Health inspection·November 20, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm and did not drink much water so fluid restrictions would not bother him. Resident #286 said he was not aware of a need to restrict his fluid intake. He said he did not know sodas would count as fluids. During an interview with MA C on 11/20/2024 at 09:40 AM, she said she was not aware Resident #286 was on fluid restrictions. She said Resident #286's MAR did not indicate he had any fluid restrictions. Residents Affected - Few During an interview with LVN Charge Nurse D on 11/20/2024 at 09:45 AM, she said she was not aware Resident #286 was on fluid restrictions. She said Resident #286 received dialysis treatments 3 (three) times a week to remove excess fluids and wastes from his body. She said fluid restrictions were imposed when there was a need to reduce the risk of fluid overload (a condition in which the liquid portion of blood is too high). LVN Charge Nurse D said fluid overload could cause difficulty breathing, electrolyte imbalances, and heart problems. During an interview with Dietary Staff E on 11/20/2024 at 09:50 AM, she obtained Resident #286's meal ticket and said it did not have any alert nor instructions for fluid restrictions. During an interview with the CCS on 11/20/2024 at 3:05 PM, she said the baseline care plan indicated Resident #286 was on fluid restrictions but did not provide any instructions on how the restrictions were to be applied nor how the fluid restrictions were to be communicated to the dietary and nursing staff. A review of the facility's policy dated 02/2023 and titled Baseline Care Plans: indicated the following: The baseline care plan will: 1.a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders . 4. A summary of the baseline care plan shall be reviewed with the resident and representative in a language that the resident/representative can understand. The information shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 2 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0655 c. Any services and treatments to be administered by the facility and personnel acting on behalf Level of Harm - Minimal harm or potential for actual harm of the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 3 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain grooming and personal hygiene for 1 (Resident #336) of 1 resident reviewed for activities of daily living care. Residents Affected - Few The facility failed to ensure showers were provided to Resident #336, on her scheduled shower days. This failure could place residents at risk for social isolation and a loss of dignity and self-worth. Findings included: Review of Resident #336's Face Sheet, dated 11/20/24, revealed she was an [AGE] year-old female who readmitted to the facility on [DATE] with diagnoses to include: weakness, age related physical debility, muscle wasting and atrophy, not elsewhere classified, unspecified site, acute candidiasis of vulva and vagina (vaginal yeast infection) , neuromuscular dysfunction of bladder, unspecified, morbid (severe) obesity due to excess calories and, other lack of coordination. Review of Resident # 336's ADL Plan of Care, dated 10/25/2024, revealed she had a potential for Activities of Daily Living self-care performance deficit. She is maximum assist with bathing /showers, and she is dependent on staff for meeting emotional, intellectual, physical, and social need, related to cognitive deficits. During an interview on 11/20/24 at 9:30AM, Resident #336 said the aide was not giving her regular showers. She said her shower days were Monday, Wednesday and Friday. She said CNA A would answer her call light and tell her she would come back, but most of the time, she did not come back, and that would leave her feeling dirty. Resident #336 said, several times, CNA A would come back at 3:00 AM or 4:00 AM and wake her up to change her, she said she did not like that. Resident #336 said, many times, CNA A would come back at the end of her shift and tell her, she did not have time to shower her, change her brief or whatever her need was. Resident #336 said her daughter must have said something to someone, because another aide started providing care to her and she had not seen CNA A anymore. During an interview on 11/20/24 at 8:46 AM, MRC/SC said she was informed by the previous DON, that CNA A could not go into Resident #336's room. She said she did know what the reasoning was, but she assigned another aide from another hall to provided services to resident #366's room. She said the previous DON is no longer with the facility. During an interview on 11/20/24 at 9:40 AM, when asked, the DON said CNA A was let go, because she was not changing residents at night and providing other care. She said she believed those were issues occurring under the previous DON, before she joined the facility. The DON said, on 11/15/2024, Resident #336 requested to change her shower days from Tuesday, Thursday, Saturday to Monday, Wednesday, and Friday. During an interview on 11/20/24 at 11:50 AM, the SW said he had not received a grievance from Resident #336 or her daughter. He said he began work on 10/14/24, and since he had been there, he was not aware of a grievance from Resident #336 or her daughter. He said the ADM was handling grievances, prior to his joining the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 4 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/20/24 at 4:54 PM, the ADM said she was handling grievances before the current SW was hired. She said she believed she spoke with Resident #336's daughter a couple of times on the phone, but she did not remember