Health inspection·October 30, 2024

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few enough for extras, you get what you get. Resident # 1 said he received one egg, one strip of bacon, and one biscuit that morning. Resident #1 said he has asked before for an extra biscuit, but they had told him there was no more and not to be selfish that there were more residents at the facility, so he quit asking . 2. Record review of Resident #2's face sheet dated 10/29/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and discharged home on [DATE]. Resident #2 had diagnoses which included cerebral ischemic attack (occurs when blood flow to the brain is reduced or blocked), essential hypertension (high blood pressure), protein-calorie malnutrition (inadequate intake of proteins and calories in diet), and end stage renal disease (permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to sustain life). Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment did not indicate Resident #2 had a swallowing disorder or a significant weight loss/gain of 5 percent in the last 6 months. Record review of Resident #2's comprehensive care plan revised 04/18/24, indicated Resident #2 was on a regular diet with thin liquids. The care plan interventions indicated Resident #2 will follow diet orders. Record review of Resident #2's physician order report dated 12/28/23-05/17/24, indicated Resident #2 had an order for regular diet with a start date of 12/18/23. Record review of a grievance form dated 04/03/24, indicated Resident #2 made the complaint himself. The grievance form indicated under detail of complaint of grievance [Resident #2] feels like dietary department is frequently running low on food or out of a certain items ie: eggs, biscuit. During an observation of facility lunch menu on 10/29/24 at 11:35 AM, that was displayed at the entrance of the dining room, indicated lunch meal was as followed: Baked pork steak lyonnaise, potatoes, sliced carrots, cornbread, and applesauce . During an observation and interview on 10/29/24 at 12:40 PM, the test tray was placed on the cart. The test tray portion size appeared to be adequate. [NAME] A said they had ran out of cornbread so none were placed on the test tray. During an observation and interview on 10/29/24 at 12:51 PM, the Dietary Supervisor said they had run out of the main lunch meal and the alternate meat and needed to take the test tray for a resident that had requested he wanted what was served for lunch . The Dietary Supervisor said that running out of food usually did not happen. During an interview on 10/29/24 at 12:55 PM, the Dietary Supervisor said if a resident requested for extra servings of the meal they would have to fix an alternate meal. The Dietary Supervisor said depending on what the resident wanted, they could fix them sandwiches or a grilled cheese sandwich. The Dietary Supervisor said if the resident wanted what they had for lunch and they did not have extras, then the cook would have to make more. The Dietary Supervisor said she would not let a resident be without eating. The Dietary Supervisor said she had ready to cook meats that could be cooked quickly if needed. The Dietary Supervisor said the cook and herself were responsible for ensuring the residents had enough food . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 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 675788 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Commerce 2901 Sterling Hart Dr Commerce, TX 75428 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/29/24 at 12:59 PM, [NAME] A said she had worked at the facility for 13 years. [NAME] A said the Dietary Supervisor and herself were responsible for ensuring there was enough food cooked if the residents requested for extra portions. The Dietary Supervisor said she usually cooked an extra kind of meat as an alternate. [NAME] A said there were residents at the facility that required double portions. [NAME] A said if a resident requested extra food, she would ask them what they wanted, and she would cook it for them . So, this would not affect the residents. [NAME] A was unable to give a reason as to why they ran out of food. During an interview on 10/30/24 at 12:13 PM, LVN B said she had not received any complaints of not having enough food from residents. LVN B said she had not seen the facility run out of food. LVN B said if a resident requested extra food, during their meal, they had the right to receive more food. LVN B said if a resident requested extra food and there was not enough extra made, they could go hungry. LVN B said they Dietary Supervisor and the Administrator were responsible for ensuring there was an adequate amount of food made with each meal . During an interview on 10/30/24 at 2:14 PM, the DON said there should be enough food made for seconds as well as an alternate meal. The DON said she had not heard or seen any issues of running out of food. The DON said it was important for there to be an adequate amount of food because if a resident said they were still hungry then they must accommodate. The DON said if they ran out of food, then the cook was responsible for making more food. The DON said the Dietary Supervisor and the Administrator were responsible for ensuring there was an adequate amount of food made with each meal. The DON said the residents were not at any risk because they had already received some food and there were no risks to that. The Administrator was not available for interview. Record review of the facility's policy titled Food and Nutrition Services revised September 2021, indicated . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes, and eating habits, as well as physical functional, and psychosocial factors that affect eating and nutritional intake and utilization. 4. Reasonable efforts will be made to accommodate resident choices and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675788 If continuation sheet Page 3 of 3