Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Mansfield during CMS and state inspections, most recent first.
A resident with a history of stroke, dysphagia, and hemiplegia, who required a finger foods diet to promote self-feeding, was served a regular meal that was not prepared according to the prescribed dietary instructions. The meal was not separated or cut into appropriate pieces, preventing the resident from feeding herself, and staff interviews confirmed the oversight in both kitchen preparation and nursing verification.
A resident with a Stage 4 sacral pressure ulcer was found without a dressing, which had become dislodged and allowed fecal contamination. The facility lacked PRN wound care orders and specific procedures for such situations, leading to inadequate care. Staff interviews revealed communication issues and conflicting accounts of care provided, while the facility's wound care policy did not address dislodged or contaminated dressings.
The facility failed to provide a safe and clean environment for several residents, as observed during a survey. A resident's room contained a portable toilet filled with liquid waste and a trashcan with soiled supplies, while a shared bathroom for four residents had similar issues. Additionally, disassembled nightstand hardware posed a safety hazard for another resident. Staff interviews revealed a lack of adherence to sanitation protocols and failure to report environmental hazards.
The facility's kitchen failed to meet food safety standards, with uncovered food, improper storage of thickener, unclean dry storage containers, and a trash can without a lid near thawing fish. The Dietary Manager and Administrator acknowledged these issues, which could lead to cross-contamination and foodborne illnesses.
The facility failed to provide proper respiratory care for two residents, leading to potential health risks. A resident's nasal cannula was stored in a soiled, undated bag, and another resident's oxygen concentrator filter was dusty with an empty humidifier bottle. The facility did not document required maintenance tasks, and staff interviews revealed expectations were not met, indicating a failure in following procedures for respiratory care.
The facility failed to maintain an effective Infection Prevention and Control Program, with deficiencies observed in laundry handling and medication administration. Staff placed personal belongings in laundry carts with residents' clothing, lacked a barrier between clean and dirty laundry areas, and did not follow hand hygiene protocols during medication administration.
The facility failed to ensure care plans were developed in consultation with residents and their representatives for four residents. The Social Worker acknowledged the issue, citing a lack of consistent staff until December 2023, which led to missed care plan meetings and non-compliance with the facility's policy.
The facility failed to provide a clean and functional environment for six residents, leading to various deficiencies such as grimy floors, damaged furniture, and malfunctioning bathrooms. Residents expressed dissatisfaction and reported ongoing issues, while the Environmental Service Director and Administrator acknowledged the challenges in maintaining the facility.
The facility failed to provide palatable and attractive food, as observed during two lunch meals. Residents reported dissatisfaction with the food quality, and state surveyors confirmed these complaints through test trays. The new Dietary Manager faced challenges with staff training and food supply constraints, contributing to the problem. Despite efforts to improve the situation, the Dietary Manager ultimately decided to leave the facility.
The facility failed to maintain sanitary conditions in their kitchen, with a deep fryer having a thick build-up of grease and food particles, and a stove surface with blackened food debris. The dietary manager acknowledged the deep fryer was cleaned only once a month, and the Dietitian noted that a month was too long to use the same fryer grease. This failure could place 62 residents at risk of food-borne illness.
The facility failed to maintain a safe, functional, and sanitary environment in three hallways, with pervasive urine odors and grime buildup observed. Interviews revealed that the building's age and lack of maintenance staff contributed to the issues, and a family member expressed concerns about the facility's cleanliness and its impact on residents.
The facility failed to ensure a resident's call light was within reach, despite the resident's severe cognitive impairment and physical disabilities. Staff acknowledged the importance of call light accessibility but did not consistently place it within reach, contrary to facility policy.
The facility failed to implement a comprehensive care plan for a resident with multiple medical and psychological needs, including PTSD and a colostomy. Interviews revealed that the care plan responsibilities were shared among staff, but due to a change in DONs, the initial care plan was not completed as required.
The facility failed to ensure the call system was working properly in zones 1 and 2, causing false alarms and delays in responding to residents' needs. Staff struggled to identify and resolve the issue, and the outdated system was not addressed in the facility's maintenance policies.
