Health inspection·August 7, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 08/06/2024 at 10:39 AM the Dietary supervisor (DS) stated the facility only had food available for lunch, dinner, and lunch the next day. The DS stated she had to substitute her menus in the last week from 08/01/2024 through 08/06/2024 due to food and ingredients not being available or residents dislikes. She also stated the facility was supposed to have 7 days' worth of food. She stated she usually ordered on Tuesdays and deliveries were done on Wednesdays. The DS stated her orders for last Wednesday, 07/31/2024 was not approved by Corporate because July had 5 Wednesdays, and her budget had exceeded the month for the month of July. She stated she was going to the store daily or more than once a day to purchase food to cook. She stated the Administrator was made aware Corporate did not approve the food order. She stated the Administrator gave her personal credit card to use daily. The DS stated she did not discuss with the RD before substituting the menu for the week. During an interview on 08/06/2024 at 12:18 PM the Administrator (ADM) stated she was made aware by the DS that corporate did not approve the food order on 07/31/2024. The ADM stated she gave the DS her credit card to use and purchase food. The ADM stated as of Wednesday 7/31/2024 the facility had 5 days' worth of food. The ADM stated the facility was supposed to have 7 days' worth of food available in case of emergency. The ADM stated Corporate was not made aware the facility had only 1 day worth of food available until the State Surveyors started to ask. The ADM also stated the DS was supposed to purchase food from the local grocery store on 08/05/2024 but she didn't. The ADM stated the facility did not have emergency food supplies for sheltering in place or evacuations. The administrator provided a list of food for emergency . Interview attempts made to call the RD on 08/06/2024 at about 4:54 PM and 4:57 PM but were unsuccessful During an interview on 08/07/2024 at 09:33 AM, the RD stated her last visit in the facility was about 07/24/2024. She stated she was not contacted by the DS regarding changes made to the menu in the last week. She stated she was contacted last night (08/07/2024) regarding changes for breakfast and lunch on 08/07/2024. The RD stated she told the DS to contact her regarding changes to the menu so she (RD) could sign off on the changes. The RD stated she coached the DS to replace protein for protein, starch for starch and vegetables for vegetable. The RD stated the facility had a liberalized style diet to enable the residents to make decisions to control their meals, more homelike. During an interview on 08/07/2024 at 1:49 PM, [NAME] #2 stated during the last week it had been had to cook due to food not being available. She stated she asked the DS what she was cooking because there was nothing available in the kitchen. She stated it was hard to follow the posted menus because there was no food supply, they had to cook based on what was available in the kitchen. She stated on some days the DS had to go to the local store to get food supplies and juices to be able to feed the residents. She stated the residents complained all the time stating they cook the same food all the time. She stated it made the job harder when the supplies were not available . Record review of the facility's Menu substation form reflected the following changes were made and not signed off by the RD: 08/01/2024 the entire dinner meal was substituted with chop steak with gravy, noodle, broccoli due to residents' dislikes. Record review of facility's invoices for food for the last 60 days reflected food was delivered on the following dates: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 If continuation sheet Page 2 of 5 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 676044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Magnolia 1105 N Magnolia Luling, TX 78648 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 0803 Level of Harm - Minimal harm or potential for actual harm 06/05/2024, 06/12/2024, 06/19/2024, 06/26/2024, 07/03/2024, 07/10/2024, 07/17/2024, 07/24/2024. No delivery was made 07/31/2024. 08/02/2024 the entire lunch meal was substituted with shrimp, Mac and cheese veggie with no reason for substitution. Residents Affected - Many 08/02/2024 the entire dinner meal was substituted with Enchiladas, rice and salad due to residents dislikes. 08/03/2024 the entire lunch meal of was substituted with chili beans, veggies, and corn bread due to being out of sausages. 08/04/2024 the entire lunch meal of was substituted with fried chicken, mashed potatoes, and veggies due to residents dislikes. 08/05/2024 the entire lunch meal of was substituted with carne guisada , salad, rice due to being out of chicken. 