Avir at Jacksboro

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the residents were treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 7 residents (Resident #2, Resident #3, Resident #4) reviewed for resident rights. The facility failed to ensure Resident #2, Resident #3, and Resident #4 were able to exercise his or her rights as a resident of the facility and as a citizen of the United States to be treated with dignity. The facility failed to ensure Resident #2, Resident #3, and Resident #4 exercised his or her rights without interference, coercion, discrimination, or reprisal from the facility staff. The facility failed to support Resident #3 in exercising her rights to have her personal property as required. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 7 residents (Resident #3, Resident #4, Resident #5) reviewed for care plans. The facility failed to ensure the staff developed the comprehensive care plan goals and interventions from the comprehensive assessment for Resident #3, Resident #4 and Resident #5. The facility failed to ensure the comprehensive care plans for Resident #3, Resident #4 and Resident #5 described the resident's goals for admission and desired outcomes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:Cook A wore a hair restraint properly covering his facial hair. These failures could place residents at risk for foodborne illness and compromised health status and hair in food.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 1 of 12 months (July 2025) reviewed for RN Coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for 6 of 31 days in July of 2025. This failure placed all residents at risk for inconsistency in care, services and decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure proper sanitization of kitchen waste was kept in tightly closed trash cans.2. The facility failed to ensure that personnel change their gloves and wash their hands before serving and in between tasks. 3. The facility failed to ensure that food and nutrition services staff wear hair restraints. These failures placed the residents at risk of foodborne illness and being served food items that may be contaminated.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 16 of 52 rooms (Room #s 3, 4, 6, 10, 12, 14, 22, 43, 44, 46, 47, 50, 51, 52, 53, and 54) observed for cleanliness and condition. 1. The doorway transition strips used to provide a smooth floor transition between the hallway and the room for the door thresholds were missing for resident Room #s 10, 12, 43, 44, 46, 47, 51, 52, and 54.2. Square vinyl floor tiles were broken and/or missing in Room #s 14, 22, 43, 44, 50, and by the nurse's desk in Hall C.3. The floors were soiled with a dark-colored build-up of dirt along the base of the toilets, cove-base (vinyl baseboard), and door frames in the restrooms for Room #s 3, 4, and 6.4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's nebulizer nasal cannula and oxygen nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (April 2024, May 2024, and June 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 19 days of 91 days in April, May, and June 2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: A. The facility's walk-in refrigerator had dust, food crumbs, and dried, spilled milk on the floor and underneath shelves. B. Kitchen floors were not swept and free from dirt, food particles, and trash. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #28) of 5 residents reviewed for infection control, in that: The facility failed to ensure clinical staff donned (put on) proper personal protective equipment when providing care to Resident #28, who was on contact isolation precautions, including gown, gloves, and mask. Facility failed to ensure that staff used proper laundry handling precautions. This failure could affect residents and place them at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 1 facility reviewed for environmental concerns. The facility failed to replace a ceiling panel, repair water discoloration marks, repair the leak in the ceiling in Resident #29's room and repair water discoloration marks and the sagging ceiling in the dining area. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Resident #11) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts observed for medication storage. The facility did not ensure the Medication Cart (C/D hall cart) was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them.

Inspectors wroteBased on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of one resident (Resident #40) reviewed for quality of care . The facility failed to ensure Resident #40 had physician orders regarding care of the surgery site, post hip replacement surgery, on 07/30/2023. The 8 surgical staples were not removed until 08/13/2023, 14 days after surgery which resulted in a superficial infection. This failure could place residents at risk of unmet care needs and infection.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 12 of 12 residents (Resident #1, Resident #10, Resident #11, Resident #12, Resident #14, Resident #15, Resident #19, Resident #22, Resident #23, Resident #28, Resident #40, and Resident #193) reviewed for care plans. The facility failed to ensure resident care plans were developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present and at the care conference and involved in the care planning process. This failure could place residents at risk of not have having their care plans completed accurately and timely.

Inspectors wroteBased on interview and record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 3 months (January, FebruaryFebruary, and March 2023) reviewed for nursing services. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours on ten weekends January, February, and March 2023 This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interviews and record reviews the facility failed to a comprehensive assessment was completed within 14 days after the facility determined or should have determined, that there was a significant change in the resident's physical condition or mental condition for 2 of 10 residents (Residents #14, and Resident #40) reviewed for assessments. The facility failed to capture a comprehensive MDS assessment after Resident # 14 and Resident #40 had a significant decline and a hospital stay. This failure could place residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 15 sampled residents (Residents #'s 12) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #12's MDS was accurately coded as receiving dialysis. 2. The facility failed to ensure Resident #12's MDS continence status was accurately . This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents, (Resident #11) reviewed for PASRR Level 1 screenings. The facility did not correctly identify Resident #11 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of the resident's admission for 1 of 5 residents (Resident #19) whose records were reviewed in that: for care plans. The facility failed to ensure Resident #19 had a base line care plan developed and implemented upon admission on [DATE]. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility.

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 1 (Resident #40) residents reviewed for clinical records in that: The facility staff were unable to locate documentation in Resident #40s clinical record regarding when to remove surgical staples. This failure could place residents at risk of not having care needs met