Resident #336's daughter having a grievance about anything. The ADM said CNA A was terminated from the facility for poor performance. Review of the shower sheets and the action plan, the DON provided for Resident #366, for the past six weeks, revealed Resident #336 received 14 of the 18 showers she was scheduled to receive. The action plan revealed, Problem: showers are not completed on all residents. Goal: all showers will be completed CNA/shower aide during the shift that is assigned. Review of a policy titled Resident Showers, with an implemented date of 07/2022: Policy Explanation and Compliance Guidelines revealed, 1. Resident will be provided showers as per request or as per facility scheduled protocols and based upon resident safety. During the exit conference, the ADM said she would forward the Corrective Action Notice for CNA A, after she receives a copy from the facility's home office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 5 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 4 residents reviewed for hydration status (Resident #286). Residents Affected - Few The facility failed to ensure Resident #286's physician's order for fluid restrictions was initiated and was communicated to the nursing and dietary departments for 8 (eight) days. The facility failed to clarify the physician's order for fluid restrictions to include the breakdown of the amount of fluid per 24 hours to be distributed between the dietary and nursing departments. These failures could place residents with fluid restrictions risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: A record review of Resident #286's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. He had multiple diagnoses which included End Stage Renal Disease (permanent kidney failure) on hemodialysis (a dialysis treatment that removes excess fluids and wastes from the body and helps regulate blood pressure and mineral levels). A review of Resident #286's BIMS assessment dated [DATE] revealed he had a score of 12 indicating his cognition was moderately impaired. A record review of Resident #286's admitting physician orders indicated an order dated 11/12/2024 for fluid restrictions. The order read, regular diet, fluid restriction 1200cc. The order did not provide any instructions as to how 1200cc of fluid were to be distributed throughout the day. A review of Resident #286's the hospital's discharge orders dated 11/04/2024 indicated an order to limit all fluid intake to 1200-1500cc (40-50 oz,) per day for Resident #286. A record review of Resident #286's MAR dated November 2024 did not indicate any instructions for limiting fluids when administering medications. A record review of Resident #286's meal ticket dated 11/20/2024 indicated he was to be served an 8 fluid oz. beverage at breakfast, lunch, and dinner plus a cup of milk at breakfast and lunch. The meal ticket did not provide any instructions to restrict or limit fluids at meals. A record review of Resident #286's baseline care plan dated 11/12/2024 indicated he was on fluid restrictions. The care plan did not include the specific amount of fluids he was limited to nor did it include any instructions for the distribution of the restricted fluids throughout the day. A record review of medical records did not indicate Resident #286 had received any instructions nor education on fluid restrictions nor that fluid restrictions were in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 6 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident #286 on 11/20/2024 at 09:20 AM, he said he preferred Dr. Pepper and did not drink much water so fluid restrictions would not bother him. Resident #286 said he was not aware of a need to restrict his fluid intake. He said he did not know sodas would be count as fluids. During an interview with MA C on 11/20/2024 at 09:40 AM, she said she was not aware Resident #286 was on fluid restrictions. She said if a resident was on fluid restrictions, it would be noted on the MAR and it would provide instructions on how much water was to be allowed for medication administration. MA C said Resident #286's MAR did not indicate he had fluid restrictions. During an interview with LVN Charge Nurse D on 11/20/2024 at 09:45 AM, she said she was not aware Resident #286 was on fluid restrictions. She said Resident #286 received dialysis treatments 3 (three) times a week to remove excess fluids and wastes from his body. She said fluid restrictions were imposed when there was a need to reduce the risk of fluid overload (a condition in which the liquid portion of blood is too high). LVN Charge Nurse D said fluid overload could cause difficulty breathing, electrolyte imbalances, and heart problems. During an interview with Dietary Staff D on 11/20/2024 at 09:50 AM, she said if a resident was on fluid restrictions, nursing would send a communication form with the breakdown of the amount of fluids to be provided with each meal to dietary. Dietary staff D said dietary would then add the amounts of fluids allowed at each meal to the resident's meal ticket. Dietary staff D said an alert for fluid restrictions would also be added to the meal ticket so dietary and nursing staff would know not to exceed the designated fluid amounts. Dietary staff D said Resident #286's meal ticket did not have any alert nor instructions for fluid restrictions. During an interview with the VPCO and DON on 11/20/2024 at 10:15 AM, they said Resident #286's physician's order was for Resident #286 to be restricted to no more than 1200cc of fluids daily. They said they did not know why the fluid restrictions had been changed from the hospital's order of 