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. (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 04/09/2025 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)