Health inspection·December 11, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few 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. The findings included: Record review of Resident #1's face sheet, dated 12/10/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (severe or complete loss of strength or paralysis), Shortness of breath, Nasal congestion (stuffy nose), nutritional deficiencies, Urinary tract infection (infection that affects a part of the urinary tract), type 2 diabetes (adult diabetes). Record review of Resident #1's MDS quarterly assessment, dated 12/04/2024, reflected a BIMS score of 8, which indicated moderate cognitive impairment. Section I: Stroke, Diabetes Section O: None. Record review of Resident #1's Physician Orders, dated 10/12/2024, reflected an order for Oxygen at 2 liters per minute for shortness of breath/saturation (The amount of oxygen in a person's blood) below 90% as needed, PRN. A separate order dated 10/12/2024 stated to change the humidifier, nasal cannula/mask, and oxygen tubing every week on Sunday. Physician orders dated 11/29/2024 reflected an order for Albuterol/Ipratropium 0.5mg/3mg/3ml, give 1 vial via nebulizer mask every 4hrs prn cough/shortness of breath, PRN. A separate order dated 10/12/2024 stated to change the humidifier, nasal cannula/mask, and oxygen tubing every week on Sunday. Record review of Resident #1's quarterly Care Plan, dated 11/27/2024, reflected a care plan that does not include oxygen therapy. (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: 455808 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 455808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksboro 211 E Jasper St Jacksboro, TX 76458 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)