Failure to Provide Prescribed Finger Foods Diet
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of a resident who required finger foods to promote self-feeding due to physical and cognitive impairments. The resident, a female with a history of stroke, dysphagia, hemiplegia, and moderate cognitive impairment, had physician orders and a care plan specifying a regular diet with thin liquids, low concentrated sweets, and special instructions for finger foods. On the observed lunch meal, the resident was served a regular tray with spaghetti noodles, meatballs with sauce, vegetables, and a dessert, rather than food items prepared as finger foods. The meal ticket indicated finger foods, but the food was not separated or cut into pieces suitable for self-feeding, and the resident was unable to feed herself as a result. Staff interviews confirmed that the resident was the only individual on a finger foods diet and that the kitchen was responsible for preparing the food accordingly, with nursing staff expected to verify the diet before serving. Both the DON and Dining Services Manager acknowledged that the meal provided did not meet the finger foods requirement, as the items were not separated or cut into appropriate sizes. The oversight was attributed to a failure in the kitchen to prepare the meal as ordered, and the nursing staff did not identify the discrepancy before serving. The facility's inservice materials described the finger foods diet as providing bite-sized pieces or sandwiches to promote self-feeding for residents with difficulty using utensils.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a Stage 4 sacral pressure ulcer. The resident, who was non-responsive and required total assistance for all activities of daily living, was observed without a dressing on the pressure ulcer, which was contaminated with feces. The dressing had become dislodged, and the nursing staff did not have PRN wound care orders to address such situations. The lack of immediate replacement of the dressing after it was dislodged allowed the wound to become contaminated, increasing the risk of infection. Interviews with the staff revealed a lack of communication and awareness regarding the resident's condition. The LVN was unaware of when the dressing had come off, and the CNAs involved in the resident's care provided conflicting accounts of their actions. The facility's wound care policy did not address procedures for when a dressing becomes dislodged or contaminated, contributing to the deficiency in care. The Wound Care Nurse confirmed that the nurses were responsible for following the physician's orders for wound care, but the absence of specific guidance for unexpected situations led to inadequate care for the resident's pressure ulcer.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as observed during a survey. Resident #7's room contained a portable toilet filled with a yellow liquid and a trashcan filled with soiled incontinent supplies, which were not disposed of properly. This oversight occurred despite the resident requiring staff assistance for hygiene and toileting due to moderate cognitive impairment and other health conditions such as COPD and major depressive disorder. In the shared bathroom for Residents #8, #9, #10, and #11, surveyors found a trashcan filled with soiled incontinent supplies. These residents had varying degrees of cognitive impairment and required assistance with activities of daily living, including toileting. Interviews with staff revealed a lack of awareness and adherence to proper sanitation protocols, as the trash was not discarded in a biohazard waste location as required. Additionally, Resident #12's environment was compromised by the presence of disassembled nightstand hardware, including sharp metal components, which posed a safety hazard. This resident, who had vascular dementia and required substantial assistance, was at risk of injury due to the exposed materials. Staff interviews indicated a failure to report and address these environmental hazards promptly, contributing to the unsafe conditions observed.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included uncovered food on preparation tables, a serving spoon left inside a pan of apple cobbler, and an open carton of thickener stored improperly. Additionally, dry storage containers were found to be unclean with dried food particles, and a prep table was observed with food debris, brown spots, and rust. A kitchen trash can without a lid was placed near fish being thawed in an uncovered container, which could lead to cross-contamination. Interviews with the Dietary Manager (DM) and the Administrator revealed acknowledgment of these lapses. The DM admitted to forgetting to cover the food and replace the cap on the thickener, and recognized the need for cleanliness and proper storage to prevent foodborne illnesses. The Administrator confirmed the facility's expectations for food safety, including covering food, cleaning utensils and containers, and ensuring trash cans are covered to prevent contamination. The facility's policy on food preparation and handling, which aligns with state and US Food Codes and HACCP guidelines, was not followed, particularly regarding the proper thawing of fish.
Deficiency in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents, leading to potential risks of respiratory infections and inadequate oxygen therapy. Resident #1, a male with a history of COPD and acute and chronic respiratory failure, had his nasal cannula stored in a soiled, undated plastic bag, which was not in compliance with the facility's procedures. Observations revealed that the nasal cannula was stored improperly, and the nursing staff did not document the performance of medical tasks ordered by the physician, such as monitoring and changing the oxygen tubing and humidification bottle. Resident #7, a female with similar respiratory conditions, was found to have an oxygen concentrator filter filled with dust and particles, and the humidifier water bottle was empty and undated. The facility's records did not reflect that the nursing staff had performed the required maintenance tasks, such as cleaning the concentrator filter and changing the tubing and humidifier. Interviews with the Director of Nursing (DON) and other staff members revealed that there was an expectation for these tasks to be completed, but they were not consistently carried out. The facility's policy on oxygen administration outlined specific steps for maintaining equipment and ensuring proper documentation, but these were not followed in the cases of Residents #1 and #7. The lack of adherence to these procedures could lead to inadequate respiratory care and potential health risks for the residents. The observations and interviews highlighted a failure in the facility's processes to ensure that physician orders were followed and that equipment was maintained in a clean and functional state.
