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 Page 1 of 4 675792 675792 03/05/2024 Avir at Mansfield 1402 E Broad St Mansfield, TX 76063

F 0584 covered air conditioner vents could create breathing problems. Level of Harm - Minimal harm or potential for actual harm In an interview on 03/05/24 at 7:07 p.m., the Administrator stated it was the facility's expectation that ceiling tiles and air conditioner vent covers be cleaned or replaced, as needed. The Administrator stated if the air conditioner vent cover and ceiling tiles were not changed as needed, resident could breathe in particles and become ill. The Administrator stated facility management and the Maintenance Director would conduct room rounds and report all maintenance issues for the Maintenance Director to repair. The Administrator stated she would monitor to ensure all maintenance needs were completed as needed. Residents Affected - Some Record review of the facility's policy entitled Homelike Environment, revised February 2021, read in part: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and environment . 675792 Page 2 of 4 675792 03/05/2024 Avir at Mansfield 1402 E Broad St Mansfield, TX 76063

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 in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Few 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. The findings included: Observations on 03/05/24 at 11:05 a.m., accompanied by the Dietary Manager, of the facility's walk in cooler revealed the following: - The temperature log near the door of the facility's cooler had the last recorded temperature dated 02/12/24. - a Ziploc bag of prepared meat, labeled taco meat and dated 02/24/24. - a covered bowl of fruit that was not labeled or dated In an interview on 03/05/24 at 11:11 a.m., [NAME] A stated he did not realize the prepared meat was in the cooler since 02/24/24 or how long the bowl of unlabeled fruit was in the cooler. [NAME] A stated prepared foods should be discarded after 3 days. [NAME] A stated all dietary staff who prepare food and place them in the facility's cooler or freezer should be sealed, labeled and dated. In an interview on 03/05/24 at 2:22 p.m., the Dietary Manager stated she had been the facility's dietary manager for two days. The Dietary Manager stated the expectation was for all food items stored in the facility's kitchen should be labeled, dated and sealed. The Dietary Manager stated all prepared foods had a shelf life of 3 days and the cooler and freezers temperature should be monitored and recorded on each shift. The Dietary Manager stated all dietary staff were responsible ensuring foods are stored correctly and temperature logs were completed according to policy. The Dietary Manager stated not doing these things could cause foodborne illnesses. The Dietary Manager stated she would begin to Inservice dietary staff on food storage and cooer temperature log responsibility, and she would conduct food storage checks to ensure items are stored properly. In an interview on 03/05/24 at 7:07 p.m., the Administrator stated it was the facility's expectation that all foods stored in the kitchen be labeled, dated and discarded by their use by date. The Administrator stated it was also the facility's expectation that the cooler and freezer temperatures were monitored and recorded daily. The Administrator stated not doing these things could cause food related illnesses. The Administrator stated dietary staff would be in serviced and the Dietary Manager 675792 Page 3 of 4 675792 03/05/2024 Avir at Mansfield 1402 E Broad St Mansfield, TX 76063

F 0812 would conduct weekly audits for food storage and temperature logs. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy, dated 2018 and entitled Food Storage, read in part: Residents Affected - Few Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Codes and guidelines. Procedure: . d. date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. use all leftovers within 72 hours. Discard items that are over 72 hours old . h . check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41 degrees or below. Temperatures should be checked each morning when the kitchen is opened, once during the day and in the evening when the kitchen is closed. Record the temperature on a log that is kept near the refrigerator. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of Health & Human Services, read in part: .3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . 675792 Page 4 of 4