Health inspection·November 23, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few 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. Findings included: Record review of Resident #1's undated face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Stage 4 pressure ulcer of sacrum. Record review of Resident #1's quarterly MDS, dated [DATE], reflected his BIMS score was not calculated due to his medical condition. His Functional Status assessment indicated he required total assistance from staff for all of his ADLs. His Skin Conditions did not reflect any pressure ulcers. Record review of Resident #1's care plan, dated 09/27/24, indicated he had a Stage 4 pressure ulcer to his coccyx that was being treated by the wound care physician. Record review of Resident #1's physicians orders reflected an order, dated 11/19/24, which reflected: Wound Treatment Order: Location: (sacrum and right buttock) Clean with Normal Saline/Wound Cleanser. Apply:(Dilute 1/4 of Dakins solution onto kerlix). Cover with Primary Dressing:(optiform/bordered dressing). Once A Day 06:00 AM - 06:00 PM Observation on 11/23/24 at 11:00 AM of Resident #1 revealed he was on his back in bed, tracheostomy in place, feeding tube in place with feeding infusing, and a urinary catheter draining amber colored urine. The resident was not responsive to verbal stimulation. Observation and interview on 11/23/24 at 11:40 AM with LVN A revealed Resident #1's pressure ulcer (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 2 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 11/23/2024 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)