Infection Control Deficiencies in Laundry Handling and Medication Administration
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several deficiencies observed in the handling, storage, and processing of linens and residents' clothing. Staff were found placing their personal belongings, such as purses, in the same laundry cart with residents' personal clothing, leading to potential cross-contamination. Additionally, there was no barrier between the clean and dirty areas of the laundry room, and personal items like cellphones, car keys, and water bottles were found on the table used for sorting and folding laundry. These actions were contrary to the facility's infection control policies and posed a risk of spreading infections among residents. In another instance, a medication aide failed to wear gloves and perform hand hygiene while administering medication to a resident. The aide opened a capsule with bare fingers and mixed it into applesauce, which was against the facility's guidelines for medication administration. The Director of Nursing confirmed that staff were expected to perform hand hygiene before and after medication administration and to wear gloves when handling medications to prevent contamination. Interviews with various staff members, including laundry aides and the housekeeping supervisor, revealed a lack of awareness and adherence to infection control protocols. The housekeeping supervisor admitted to not being informed about the need for a barrier between clean and dirty areas in the laundry room and had not reviewed the laundry policy. The facility administrator was also unaware of the issues in the laundry room. Despite requests, the facility did not provide a policy for laundry room procedures before the survey exit.
Failure to Involve Residents and Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure care plans were developed in consultation with the residents and their representatives for four residents. Specifically, the facility did not invite Resident #20, Resident #24, Resident #42, and Resident #167, or their representatives, to participate in the comprehensive care plan meetings as required by resident rights guidelines. This failure was identified through interviews and record reviews, which revealed that care plan conferences were not held with the residents or their representatives after specific dates, despite the facility's policy encouraging such participation. For instance, Resident #20's last documented care plan meeting with her sister was on 09/18/2023, and no further meetings were held after that date. Similarly, Resident #24, Resident #42, and Resident #167 had no documented care plan meetings with their representatives after 09/13/2023, 08/24/2023, and 08/23/2023, respectively. The Social Worker (SW) acknowledged the issue, stating that the facility had been without a consistent SW on staff until December 2023. The new SW was working on setting up care plan meetings to align with the Minimum Data Set (MDS) schedules and had been inviting residents and their family members or representatives to these quarterly meetings. However, the lack of consistent care plan meetings prior to this had affected the residents' ability to participate in their care planning, which is crucial for addressing their daily care needs and setting appropriate goals. The facility's policy emphasizes the importance of resident and representative participation in care plan development, but this was not adhered to in these cases, leading to the identified deficiency.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to provide a clean and functional environment for six residents, leading to various deficiencies. Resident #34's room had grimy, stained, and dusty floors, a damaged chest, and a bent privacy curtain runner. The shared bathroom with Resident #54 had a non-working sink and toilet, a damaged wall, and mismatched tiles. Resident #34's door could not close completely due to the placement of a bed. Resident #16's room had gnats, and the unmade bed was saturated with urine. Resident #59's room had a cracked, flaking film over part of the window and a damaged windowsill and wall. Resident #36's room was only partially painted, had damage to the baseboard and walls, and a grimy, stained bathroom with unrepaired damage. Resident #7's room had a dusty, grimy, stained floor with cracked tiles, damaged walls, and a damaged dresser with a hinged padlock. Resident #34, a [AGE] year-old female with multiple diagnoses including paraplegia and pressure ulcers, expressed dissatisfaction with the facility's conditions. She reported issues with the bathroom flooding, a non-draining sink, and a malfunctioning toilet. Resident #54, a [AGE] year-old female with congestive heart failure and other conditions, shared similar concerns about the shared bathroom. Resident #16, an [AGE] year-old male with a history of stroke and other conditions, had a room with a broken windowsill and damaged wall. Resident #59, a [AGE] year-old male with a history of stroke, had a room with a urine-saturated bed and gnats. Resident #36, a [AGE] year-old female with end-stage kidney disease, reported ongoing issues with her room's state, including a grimy floor, broken tiles, and an unfinished paint job. Resident #7, an [AGE] year-old female with chronic kidney disease and dementia, had a room with a strong urine smell, damaged walls, and a damaged dresser. The Environmental Service Director acknowledged the poor condition of the floors and the challenges in maintaining cleanliness. The Administrator, who started in February 2024, noted that the building was very old and required significant upkeep. She mentioned that the corporation was supportive of making improvements but did not have a specific timeline for new flooring. The Administrator also highlighted the importance of maintaining a clean and homelike environment for infection control and quality of life. Despite regular pest control, issues with gnats were not previously known. The facility's policies on maintaining a homelike environment and providing maintenance services were not adequately followed, leading to the observed deficiencies.