1200-1500cc to 1200cc only. They said the fluid restrictions should have been clarified with a breakdown of how the allotment of fluids would be distributed between dietary and nursing. They said the fluid limitations should have been on the MAR and on the meal ticket. The VPCO and DON said Resident #286 was receiving dialysis and was at risk for fluid overload. During an interview with the DON on 11/20/2024 at 03:15 PM, she said she and the nursing management team met daily and reviewed new orders. She said they had not noticed the discrepancy between the hospital discharge order and the facility's order for fluid restrictions nor the absence of instructions for the distribution of the allotted fluids. The DON said Resident #286 had not been on any fluid restrictions since his admission to the facility on [DATE]. A review of the facility's policy dated 07/2022 and titled Fluid Restrictions' indicated the following: Policy: It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. Compliancy Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 7 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. The nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department and will be recorded on the medical record or other format as per facility protocol. 2. The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes. 3. The food and nutrition department will be notified by facility communication methods of the fluid restriction. 5. The risks and benefits of the fluid restriction will be explained to the resident and/or resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 8 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services (Residents #286). The facility failed to ensure MA C did not leave Resident #286's medications at bedside unattended. This failure could place residents at risk of not receiving medications as ordered by the physician. Findings included: A record review of Resident #286's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. He had multiple diagnoses which included End Stage Renal Disease on hemodialysis, Diabetes Mellitus, atrial fibrillation (an irregular heart rate), coronary artery disease, chronic obstructive pulmonary disease, and cerebrovascular accident (stroke). A review of Resident #286's BIMS assessment dated [DATE] revealed he had a score of 12 indicating his cognition was moderately impaired. During an observation and interview on 11/20/2024 at 09:20 AM, Resident #286 was noted to be lying in bed with his eyes closed and no one else was in the room. An over-the-bed table was stationed beside his bed and was noted to have a cup of clear liquid and a small plastic container with 12 (twelve) pills in it on the table. Resident #286 responded to his name being called. He said someone must have left his pills there. He said he did not see anyone bring the medications in and leave them. Resident #286 said he guessed they were his pills. During an interview with MA C on 11/20/2024 at 09:40 AM, she said she was the person responsible for administering Resident #286 his medications. She said she took his medications into his room and told him he had medications to take. MA C said she watched him start taking his pills and left the room. She said she did not stay and ensure he took all his medications. MA C said she was supposed to stay with the resident and see him take all his medications. During an interview with the DON 11/20/2024 at 09:25 AM, she said she expected medication aides and nurses to stay with residents and ensure all medications are consumed before leaving. She said the act of not staying with residents until all medications were consumed placed residents at risk for not receiving their medications. A review of the facility's policy dated 07/2022 and titled Medication Administration indicated the following: 17. Administer medication as ordered . 18. Observe resident consumption of medication FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 9 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 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 under sanitary conditions for 1 of 1 facility kitchens. Residents Affected - Some The facility failed to ensure the dry pantry was clean and food containers were kept clean. The facility failed to ensure food items were labeled or dated. The facility failed to ensure the freezers and coolers were clean inside and outside. The facility failed to ensure potentially hazardous food items were thawed in a way to contain liquid seepage. The facility failed to ensure the deep fryer was clean and contained fresh grease. The facility failed to ensure stainless steel serving pans were air dried before stacking and storing. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations and interviews on 11/18/24 of the kitchen the following was noted: *at 9:41 AM in the dry pantry: dried spills were on the floor, dried pinto beans were scattered on the floor, pieces of paper and cardboard were on the floor, *at 9:42 AM on the open wire rack (next to bulk bins) on the bottom shelf the following containers had flour-like substances, corn meal like substances, and brown dirt-like substances on the lids and bodies of the containers: one 56 oz. Paprika, one 8 oz. Bay Leaves, one 1 gal. Soy Sauce, one 1 gal. white distilled vinegar, one 1 gal. light corn syrup. These containers were sticky and greasy to the touch, *at 9:48 AM in the 2 door cooler (adjacent to the ice machine) there were the following: one 46 oz Honey Thick Cranberry Juice Cocktail had no open date. Packaging indicated After opening, may be kept up to 7 days under refrigeration. one 46 oz Honey Thick Orange Juice had no open date. Packaging indicated After opening, may be kept up to 7 days under refrigeration. one 46 oz. Nectar Thick Water with Lemon had no open date. Packaging indicated Discard if not used within 10 days of opening. 