Inspection·July 30, 2024

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 interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Few The facility failed to ensure [NAME] A checked and logged food temperatures before serving breakfast on 07/29/24. This failure could place residents who received meals and/or snacks from the kitchen at risk for foodborne illness. Findings included: Record review of the facility's food temperature logbook revealed no entries for breakfast meal service on 07/29/24. During an interview on 07/29/24 at 11:18 a.m., DA A revealed kitchen staff received complaints about the food being cold, but not during her workdays. DA A stated her workdays were Monday through Friday. DA A also stated cooks checked food temperatures before each meal service and documented food temperatures in the logbook. DA A stated residents' health could not be affected if the cook forgot to check and log food temperatures before serving meals because nursing staff would notify cooks if residents' meals were cold. During an interview on 07/29/24 at 11:23 a.m., [NAME] B revealed kitchen staff did not receive any complaints about the food being cold during her shift. [NAME] B stated she worked Thursday, Friday and Monday mornings. [NAME] B also stated Cooks checked and documented food temperatures in the logbook before meals were served for each meal service. [NAME] B stated she documented food temperatures in the logbook. [NAME] B also stated she forgot to take and document food temperatures for breakfast meal service because she was running behind and forgot about it. [NAME] B stated residents' health could not be affected if cook forgot to check and log food temperatures before serving meals because nursing staff would notify cooks if residents' meals were cold. During an interview on 07/29/24 at 3:41 p.m., the DM revealed he sometimes received complaints about the food being cold, but he did not receive anything recently. The DM stated the cooks checked food temperatures before serving meals. The DM also stated cooks documented food temperature in the logbook. The DM stated residents' health could be affected if cooks did not check and document food temperatures before serving meals because food temperature could not be right. The DM explained residents could also become sick, but it was dependent on the meat and if the meat was not the right temperature. The DM further explained that residents could get food bugs. The DM stated he was informed by (continued on next page) 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: 676486 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 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 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)