Facility Fails to Provide Palatable and Attractive Food
Penalty
Summary
The facility failed to ensure that food provided to residents was palatable and attractive, as observed during two lunch meals. Residents reported dissatisfaction with the food quality, stating that it had declined since the new Dietary Manager (DM) started. During interviews, residents expressed that the food was terrible, and this sentiment was echoed in a group interview where all participants agreed on the poor quality and flavor of the food. Observations by state surveyors confirmed these complaints, noting that the food lacked flavor, was unappealing in appearance, and in some cases, was overcooked or stale. The Dietary Manager acknowledged these issues and mentioned challenges with staff training and food supply constraints, which contributed to the problem. On 04/23/24, a test tray of regular and pureed diets revealed that the chicken enchiladas were dry, cracked, and lacked sauce, making them unappealing. The rice and beans also had very little flavor. On 04/25/24, another test tray showed that while the barbequed chicken thigh and potato salad were acceptable, the green beans were overcooked, oily, and had a slimy texture, and the cake was dry and stale. The Dietician, who had been with the facility since February 2024, stated that she had not been made aware of food complaints and noted that the menu was pre-programmed with standardized recipes that should have some flavor. The Dietary Manager, who had been at the facility for about two months, admitted that the previous cooks were not using recipes and that she was working on training the new dietary staff to follow recipes and taste the food they cooked. She also mentioned issues with the food supply, such as items being unavailable or not delivered, and constraints due to the facility's budget and food plan. Despite her efforts to improve the situation, she faced resistance from residents and staff, and ultimately, she had put in her notice to leave the facility. The Administrator was unaware of the specific issues with the food served during the survey but acknowledged ongoing efforts to address residents' dietary preferences.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in their only kitchen. During an observation, the deep fryer was found to have a thick build-up of brown and black grease with food particles around the inside edges, and grease had run off the edges and down the sides of the deep fryer. The stove surface under the metal grates also had a build-up of blackened food debris. The dietary manager acknowledged that the deep fryer had old grease in it and revealed that it was cleaned only once a month, with the used grease being used to fry foods throughout the month. The dietary staff was responsible for cleaning the deep fryer, but there was no specific policy related to its cleaning. The facility's policy indicated that all kitchen equipment should be cleaned on a regular scheduled basis, but this was not adhered to in practice. An interview with the Dietitian revealed that she had limited knowledge of the facility's practices as she had only been contracted since February 2024. She stated that a month was too long to use the same fryer grease and mentioned that she had noted the need to clean the fryer during her visits. However, the facility had not scored low enough on her checklist to require a performance improvement plan. The FDA Codes emphasize the importance of proper installation and location of equipment for ease of cleaning to prevent the accumulation of debris and attractants for insects and rodents. This failure could place 62 residents who consumed food prepared in the kitchen at risk of food-borne illness.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for three hallways, including the front hall, hall 16-39, and hall 40-54. Observations made by state surveyors revealed pervasive urine odors and dirt and grime, particularly around doorways and along the edges of the hallways. The urine odor was strongest near rooms 40-58 and 12-24 and persisted throughout the survey period. The floors in these areas had a buildup of staining and grime, and the doorways appeared dusty at the bottoms of many doorframes. The hallway leading to the kitchen was also noted to be grimy and stained. Housekeeping staff were not observed on the hallways during these times, and the Environmental Service Director indicated that the floors were very old and had a buildup of negligence, preventing them from being thoroughly cleaned. Interviews with the Administrator and the Environmental Service Director revealed that the facility had been without a floor tech for two years before the current Environmental Service Director started in 2022. The Administrator acknowledged that the building was very old and that the condition and cleanliness of the building were infection control and quality of life issues. She mentioned that the corporation had discussed replacing the floors but did not know when that would happen. The Environmental Service Director also noted that the corporation had replaced floors in some rooms and at a sister facility but not in the entire facility yet. A family member of a resident expressed concerns about the strong odor of urine and feces and the overall filthiness of the facility, including the resident's room. She mentioned that she did not bring the resident's children to visit because she feared they might catch something and kept her mask on during visits for the same reason. She also observed that the other side of the building seemed cleaner and brighter, possibly because the residents on that side talked less and wouldn't complain as much. The facility's policies on maintaining a homelike environment and providing maintenance services were reviewed, but the observations and interviews indicated that these policies were not being effectively implemented.