Avir At Western Hills

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 confidential residents interviewed for grievances.

The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance. Findings included: Review of the November and December 2025 grievance logs revealed 5 grievances in November, all which had documented follow up dates and resolutions noted. 7 grievances were documented in December which had follow up dates and resolutions noted. In confidential interviews on 12/29/2025 with residents who had filed grievances with the facility revealed none of them had received written findings of their grievances. Some stated that they never received verbal investigation findings and were not aware if staff they had complained about had received education, or disciplinary action. The confidential residents all recalled being spoken to by the ADM, who served as the grievance official, for him to gather additional information pertaining to their grievance, but not all of them recalled him coming back to inform them of the outcome of their complaint and what the actions would be taken to correct and identified problems pertaining to their grievances. In an interview on 12/29/2025 at 12:23 PM with the ADM who served as the grievance official, he stated that he communicated the findings of grievance investigations verbally to the complainants. He stated that he did not give them written results because he was not aware the Grievance policy stated that he needed to give the griever something in writing. He stated that the policies were all new due to the company change. He stated that it would be important to deliver written resolutions, so the griever had something to refer to later. He later stated that none of the administrators he had spoken with gave out written resolutions, and his boss was not familiar with that process either. Review of the facility's ‘Grievances/Complaints, Filing' policy dated April 2017, revealed The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avir at Western Hills

512 Draper Dr Temple, TX 76504

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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

served accurately. She stated they started that process about a couple weeks ago, ensuring plates were accurate before sending out. In an interview on 12/29/2025 at 9:45 AM with the DA, she stated that she was well aware of Resident #1's allergy and preferences because Resident #1 would often write things on her meal tickets and send them back to the kitchen. She stated that on 12/24/25, [NAME] A had to leave due to getting sick at work, and the DA had to take over food preparation. She stated that it was an emergency and if she were responsible for any food mistakes she was horribly mistaken and apologetic.

She stated that she had been in-serviced about a month ago on resident preferences and she knew how to look at resident tickets before making their side dishes. In an interview on 12/29/2025 at 11:27 AM with the DM, she stated she became the DM in October 2025 and prior to that, she was the cook for about 5 years.

She stated she was aware of the preferences of Resident #1. She stated that she had been working on going around and completing all the residents' food preferences and that sometimes the nurses would send her communication slips pertaining to diet changes. She stated she was in the process of doing every resident's food preference while also learning her role. She stated that it was important to honor allergies because it could affect the resident's health, and they honor preferences so residents could enjoy their food. She stated that on 12/27/25 Resident #1 was served sliced ham. She stated that she talked to her cook and the cook stated that agency staff were giving residents the wrong trays, and trays were having to be re-made that day. She stated that agency was only to blame on that one occurrence. She provided the surveyor with a copy of employee counseling she had done with the new cook aide that may have been responsible for passing tomatoes to Resident #1 on multiple occasions. In an interview on 12/29/2025 at 12:23 PM with the ADM, he stated that the food on 12/27/25 should not have left the kitchen to go to Resident #1 due to there being pork on the plate. He stated that he, nursing staff, and kitchen staff were aware of Resident #1's allergies and preferences and that the DM had conducted an in-service before on accuracy in meal service. He stated that trays should be checked before leaving the kitchen and ensuring

the right tray is given to the right residents. He stated that it was a resident right to eat what they wanted and adhering to resident allergies would prevent adverse health reactions. Review of an in-service dated 11/18/25, titled [Resident #1] and conducted by the DM reflected, Staff was in serviced of not putting tomatoes on Resident food. 3 cooks and 2 dietary aide signatures were visible. Review of 2 records of employee counseling dated 12/10/25 and 11/27/25 reflected that the DM had provided education/counseling to a dietary aide pertaining to reviewing meal tickets prior to trays leaving the kitchen.

Review of the facility's ‘Food and Nutrition Services' policy dated October 2017 reflected, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident

Event ID:

Facility ID:

If continuation sheet