Inspection·May 1, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 3 residents reviewed for resident rights. (Resident #1) The facility failed to ensure CNA A did not go through Resident #1's personal posessions without his permission or remove items from his room without his permission. This negative finding caused the resident to be distressed and could cause residents to feel disrespected. Findings included: Record review of Resident #1's face sheet, with no date, indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were depression and muscle wasting. Record review of Resident #1's Annual MDS assessment dated [DATE] indicated his cognition was intact with a BIMS (brief interview for mental status) score of 13. His assessment for mood and behaviors did not indicate any concerns. Record review of Resident #1's Care Plan dated 4/3/24 indicated a problem of General. The approaches were the resident preferred showers or baths once a day on Monday, Wednesday, and Friday on the 6 am to 2 pm shift. During an interview on 5/1/24 at 9: 45 a.m., Resident #1 said on 4/30/24, CNA A came into his room and started opening his nightstand drawers and rummaging through them. He said she continued to go through his things, and he asked her what she was doing, and she ignored him. Resident # 1 said he got mad and started yelling at her and told her to get out and leave his things alone. He said to make things worse, when he left his room to talk to the DON about CNA A going through his things without permission, CNA A and CNA B had gone in his room and taken all his towels. He said some of the towels were his own personal towels and they had taken those as well. During an interview on 5/1/24 at 10:14 a.m., CNA A said she was asked by the ADON to check resident rooms for towels. She was just doing what she was told. She was told to get the extra towels out of residents' rooms and that was what she was doing. She said Resident #1 took a shower every day and sometimes twice a day and felt he always needed extra towels. She said she did not have any problems with anyone else but Resident #1. CNA A said she had knocked on Resident #1's door and told him she was checking for towels. She told him she was going to check his dresser drawers and he appeared (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: 675011 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 675011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jacksonville 305 Bonita St Jacksonville, TX 75766 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)