Avir at Mansfield

In the surveyor’s words

From the most serious findings on record at Avir at Mansfield, in the surveyor’s own words.

• Immediate jeopardy, patternF580Jun 17, 2023

  Based on observation, interview, and record review, the facility failed to immediately inform the physician and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status (deterioration in health in either life-threatening conditions) for one (Resident #1) of eleven residents reviewed for physician notification. The facility failed to ensure LVN B notified the physician on 06/10/23 when Resident #1 suffered from heat exhaustion when the temperature reached 95 degrees Fahrenheit. Resident #1 was found unresponsive outside by the patio, which resulted in the resident having a change of condition. […]

• Immediate jeopardy, patternF600Jun 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure the right to be free from neglect was provided for one (Resident #1) of eleven residents reviewed for neglect. The facility failed to ensure Resident #1 was free from neglect when the facility failed to notify the physician when Resident #1 was unresponsive after extreme heat exposure and failed to provide Resident #1 with timely hospitalization following the incident. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. […]

• Immediate jeopardy, patternF607Jun 17, 2023

  Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of eleven residents reviewed for incidents. The facility failed to implement their abuse and neglect policy by failing to ensure Resident #1 was free from neglect. Over several days, multiple staff did not provide goods and services of proper care. The facility failed to ensure LVN B did not neglect Resident #1 when she failed to notify the physician on 06/10/23 when Resident #1 suffered from heat exhaustion when the temperature reached 95 degrees Fahrenheit. Resident #1 was found unresponsive outside by the patio, which resulted in the resident having a change of condition. […]

• Immediate jeopardy, isolatedF689Jun 17, 2023

  Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent heat exhaustion while outside in the courtyard for 1 (Resident #1) of eleven residents reviewed for accident hazards and supervision. The facility failed to provide necessary supervision to prevent accidents by failing to have measures in place to ensure residents who went outside on high heat days was provided with supervision, this failure resulted in Resident #1 being found in the courtyard unresponsive due to extreme heat exposure. […]

• Immediate jeopardy, isolatedF689Feb 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident # 67) of 18 residents reviewed for smoking. CNA D failed to comply with the facility's smoking policy, when she failed to provide continuous direct supervision to residents during their smoke break, which resulted in Resident #67's hair and scalp being burned. Another resident had to pat out the burning hair, and Resident #67 sustained a superficial burn (affecting the top layer of skin) to her scalp. An Immediate Jeopardy (IJ) was identified to have existed from 01/18/23 through 01/25/23. […]