Health inspection·August 31, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 08/31/23 at 9:48 a.m. revealed Resident #1 lying in bed and a strong odor of urine was noted in the resident's room. The resident complained of back pain and stated she needed assistance with repositioning. Resident #1 stated staff were helpful but at times she had to wait a long time for staff to change her soiled incontinent brief. She stated the wait could be for up to an hour or more and could occur at any time of day or night. The resident stated she did not like to lay in wet urine for long periods of time and she was currently wet. Observation on 08/31/23 at 9:55 a.m. revealed CNA A and CNA B provided incontinent care and linen change for Resident #1. The resident was wearing an adult incontinent brief that was heavily saturated with urine, and also soiled with feces. The resident's buttock was slightly red, and she was lying on a bedsheet that had a large dried brown ring. 2. Record review of Resident #2's physician's orders, dated 08/2023, revealed the resident was a [AGE] year-old female with an admission date of 11/05/22. Resident #2 had diagnoses which included dysuria (discomfort during urination). Record review of Resident #2's annual MDS assessment, dated 05/24/23, revealed a BIMS of 14, which indicated intact cognition. The assessment reflected the resident was always incontinent of bowel/bladder, used a wheelchair for mobility, was totally dependent on two people for transfers, required extensive physical assistance of two people for bed mobility, dressing and extensive physical assistance of one person for personal hygiene. Record review of Resident #2's care plan, dated 06/22/23, revealed the risk for pressure ulcers, history of urinary tract infection, urinary and bowel incontinence were addressed. Interventions included keeping the perineal (the area extending from the anus to the vulva in the female and to the scrotum in the male), area dry, keeping the resident as clean/dry as possible, minimizing skin exposure to moisture, keeping linens clean/dry, monitoring for incontinence every two hours, as needed, and changing the resident promptly. Record review of Resident #2's Braden scale for predicting pressure ulcer risk, dated 04/30/23, revealed the degree to which the resident's skin was exposed to moisture was a risk factor for pressure ulcer development. Observation and interview of Resident #2 on 08/31/23 at 9:50 a.m. revealed the resident lying in bed and a strong odor of urine was noted in the resident's room. The resident stated she knew staff were busy and were doing the best they could, so she just waited for her turn to have her incontinent brief changed. She stated there were times she had to remain wet with urine for long periods and she was currently wet. Resident #2 stated she had not had her incontinent brief changed or incontinent care provided since 5:00 a.m. on the morning of 08/31/23. Interview on 08/31/23 at 10:28 a.m. CNA A and CNA B stated they were sisters and arrived at work on 08/31/23 at approximately 6:30 a.m. or 6:45 a.m. They stated they were not able to provide residents with timely incontinent care since they arrived. They both stated it was difficult to provide incontinent care every two hours and they would be lucky to make one round during their 8-hour shift due to having heavier care residents on their hall and needing more help. CNA A stated she often found residents with dark brown rings on their linen when she arrived at work. CNA B stated clean linen were often found covering urine-soaked bedsheets. They both stated they reported the issue to the DON but continued to find residents in the same conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 2 of 3 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/31/23 at 3:00 p.m., the DON stated she was currently working on a change in scheduling that would place Medication Aides on the floor to provide resident care. The DON stated her expectations were for staff to provide incontinent care for dependent residents at least every two hours and as needed. Record review of the facility's policy/procedure entitled Perineal Care, revised 01/20/23, reflected the policy statement was a definition of perineal care and the purpose as follows: Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. The policy/procedure did not address providing incontinent care to include how often dependent residents should receive incontinent care. Event ID: Facility ID: 675792 If continuation sheet Page 3 of 3