Inspection·February 25, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few desaturate (decrease from normal breathing range) due her diagnoses of COPD (chronic obstructive pulmonary disorder) and pneumonia. LVN A said she was Resident #1's nurse on 2/11/26. LVN A said resident had taken her oxygen mask off and she told her to put it back on or you'll have to go to the hospital. LVN A said she spoke matter of fact to the resident, but not in a mean way. LVN A said she was instructed to be blunt with Resident #1 from a staff member at the state hospital, where Resident #1 was a patient. LVN A denied ever forcefully placing an oxygen mask on Resident #1's face. During an interview on 2/25/26 at 9:35 a.m., RN B said she was working on 2/11/26, the day of the allegation, but was not a witness to it. RN B said she Resident # 1 frequently removed her oxygen but was generally redirectable to put it back on. RN B said she had never heard LVN A use abusive language toward residents or tell them they would die. During an interview on 2/25/26 at 10:00 a.m., the Maintenance Director said his employee, Laundry Aide, reported the allegation to him immediately upon witnessing it. He said he went to Resident #1's room and spoke to Sitter C and Sitter C wanted to file a grievance. The Maintenance Director said he went to the ADON and alerted her of the situation and then had Laundry Aide write a statement which he delivered to the ADON. The Maintenance Director said Laundry Aide told him LVN A forcefully placed an oxygen mask onto Resident #1's face and was verbally abusive. During an interview on 2/25/26 at 10:15 p.m., the Laundry Aide said she delivered laundry to room [ROOM NUMBER] on hall 100. The Laundry Aide said when she went into the room LVN A was yelling at Resident #1 to put her mask back on or she would go to the hospital. The Laundry Aide said LVN A forcefully pushed the oxygen mask back down on to Resident #1's face and pulled the straps into place. The Laundry Aide said she stayed in the room until LVN A left and immediately called her supervisor to alert him of the incident. The laundry aide said she had training in abuse and neglect and was to alert the ADM or her direct supervisor if the ADM was unavailable, and the ADM was out of the office on a facility related travel. The laundry aide said she was never interviewed by the ADON in regard to the incident, but she did write a statement and give it to her supervisor. During an interview on 2/25/26 at 10:35 a.m., the ADON said she first learned of the incident immediately after it happened from the Maintenance Director. The ADON said she went to Resident #1's room and spoke to Sitter C. The ADON said Sitter C reported LVN A had been blunt with resident about keeping her mask on and the risks of taking it off, but did not report LVN A forcefully placed an oxygen mask over Resident #1's face. The ADON said she investigated the incident and did not consider it reportable to the state because Sitter C did not mention LVN A forcefully placing an oxygen mask on Resident #1's face. The ADON said she had training in abuse and neglect and reporting requirements. The ADON said her investigation included interviews with other residents and sitters from the state hospital who sat with Resident #1. The ADON said she completed 1-on-1 coaching with LVN A regarding her customer service skills and tone of voice when speaking to residents. During a telephone interview on 2/25/26 at 10:55 a.m., Sitter C said she worked at the state hospital and was assigned to sit with Resident #1 on 2/11/26 on the evening shift (2pm-10pm). Sitter C said resident had taken off her oxygen mask to clean her mouth. Sitter C said LVN A came in and yelled at Resident #1 to put her mask back on. Sitter C said when Resident #1 did not put her mask on, LVN A walked to the bed and forcefully put her mask on her while yelling If you don't put this mask on you're going to die. Sitter C said the resident did not verbally respond to the incident, but that she looked frightened. Sitter C said she told the ADON the same information as she told this surveyor. Sitter C said she was always able to redirect Resident #1 and wasn't aware of any orders to speak to resident bluntly or matter of fact. During an interview on 2/25/26 at 1:45 p.m., the ADM said the incident occurred on 2/11/26 and she was not notified until 2/13/26. The ADM said she was notified by the ADON who told her the incident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675011 If continuation sheet Page 2 of 3 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 02/25/2026 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was handled. The ADM said she was not aware of Laundry Aide's written statement until that day, 2/25/26. The ADM said whether the incident was reportable was hard to answer in hindsight, but she planned to implement 1 on 1 training with all staff to ensure everyone understands abuse reporting requirements. During an interview on 2/25/26 at 2:00 p.m., the DON said she was first made aware of the details of the allegation, and that a written statement existed, that day 2/25/26. The DON said the policy said to report abuse allegations to the ADM or immediate supervisor in the ADM's absence. She said allegations should be reported immediately and the DON should have reported this incident to the ADM for review. The DON said the ADON did a thorough investigation and could not conclude there was an abuse allegation based on interviews with sitters who sat with Resident #1. The DON said risks to residents from unreported abuse could be continued abuse of a resident physically, verbally, or being neglected. The DON said going forward she planned to do 1-on-1's with all staff to make sure everyone understands who to report abuse to. The DON said she expected staff to ultimately report to the ADM, and report to their direct supervisor if the ADM is not reachable. Review of facility training record dated 1/16/26 revealed the ADON completed Abuse, Neglect, and Exploitation training. Review of In-service sign in sheet titled Abuse and Neglect and Exploitation dated 1/12/26 indicated the ADON was in attendance. Record review of facility policy Abuse, Neglect Exploitation or Misappropriation - Reporting and Investigating dated 2022 indicated .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. Event ID: Facility ID: 675011 If continuation sheet Page 3 of 3