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Nursing HomeMedicaid Investigative

Avir at Mansfield

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1402 E. Broad St., Mansfield, TX 76063127 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.6/5

based on 46 Google reviews

5
4
3
2
1
Avir at Mansfield Nursing Home in Mansfield, TX — Street View
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2/ 10
low Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)

Below average in Texas · Critically understaffed (RN) · $68,080 in fines

Source: Medicare data

What this means for your family

This facility shows signs of improvement under new leadership, with some families reporting great experiences. However, the historical pattern of understaffing and hygiene issues is significant; you should specifically ask about current nurse-to-patient ratios and the facility's recent pest control protocols.

Google Reviews

Google Reviews

46 reviews on Google
Families should approach this facility with caution due to recurring reports of severe neglect, hygiene issues, and understaffing. While some recent reviews praise a new leadership team and attentive care, multiple long-term patterns of poor sanitation, lack of communication, and inadequate physical therapy persist.

Quality Themes

Tap a score for details
FoodN/AStaff4.0Clean3.0Activities5.0Meds2.0MemoryN/AComms4.0ValueN/A

Strengths

  • Attentive and caring nursing staff
  • Visible and engaged administration
  • Cleanliness in certain areas
  • Effective communication from management during positive stays

Concerns

  • Facility cleanliness and hygiene issues (smell, pests) (mentioned by 4 reviewers)
  • Understaffing leading to neglect or slow response (mentioned by 4 reviewers)
  • Outdated building and infrastructure (mentioned by 5 reviewers)
  • Difficulty reaching staff or nurses via phone (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'18(8)'20(1)'22(3)'24(10)'25(12)

Distribution · 51 analyzed

5
31
4
1
3
1
2
1
1
17

How They Respond to Reviews

35%response rate
Generic

The owner relies heavily on three distinct templates to respond to reviews. Positive reviews are met with identical copy-paste messages, while negative reviews are addressed with standardized apologies and requests for further contact.

Questions for Your Tour

  • 1I noticed that management is very engaged with the community; how do you typically communicate important facility updates or changes to the families?
  • 2What specific steps are being taken to ensure the facility remains fresh, clean, and well-maintained for the residents?
  • 3Could you walk me through your process for medication management to ensure everything is administered accurately and on schedule?
  • 4How do you ensure that nursing staff can be reached quickly at any time of the day or night if a resident has an urgent need?
  • 5What kind of daily activities or social programs do you have in place to keep the residents engaged and active?
  • 6In the event of a medical emergency after hours, what is the protocol for contacting doctors and notifying the family?

Personalized based on this facility's data


Key Review Excerpts

The level of cleanliness makes me happy when I come for visits . I would encourage the owners to invest in This building as it’s old and could be a remodel in a few areas .

Family of resident · 2025★★★★★

The facility is old but clean, family member was there for rehab to get strength back and walk with a walker. Physical therapy was worthless. No P T on weekends.

Rehab patient's family · 2024☆☆☆☆

I am a resident. I'd like to say better things but the truth is. They are extremely short handed. Due to this, everyone suffers.

Resident · 2021☆☆☆☆
Source: 46 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.21hrs
29%
Registered nurses for medical care
Total Nursing
3.05hrs
74%
All nurses + aides combined
Staff Turnover
37%
Lower is better (< 30% = good)
RN Turnover
17%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 15 measures

Medicare Rating
5/ 5
Better Than Avg

15

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
TX
2.5%
Tarrant
2.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility4.7%
Better than Avg
Here
4.7%
US
15.4%
TX
9.4%
Tarrant
8.8%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility10.6%
Better than Avg
Here
10.6%
US
19.4%
TX
14.2%
Tarrant
15.1%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.8%
Better than Avg
Here
7.8%
US
14.4%
TX
16.1%
Tarrant
13.4%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility11.9%
Better than Avg
Here
11.9%
US
19.5%
TX
18.4%
Tarrant
16.9%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
TX
96.9%
Tarrant
97.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
TX
89.2%
Tarrant
91.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

5deficiencies
2penalties
Near state avg (9.1)
18 complaint-triggered
$68,080 in fines

This facility shows concerning patterns with 19 complaint-triggered deficiencies out of 65 total, indicating families have filed reports about care issues. The most recurring problems involve maintaining clean and safe living environments, food safety and preparation, and accident prevention. While all deficiencies show correction dates, serious issues persist across multiple surveys, including recent complaints about pressure ulcer care, respiratory care, and food safety as recently as 2024-2025.

Jun 5, 2025Routine
17
0006Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

0030Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

0923Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0929Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

0565Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0561Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0849Potential for harm · IsolatedCorrected

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

0222Potential for harm · IsolatedCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0351Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0521Minimal · WidespreadCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Apr 9, 2025Complaint
1
0805Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nov 23, 2024Complaint
1
0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Aug 16, 2024Complaint
3
0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Apr 25, 2024Routine
17
0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0004Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0741Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0553Potential for harm · PatternCorrected

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0921Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0291Potential for harm · PatternCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0521Minimal · WidespreadCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Mar 5, 2024Complaint
2
0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Federal Penalties

Fine

Jul 14, 2023

$53,552

Fine

Jun 17, 2023

$14,528

Ownership & Operations

Who Operates This Facility

Owner / Operator

Hamilton County Hospital District

Organization Type

for profit

Management Company

1402 E BROAD STREET OPCO LLC

Administrator

KISSY MILLER

Chain Affiliation

Chain Name

Avir Health Group

Chain Size

117 facilities nationwide

Chain avg rating: 2.3/5 · Rank 12 of 21

Ownership & Management

Owners

Hamilton County Hospital District

Owner · Organization

100%

Eden, James

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Whitworth, Gary

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Wm 41 Flatonia Re LLC5% or Greater Mortgage InterestHooper, GradyOfficer / DirectorSlp Mansfield LLCManagerLeonard, JoshuaManagerSlp Mansfield LLCAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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