Health inspection·March 5, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based 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. The findings included: Observation on 03/05/24 from 2:05 p.m. to 2:20 p.m., revealed the following: - Occupied Rooms #11, #13, #18, and #35's air conditioner vent covers were observed to be damaged and covered in black, green and white substances. - three ceiling tiles in the facility's Zone 6 had dried brown rings on them - two ceiling tiles near the station 2 nurses' station had dried brown rings on them - three ceiling tiles in the facility's Zone 4 had dries brown rings on them - the ceiling in the facility's dining room ceiling had several dried brown rings. In an interview on 03/05/24 at 3:17 p.m., the Maintenance Director stated he was hired as the maintenance director three days prior to the investigation. The Maintenance Director stated he was aware that ceiling tiles needed to be replaced, but he had not had a chance to walk the building to see exactly how man ceiling tiles needed to be replaced. The Maintenance Director stated he was not aware of the condition of Rooms #11, #13, #18, and #35's air conditioner vent covers. The Maintenance Director stated he was solely responsible to ensure the facility's upkeep was completed as needed. The Maintenance Director stated he would walk check the ceiling tiles in the facility and air conditioner vent covers and replace them as needed. The Maintenance Director stated residents who have debris (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 4 Event ID: 675792 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 03/05/2024 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)