Avir at Mansfield

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 reviewed for resident council meeting. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns [NAME] to lack of privacy.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a clean and functional environment for 3 of 14 rooms (Residents #5, Resident #36, Resident #1, and Resident #14) reviewed for a sanitary, functional, and homelike environment, as evidenced by: 1. Resident #5's room had an unrepaired wall and noticeably hanging loose paint particles by the head of his bed. 2. The facility failed to ensure Resident #36, Resident #1 and Resident #14's restroom flooring and tiles were repaired, and faucets had both hot and cold running water in the sink. 3. The facility failed to ensure Resident #1 and Resident #14's room did not have a strong urine odor. These failures could place residents at risk for a decreased quality of life. 1. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that one of one resident (#31) removed oxygen tubing and tank before entering smoking area and smokers extinguish cigarette in designated areas. Staff failed to ensure smoking residents extinguished cigarettes in a safe manner. Staff failed to remove Resident #31's oxygen tubing and tank before entering smoking area. This failure could affect residents by placing them at risk for burns and injuries.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 resident (Resident #23) of 24 residents reviewed for resident rights, as evidenced by: The facility failed to ensure Resident #23's right to participate in walking activities were consistent with his interest and choices about aspects of his life in the facility that are significant to the resident. This failure could place residents at risk of limiting the resident's opportunity to exercise their autonomy regarding those things that are important, including interests and preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident The designated interdisciplinary team member is responsible for the following: ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #1) reviewed for dietary services. The facility failed to ensure Resident #1 received their prescribed diet special instructions finger foods for the lunch meal on 04/09/2025. This failure could place residents at risk for loss of independence and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of three residents reviewed for pressure ulcers. 1. The facility failed to ensure there were PRN wound care orders for Resident #1's Stage 4 sacral pressure ulcer per professional standards of care. 2. The facility failed to ensure Resident #1's dressing was replaced when it became dislodged, allowing the wound to become contaminated with feces. This failure could place residents at risk of developing infections to wounds.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 6 (Resident's #7, #8, #9, #10, #11, and #12) of 8 residents reviewed for environment sanitation and safety. The facility failed to ensure Resident #7's portable toilet was emptied after use and soiled briefs and wipes were discarded after completing incontinent care. The facility failed to ensure trash was discarded from the adjoined restroom for Resident's #8, #9, #10, and #11 to a biohazard waste location upon incontinent care. The facility failed to ensure hardware from a dis-assembled nightstand draw (exposing loose boards, screws, and metal frame) was removed from Resident's #12's environment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the food preparation tables were clean, food was covered and all utensils were removed during meal prep, the lid was on the kitchen trashcan near food prep table and fish, fish was properly thawed, and dry storage containers were cleaned and free of dried food particles. This failure could place residents at risk for food-borne illness. Findings Included: In an observation of the facility's only kitchen on 08/16/24 beginning at 11:30 AM revealed: 1) 1- Large stainless-steel pan of apple cobbler on the prep table uncovered. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for one (Resident #1 and #7) of 3 resident reviewed for respiratory therapy. 1. The facility failed to ensure Resident #1's NC was stored in a clean bag and dated (bag was spotted with liquid white and brown substance). 2. The facility failed to ensure Resident #7's oxygen concentrator filter was clean and free of dust, crumbs, and white particles, and the humidifier water bottle was not dated. These failures could lead to respiratory infections, poor air quality, and not having their respiratory requirements met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for1 of 1 laundry room and 1 of 6 residents (Resident # 13) reviewed for infection control. The facility failed to handle, store, and process linens and residents clothing to prevent the spread of infection by not preventing cross contamination of staff belongings and resident personal clothing when staff placed their purses, in the same laundry cart with residents personal clothing. The facility failed to have in place a barrier between the clean and dirty areas of the laundry room to prevent the spread of infection. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 4 of 4 residents (Resident #20, Resident #24, Resident #42, Resident #167) reviewed for Comprehensive Care Plan. The facility failed to ensure Resident #20, Resident#24, Resident #42, and Resident 167, and/or the resident's representative were invited to participate in the comprehensive care plan meeting per resident rights guidelines that residents have the right to participate in their planning of care. This failure affected 4 residents and placed 62 residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in their planning of care.

