F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, and record review, the facility failed to ensure the menus were followed for
1 (the lunch meal on 07/09/25) of 1 meal reviewed for food and nutrition services.The facility did not serve
the posted lunch menu of cornbread and seasoned okra. This failure could affect all residents in the facility,
who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal.
Findings included:Observation on 07/09/25 at 10:15 AM of the menu posted in the dining room reflected for
07/09/25 the following: Sausage Jambalaya, Seasoned Okra, Cornbread, and a Brownie.Review of the
facility's Week-At-A-Glance 2025 Week 3 for Wednesday reflected the following: Sausage Jambalaya,
Seasoned Okra, Cornbread, Double Chocolate Brownie.Interview on 07/09/25 at 10:40 AM with Resident
#1 revealed when he received his food, he was not sure what would be served because the menu did not
match what was served to him often. Interview on 07/09/25 at 10:45 AM with Resident #2 revealed when
she received her food, she was not sure what would be served because the menu did not match what was
served to her. Observation and interview on 07/09/25 at 11:00 AM with the DM revealed the steamtables in
the kitchen had the following food items which would be served for lunch: sausage jambalaya, sliced bread,
and capri vegetables which included green beans, carrots, squash, and zucchini. Interview on 07/09/25 at
12:30 PM with the DM revealed she always tried to follow the menu and serve what was on it for the
residents. The DM said for today's (07/09/25) lunch meal, she did substitute the cornbread with sliced bread
and okra with capri vegetables. The DM said she had to do that because the cornbread box that was
delivered appeared as if it was open so it was not usable and it was not replaced in time to serve it with the
meal. The DM said as for the okra, it was used for another meal earlier in the week and she did not have
enough to serve with lunch today (07/09/25). The DM said the if the kitchen did not serve what was posted
on the menu, it could be confusing for residents because it did not match. The DM said the cook posted the
menu, but if there were changes that needed to be made, she usually included that in the posted menu so
residents knew what they would be served that day. The DM said she expected the menu to match what the
residents were being served that day. The DM said all staff had been trained to make sure that the posted
menu matched what was being served for that meal that day.Review of the facility's Menus policy, dated
May 2014, reflected: .6. Menus are served as written, unless changed in response to preference,
unavailability of an item, or a special meal.8. Menus are posted in the nutrition services department, dining
rooms and resident/patient care areas.
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 2
Event ID:
675905
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
675905
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Grapevine
1500 Autumn Drive
Grapevine, TX 76051
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 in accordance with professional standards for food service safety for the facility's one and only kitchen
reviewed for food and nutrition services. The facility failed to ensure the four steamtable compartments in
the kitchen were clean and free of debris before food was placed in them.This failure could affect residents
who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and
food contamination. Findings included:Observation on 07/09/25 at 9:10 AM of the facility's only kitchen
revealed the four steamtable compartments had food and debris floating in them.Observation on 07/09/25
at 11:00 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris
floating in them. The steamtables had the following: the first one had a tray of sausage jambalaya; the
second one had capri vegetables and fortified mashed potatoes; the third one had mechanical soft sausage
jambalaya and brown gravy; the fourth one had pureed vegetables, pureed bread, Salisbury steaks, and
pureed jambalaya.Interview on 07/09/25 at 11:15 AM with the DM revealed she saw the food and debris in
the steamtable compartments and mentioned that they would be cleaned after the lunch service had
ended. Interview on 07/09/25 at 12:30 PM with the DM revealed normally the steamtable compartments
were cleaned at the end of each shift, which would have been after lunch and after dinner. The DM said
usually it was the cook who cleaned the steamtable compartments. The DM said the steamtable
compartments did not get cleaned between breakfast and lunch services. The DM said she normally
checked the steamtable compartments daily to ensure they were cleaned as they were supposed to be. The
DM said she saw the food and debris floating in the steamtable compartments before the lunch service
earlier, but the lunch meal was already on the line waiting to be served. The DM said the steamtable
compartments should be cleaned before food was placed on it to be served. The DM said if the steamtable
compartments were not cleaned, bacteria could get in the food. The DM said all staff had been trained to
ensure the steamtable compartments were cleaned before service and that was her expectation. Review of
the facility's Environment policy, dated May 2014, reflected: 1. The Food Service Director will insure [sic]
that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces .
Event ID:
Facility ID:
675905
If continuation sheet
Page 2 of 2
