Health inspection·April 9, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Record review of Resident #1's face sheet, dated 04/09/2025, revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral infarction (stroke), dysphagia (difficulty swallowing), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease (conditions that affect blood flow to the brain) affecting left dominant side. Record review of Resident #1's Annual MDS assessment, dated 02/07/2025, revealed a BIMS score of 8, indicating moderate cognitive impairment. Review of Section K - Swallowing/Nutritional status of the MDS, revealed Resident #1 had coughing or choking during meals or when swallowing medications. Resident #1 did not have weight loss or gain. Resident #1 required a mechanically altered diet and therapeutic diet while a resident. Record review of Resident #1's care plan, dated 02/27/2025 and edited 03/03/2025, revealed Resident #1 was on a regular diet with thin liquids, with low concentrated sweets and Resident #1 will like to have finger good with all meals. Record review of Resident #1's Physician order, start date 04/02/2025, revealed diet type: LCS Diet consistency: Regular; Fluid Consistency: thin liquids Special Instructions: finger foods. Record review of the menu on 04/09/2025 at 11:59 AM revealed the lunch menu was meatballs with spaghetti sauce, spaghetti noodles, capri vegetables, herb butter roll, cheesecake bar. Observation on 04/09/2025 at 12:33 pm, revealed Resident #1 sitting in the dining room in her wheelchair. Resident #1 had a regular tray with spaghetti sauce and meatballs on top of spaghetti noodles, and vegetables next to the noodles. Resident #1 was not feeding herself. Page 1 of 2 675792 675792 04/09/2025 Avir at Mansfield 1402 E Broad St Mansfield, TX 76063

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/09/2025 at 12:45 pm, revealed Resident #1 not feeding herself and the meal ticked read finger foods. RN A then began to feed Resident #1. Observation and interview on 04/09/2025 at 1:10 pm, RN A stated Resident #1 had eaten 80% of the spaghetti, 100% of the dessert and juice. RN A stated Resident #1 tried to feed herself but if she observed Resident #1 not eating, she would help Resident #1 to eat. When asked what finger foods meant, RN A stated like French Fries, or one she can just pick up and eat. Interview on 04/09/2025 at 1:14 pm, the Dining Services Manager stated Resident #1 was the only resident on the finger foods diet. He stated Resident #1 could eat by herself and staff would cut her food so she could eat with her hand. He said the diet was not a different type of food from the regular diet, but the way it was served so she could feed herself. He said Resident #1 had been on the finger foods diet for about 2.5 to 3 months and would not eat when she was on the mechanical soft diet prior. Interview on 04/09/2025 at 3:39 pm, the DON stated the finger foods diet was something where Resident #1 could pick up and put in her mouth herself easily and gave an example of a sandwich cut up into pieces. The DON stated today's regular lunch meal would not be considered finger food unless the noodles and sauce were separated. She said the kitchen was responsible to follow the diets, and the nurses were responsible to check the diet against the food on the tray. The DON stated the risk was a dignity issue and not a swallowing issue. She stated they did inservice staff on finger foods. Surveyor requested policy and inservice. Interview on 04/09/2025 at 4:10 pm, the DON provided an inservice on diet types and said it was completed on 03/04/2025. Interview on 04/09/2025 at 4:15 pm, [NAME] D stated only Resident #1 was on finger foods and it meant that the food was cut into little pieces so she could eat with her fingers. She stated the meatballs would be considered finger foods and they should have been separated. [NAME] D stated she was inserviced on diet types. Interview on 04/09/2025 at 4:20 pm, the Dining Services Manager stated if the items for lunch were served individually that would be considered finger foods. He stated the kitchen was responsible to cut up her food and they usually always cut up her food but today was an oversight. Interview on 04/09/2025 at 5:24 pm, the Administrator stated there was no risk for any type of choking hazards, but it would be an issue with her independence if Resident #1 was not able to pick up food. She stated her expectation was for staff to follow the diet order. She stated the kitchen would be responsible to ensure the correct diet was served and the nurse would check the tray to match what the tray card said before it was served. Record review of Therapeutic Diet In-Service, undated, revealed in part: The Finger Foods Diet is used to promote self-feeding for those residents who have difficulty using utensils due to cognitive or physical issues. Foods offered are typically in bite size pieces or offered as sandwiches. Soups are pureed and pureed into a cup for drinking. All fruits and vegetables should be bite-sized and drained, ice cream & pudding can be served in ice cream cones, on cookies & graham crackers. 675792 Page 2 of 2