Inspection·May 5, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RD stated she did not know either but could quickly look it up. The RD stated that the calibration temperature in ice water should be 32F. COOK A did not know to subtract the number displayed that showed on the thermometer for the true food temperature and stated she wrote whatever the number on the thermometer was on the log. An interview with the DM on 05/04/23 at 11:40 AM stated the kitchen staff drained the steam table wells nightly and used a lime-dissolving product as well as vinegar to clean the steam table wells. The DM stated she did not know why the steam table wells had scaling and rust. The DM stated, You should have seen them before; they were way worse. An interview with COOK B on 05/05/23 at 8:15 AM stated thermometer calibration could be done two ways; ice water or boiling water. COOK B stated ice water calibration should show 32F and boiling water should show 212F. COOK B stated another thermometer could be used and proceeded to show this surveyor where other thermometers were kept. COOK B stated correct food temperatures were important, so there was no contamination or food-borne illnesses; if the temperatures on the thermometers were off, and no adjustment was made, the temperatures in the logs would also be off. A record review of the Daily Cleaning schedules for 2023 revealed the following: *The March Daily Cleaning schedule documented the Dining table, chairs, and floor, the dish machine, doors, walls, and windows, food and dish carts, ice scoop and container, juice machine, the meat slicer, the microwave, the refrigerator, the freezer and cooler, the steamer and steam kettle, the coffee machine, and the storeroom was not cleaned on March 21, 22, 23, 24, 24 and 25, 2023. *The April Daily Cleaning schedule documented cleaning cloths, the coffee machine, the dining tables, chairs and floor, the dish machine, doors, walls and windows, food and dish carts, the ice scoop and container, the juice machine, the meat slicer, the microwave, the refrigerator, freezer and cooler, the steamer and kettle, and the store room were not cleaned on April 10th, and the dining tables, chairs and floor, doors, walls and windows, food and dish carts, ice scoop and container, juice machine, the microwave, the refrigerator, freezer and cooler, the steamer and kettle, and the store room were not cleaned on April 11, 12, 13, and 14, 2023. Interview with the DM on 05/05/23 at 8:18 AM she stated the missing documentation on the daily cleaning logs was because they were very understaffed at the time, and they just did not do it. (Clean those items) A record review of the facility's policy for Food Storage dated 12/01/11 documented 2. e. All refrigerated foods are dated, labeled, and tightly sealed, including leftovers . A record review of the facility's policy Sanitizing and Calibrating Thermometers approved Jan. 1, 2023, documented 2.There are two methods for calibrating thermometers. a. Ice Water iv. Wait a minimum of 30 seconds before adjusting .v.adjust the thermometer until it reads 32F. b. Boiling Water 3. Even if the food thermometer cannot be calibrated, it should still be checked for accuracy using either method. Any inaccuracies can be taken into consideration when using the food thermometer, or the food thermometer can be replaced. a. for example, water boils at 212F. If the food thermometer reads 214F in boiling water, it is reading two degrees too high. Therefore, two degrees must be subtracted from the temperatures displayed when taking a reading in food to find out the true temperature. The facility failed to provide a policy on personal items in the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 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 675850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Portland 221 Cedar Dr Portland, TX 78374 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to allow a resident to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one resident (resident #128) of twenty-five residents reviewed for environment. Residents Affected - Few The facility failed to ensure Resident #128 had a working call light. This failure could place residents at risk of not being able to get staff assistance when they require it. Findings included: Resident # 128 is a [AGE] year-old female that arrived at the facility on 4/27/2023. She needs help getting in and out of bed. During an observation and interview on 04/20/23 at 11:39 AM resident #128 pressed her call light and there was no light indicator on the outside of resident 128's room. Resident #128 stated she used her call light for her assistance, and she was not sure how long it has not been working. Resident #128 stated she had to scream out for help. Resident #128's family member said she had to go to the nurse's station to get someone to come help her mother. During an observation and interview on 5/3/2023 at 11:00 AM, the DON pressed resident #128's call light, re- entered resident #128's room and verified that resident #128's call light was not working. The DON stated she had worked at the facility for about a month, and she did not know resident #128's call light was not working. The DON stated she would contact the maintenance department to check and fix the call light. During an interview with the DON on 5/5/23 @ 8:23 AM she stated that during the audit process staff went into each room to check the call lights. The DON said they addressed all the issues with the call lights and switched out about two call light cords in empty rooms. The DON said if the residents call light did not work, they could have a delay in resident care, and it could possibly be dangerous. The DON said the procedure to check rooms about to be occupied was to make sure the TV call lights and the bed was functioning. She said it was policy, but not written policy to check all rooms before admission. A review of the facility's equipment and supplies used policy dated 2/26/2023 and revised January 2023 indicates Compliance Guidelines: Nurse call system, equipment and supplies needed to provide patient care and meet residents' needs should be maintained and in good repair prior to use and will be obtained or maintained from central supply or an approved vendor. Nurse call or alert system should be functional and remain in patient room when occupied and unoccupied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675850 If continuation sheet Page 3 of 3