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to call for assistance. Resident #44, a male with cerebral palsy, severe intellectual disabilities, and severe cognitive impairment, was observed multiple times without his call light within reach. On one occasion, the call light was placed behind his wheelchair, making it inaccessible. On another occasion, it was clipped to a privacy curtain in the middle of the room, again out of reach. Interviews with staff revealed that the call light should always be within reach, but it was not consistently placed correctly for Resident #44. Staff members, including CNAs and an LVN, acknowledged the importance of keeping call lights within reach and admitted that it was their responsibility to ensure this. Despite this, the call light was not consistently placed within reach for Resident #44, leading to potential risks for the resident. The facility's policy on call lights, which mandates that they be within easy reach of residents, was not followed in this case, as confirmed by the facility administrator.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with multiple medical and psychological needs. Specifically, the care plan did not address the resident's PTSD and colostomy. The resident, who was admitted with diagnoses including paraplegia, colostomy, pressure ulcers, mood disorder, bi-polar disorder, post-traumatic stress disorder, anti-social personality disorder, and seizures, was found to be fully alert and oriented during an interview. She expressed discomfort due to a large hernia and mentioned the need for surgery that would involve moving her colostomy. Despite these significant medical needs, the care plan lacked specific interventions for her colostomy and PTSD. Interviews with facility staff revealed that the responsibility for care plans was shared among the Care Coordinator Manager (CCM), Director of Nursing (DON), and Social Worker (SW). The CCM admitted that the colostomy should have been tagged in the baseline care plan and carried over to the comprehensive care plan, but this was not done. The Administrator and the new DON acknowledged that the care plans were typically done by the Interdisciplinary Team (IDT) and that the admitting RN should have put in the baseline care plan. However, due to a change in DONs, the initial care plan for the resident was not completed as required. The facility's policy mandates that comprehensive care plans be developed within 7 days after the completion of the comprehensive MDS assessment and by Day 21 of the patient's stay, but this was not adhered to in this case.
Call System Malfunction
Penalty
Summary
The facility failed to ensure that the call system was working properly for the nursing stations in zone 1 and zone 2. Observations revealed that the call system was malfunctioning, causing the call system to sound when no call light was on, and no light for call buttons appearing on the panel. Additionally, the call light of one resident would not turn off properly when used. This issue was observed multiple times, with staff struggling to identify and resolve the source of the alarm sound, which was not recognized by the call light panel at the nurse's station. Interviews with staff, including the Director of Nursing (DON), Certified Nursing Assistants (CNAs), and Licensed Vocational Nurses (LVNs), indicated that the call light system was outdated and had been experiencing issues for an unspecified period. Staff reported that the alarm sound was unfamiliar and that the system sometimes triggered false alarms, causing confusion and delays in responding to residents' needs. Maintenance personnel were also involved in attempting to diagnose and fix the problem, but the issue persisted over several days. The facility's policies for answering call lights and maintenance services were reviewed, revealing that the maintenance of the call system was not explicitly addressed. The DON eventually contacted the corporate office to request an electrician to inspect the system, as the facility's maintenance person had left without warning. The corporate office scheduled an inspection to ensure the call light system was functioning correctly across all halls to prevent future occurrences of the issue.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pavilion At Creekwood | 1.7 mi | ★★★★★ | 13 | 0 |
| Mansfield Medical Lodge | 2.8 mi | ★★★★★ | 17 | 0 |
| Matlock Place Health & Rehabilitation Center | 4.4 mi | ★★★★★ | 10 | 2 |
| Avir At Kennedale | 7.6 mi | ★★★★★ | 25 | 2 |
| Arbrook Plaza | 8.3 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.