Inspectors wroteBased on observations and interviews the facility failed to provide a clean and functional environment for six (Residents #34, #54, #16, #59, #36, and #7) out of 24 residents reviewed for a sanitary, functional, and homelike environment, as evidenced by: 1. Resident #34's room had grimy, stained, dusty floors, a badly scraped chest with missing wood veneer and handle, and grimy, stained floor, and a bent privacy curtain runner. The bathroom, which was shared with Resident #54 in the room next-door had a non-working sink and toilet, and a damaged and badly repaired wall in the bathroom. The bathroom floor was also grimy, stained, and was repaired with noticeably mismatched tiles. Resident #34's door would not close completely, due to the placement of a bed next to the door. 2. Resident #16''s room had gnats, and the unmade bed was saturated with urine. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable and attractive for two of two meals (lunch meals on 04/23/24 and 04/25/24) reviewed for food and nutrition services. The facility failed to deliver food with an appetizing taste for the lunch meals on 04/23/24 and 04/25/24. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in their only 1 of 1 kitchen. The grease in the deep fryer was dirty with blackened grease and food particles around edges. The stove surface under the metal grates had a build-up of blackened food debris. This failure could place 62 residents who consumed food prepared in the kitchen at risk of food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three hallways (front hall (Administrative offices and kitchen hallway), hall 16-39, and hall 40-54) of four halls reviewed for physical environment. 1. The facility failed to ensure the facility was free from pervasive urine odors and dirt and grime (most notably around doorways) on hallway floors. These failures could affect all residents, resulting infections, and low feelings of self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #44) of 24 residents reviewed for call lights. The facility failed to ensure Resident #44's call light was within reach of the resident. This failure could place the residents at risk of falling, injury, and feelings of low self-worth due to not being able to call for help.

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #34) of 24 residents reviewed for care plans. The facility failed to create a care plan addressing Resident #34's PTSD and colostomy. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a centralized staff work area, for two of two nursing stations reviewed for call lights. The facility failed to ensure the call system was working properly for the nursing stations in zone 1 and zone 2. On two hallways, causing the call system to sound when no call light was on, and no light for call buttons appearing on the panel. In addition, the call light of one resident (Resident #34, near station #2) would not turn off properly when used. This failure could cause residents who relied on the call light system to have a delayed response or no way to contact staff to meet their needs.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment for residents, staff, and the public on 2 of 4 halls (Zones 4 and 6), Four bedrooms (Rooms#11, #13, #18, and #35) and the 1 of 1 dining room reviewed for environmental conditions. 1. The facility failed to ensure ceiling tiles in its Zone 4, 6, and dining room were free of brown dried substances. 2. The facility failed to ensure the air condition vent covers in Rooms #11, #13, #18, and #35 were free of damage and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased 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 1 of 1 kitchen, in that: 1. The facility failed to ensure foods stored in the walk-in cooler were properly labeled and dated. 2. The facility failed to ensure leftover food was discarded prior to the use by date. 3. The facility failed to ensure cooler temperatures were monitored and recorded since 02/12/24. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler bars with the resident or resident representative and obtain informed consent prior to installation for three (Residents #1, #3, #4) of 3 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have consents signed for the quarter bed rails/enabler bars for Residents #1, #3, and #4. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #1 and Resident #2) of 10 residents reviewed for call lights. Staff failed to ensure Resident #1 and Resident #2's, call buttons were within reach. This failure could affect 2 residents who resided on Station 1 at risk for decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident # 67) of 18 residents reviewed for smoking. CNA D failed to comply with the facility's smoking policy, when she failed to provide continuous direct supervision to residents during their smoke break, which resulted in Resident #67's hair and scalp being burned. Another resident had to pat out the burning hair, and Resident #67 sustained a superficial burn (affecting the top layer of skin) to her scalp. An Immediate Jeopardy (IJ) was identified to have existed from 01/18/23 through 01/25/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for three shared restrooms and 1 of 3 shower rooms checked for hot water temperature in the [NAME] side of the facility. The facility failed to provide hot water for the [NAME] side of the facility restrooms and shower room. This failure could affect residents who take showers on the [NAME] side of the facility by placing them at risk for uncomfortable environment, low self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one (lunch meal) of one meal services reviewed. The facility failed to ensure the Dietary Manager prepared the pureed lunch meal in a manner to conserve nutrition, flavor, and palatability on 02/22/23. Tap water was used to obtain an appropriate consistency. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. -The Facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 6 residents (Resident #24) reviewed for tube feeding. LVN A failed to flush Resident #24's g-tube prior to initiating a bolus feeding (feeding method using a syringe to deliver formula through feeding tube). LVN A failed to follow physician orders regarding Resident #24's bolus feeding by adding water to the formula. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for one (Resident #44) of two residents reviewed for respiratory therapy. The facility failed to ensure Resident #44 had an order prescribed by a physician to receive oxygen. Resident #44 was receiving oxygen without any physician orders from 02/02/23 - 02/23/23. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #41) of 4 residents reviewed for pharmaceutical services. LVN C failed to follow the facility policy for flushing Resident #41's gastrostomy tube with 15 mL (or prescribed amount) of water before, between, and after medications, when she administered Aspirin 81 mg, Vitamin D 25 mg, Omega 3 capsule, Thiamin Vitamin B-1, FeSo4 (ferrous sulphate) 10 ml, and Keppra 2.5 ml to the resident. These failures could put residents who received medications via gastrostomy tube at risk for overload and aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for two (Station 1 front medication cart and Station 1 back medication cart) of four medication carts reviewed for labeling and storage. 1. The facility failed to ensure insulin vials were dated after they were opened. 2. The facility failed to ensure expired insulins were removed from the cart. The failure could place residents at risk of receiving medications that were ineffective due to not labeling with opening dates and removing the expired medications.