitchen Sanitation and Cleaning Schedules, undated, reflected the following: .All paper goods and other disposables are to remain covered to prevent contamination. .Do not consume, handle, prepare, or store food in areas with hazardous chemicals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675587 If continuation sheet Page 11 of 11