08/06/2024 the entire lunch meal of was substituted with chicken and dressing, veggies, and cake due to being out of beef. 08/06/2024 the entire dinner meal of was substituted with spaghetti, mixed veggies and pudding due to being out of ribs. Record review of the facility's menu for a 4-week period reflected the following: Week #1- Friday 08/01/2024 dinner menu- Homemade Chicken Pot Pie Breaded Okra, Iced Chocolate Brownie Bread Slice/Margarine, Milk, Beverage of Choice, Water Week #1- Saturday 08/02/2024 lunch meal - Sausage Cuts, Blackeye Peas, seasoned Cabbage Cornbread/Margarine Butterscotch Pudding, Beverage of Choice, Water Week #1- Saturday 08/02/2024 Dinner meal - Beef Taco Salad with Shredded Com Nuggets, Tortilla/Margarine, Frosted Cake, Milk, Beverage of Choice, Water Week #2 - Sunday 08/03/3034 lunch meal - Turkey Pot Roast, Gravy, Baked potatoes, sour cream and shredded cheese, glazed carrots, dinner roll/Margarine, beverage of choice, water Week #2 - Monday 08/04/2024 lunch meal - Fried Chicken, broccoli [NAME] & Cheese, Italian [NAME] Beans, Strawberry Mousse, beverage of choice, water Week #2 - Tuesday 08/05/2024 lunch meal - Meatloaf with Tomato Sauce, Scalloped Potatoes, [NAME] Peas with Sauteed Onions, Bread Slice/Margarine, Peaches & Bananas, Beverage of Choice, Water Week #2 - Wednesday 08/06/2024 lunch meal - Beef & Bean Burrito w/ Cheese & Sour Cream, Mexican Corn, Cilantro-Lime Coleslaw, Frosted Cake, Beverage of Choice, Water Week #2 - Wednesday 08/06/2024 Dinner meal - Ritz Chicken Bake, Seasoned Rice, Broccoli Florets, Dinner Roll/Margarine, Summer Fruit Cup, Milk, Beverage of Choice, Water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 If continuation sheet Page 3 of 5 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 676044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Magnolia 1105 N Magnolia Luling, TX 78648 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 0803 Record review of the facility's alternate menu for 08/06/2024 reflected the following: Level of Harm - Minimal harm or potential for actual harm House salad, soup of choice, cheese quesadilla, loaded bake potatoes, pancakes and syrup) Record review of the facility's emergency food checklist, dated March 2021, reflected the following: Residents Affected - Many Canned luncheon meats, Tuna, Canned ham and chicken, Cold cereals, Beverage drink, instant, Canned fruit juice, Powdered milk, Peanut butter, Jelly, [NAME] crackers/vanilla wafers Canned Fruit, Soup, Chili, Oatmeal, Biscuit Mix, Mayonnaise/Mustard, Special Snacks/Supplements, Crackers, Bread, Baby food (pureed diets) Canned Ravioli/Spaghetti Canned Vegetables Potatoes (flakes), Gravy Mix, Powdered thickener . Record review of the document provided by facility's ADM regarding food regulations reflected the following: Texas Administrative Code Title 26 Part I Chapter 554 Subchapter L Rule §554.1107; Health and Human Services Health And Human Services Commission Nursing Facility Requirements For [NAME] Censure And Medicaid Certification Food And Nutrition Services Menus, Nutritional Adequacy and Meal Service a) Menus must: (1) meet the nutritional needs of residents in accordance with established national guidelines. (2) be prepared at least one week in advance. (3) be written for each type of diet ordered in the facility, in accordance with the facility's diet manual; (4) be written or completely evaluated for nutritional adequacy by the facility's qualified dietitian; (5) vary from week to week, taking the general age-group of residents into consideration. (6) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 If continuation sheet Page 4 of 5 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 676044 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Magnolia 1105 N Magnolia Luling, TX 78648 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 0803 be followed unless substitutions are documented as required in subsection (d) of this section; Level of Harm - Minimal harm or potential for actual harm (7) Residents Affected - Many reflect, based on a facility's reasonable effort, the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups; and (c) The facility must ensure that a current diet manual, approved by the qualified dietitian, is readily available to dietary service personnel and the supervisor of nursing service. To be current, the diet manual must be no more than five years old. (d) The facility must retain records of menus served, including substitutions, and food purchased for 30 days. A list of residents receiving special diets and a record of their diets must be kept in the dietary area for at least 30 ·days. (e) The facility must post the current week's menu: (f) The dietary department must keep a seven-day supply of staple foods and a two-day supply of perishable foods at all times. The facility is allowed the flexibility to use food on hand to make substitutions at any interval as long as comparable nutritional value is maintained. Any substitution of menu items must be recorded on the day of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676044 If continuation sheet Page 5 of 5