2 food trays with covered individual serving bowls containing an unknown food product were not labeled and dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 10 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 *at 9:55 AM 2 door freezer (first on the right) the handles were soiled with food debris and the front of the left door had a brown/red smear of an unknown substance on it. Vents on front of the freezer were soiled with food/dried liquid splash. *at 9:57 AM 2 door freezer (second on right) a large amount of food detritus in the bottom of the freezer. Vents on front of the freezer were soiled with food/dried liquid splash. *at 9:58 AM 2 door freezer (third on the right) there was no shelving present and boxes of food were being stacked one on top of another crushing the boxes and product on the bottom. Vents on front of the freezer were soiled with food/dried liquid splash. *at 10:00 AM 2 door cooler (first on the left) the bottom shelf was soiled with food detritus and liquid spillage. There were some missing shelving and some shelving had fallen to the bottom. Vents on front of the cooler were soiled with food/dried liquid splash. *at 10:04 AM 2 door cooler (second on the left) a 10 lb. chub of hamburger meat was thawing on the bottom shelf on the left side. It was not in a tub or on a tray and blood had seeped out of the hamburger meat packaging and had pooled on the bottom shelf on the whole left side of the cooler. The blood had also pooled under a 3 gallon plastic container covered with foil that was labeled as beef noodle and dated 9/16. Vents on front of the cooler were soiled with food/dried liquid splash. *at 10:05 AM the deep fryer had a build-up of grease on the flat surfaces and backsplash, food detritus and crumbs were floating on the grease. *at 10:08 AM where stainless steel serving pans were stored under the steam table the following was noted: 2-quarter-sized 6 deep stacked wet 3-quarter-sized 4 deep stacked wet 1 quarter-sized 8 deep has spilled food detritus and a greasy film on pan 1 half-sized 4 deep stacked wet and had a greasy film 2 half-sized 6 deep stacked wet and had a greasy film 4 half-sized 8 deep stacked wet During an interview on 11/18/2024 at 10:15 AM, the DM made notes to correct the issues noted. She said she was manager at a sister facility and had just come to the facility to help out since the previous DM had walked out on Saturday. She said there were 2 employees that had been there for only 3 days and the cook was a fairly new cook. She said she brought 3 of her employees with her that were not on duty at her facility to begin cleaning the kitchen. She said she had no way to know if the beef noodles were actually dated from September or if someone had meant to put a November date, but she said it would be thrown away. She did not have an answer for the bloody meat in the bottom of the cooler. She said she could not believe it had not been placed in a tray or tub to thaw. She said the thickened liquids were to be dated when opened. She said the dates on the boxes were the truck date indicating when they were delivered to the facility. She said dishes and pans were not to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 11 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 stacked wet but were supposed to be air-dried before putting away. She said she was unsure when the deep fryer had been cleaned since she had just arrived. She said it should be cleaned weekly if used frequently. During an interview on 1119/2024 at 10:45 AM, the administrator said they had been having some issues with the dining services and the previous dietary manager had just walked out without notice. She said the dietary manager from a sister facility was currently in the facility and working to clean up the sanitary issues noted. She said they also had some new employees in dietary that were still being trained on sanitation. Review of a facility policy, dated 07/2022, on Sanitation Inspection indicated .1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. Review of a facility policy, dated 07/2022, on Date Marking for Food Safety indicated .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that afe expiring, and shall be discarded accordingly.7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, . The Texas Food Establishment Rules, dated October 2015, revealed: §228.68. Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned as specified under §§228.113, 228.114 and 228.115 of this title and sanitized as specified under §§228.116, 228.117 and 228.118 of this title; . §228.114. Frequency of Cleaning. .(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues Food and Drug Administration Code, Dated, 2013, indicated the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. .3-305.11 Food Storage Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 12 of 13 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 745021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Lindale 13905 Fm 2710 Lindale, TX 75771 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 (2) Where it is not exposed to slash, dust or other contamination . Level of Harm - Minimal harm or potential for actual harm .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . .(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. Residents Affected - Some (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745021 If continuation sheet Page 13 of 13