Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Jacksboro during CMS and state inspections, most recent first.
Surveyors observed a cook preparing food on multiple occasions without a beard restraint properly covering his facial hair, despite facility policy and FDA Food Code requirements that food service staff wear hair and beard restraints to prevent hair from contacting exposed food and clean equipment. The cook admitted he should have worn a facial hair restraint but forgot, and the Administrator confirmed that staff are expected to wear hair restraints whenever they enter the kitchen, noting the potential for hair in food and infection control concerns.
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week on multiple days in July 2025. The Administrator acknowledged the gaps in weekend coverage, and staffing records showed no RN coverage for the required hours on several dates. The Corporate Nurse Consultant and Administrator both stated that RN coverage was expected to be 7 days a week and 8 hours per day, consistent with the facility policy.
Food service staff failed to follow required hand hygiene, glove use, hair restraint, and trash container practices. An employee was observed handling rolls, plates, tray carts, and a cell phone while wearing the same gloves, going in and out of the kitchen without washing hands or changing gloves, and not wearing a beard cover. An open-top trash can was also observed being moved through the dining area without a lid, and another trash can near the drink station was also uncovered.
Unsafe and Unsanitary Room Conditions: Surveyors observed missing doorway transition strips, broken and missing vinyl floor tiles, and soiled restroom floors with buildup around toilets, cove-base, and door frames in multiple resident rooms. Other findings included a fly paper strip above a bed, chewing tobacco on a room floor, an open dresser drawer with dried pizza, a soiled drainpipe, and a restroom with a urine odor. Staff interviews confirmed daily cleaning expectations, deep-cleaning practices, and awareness of damaged flooring and dirty bathrooms.
A resident with respiratory needs had her nebulizer and oxygen equipment improperly stored, with tubing and cannulas left unbagged, contrary to facility policy. Interviews with the Administrator and DON confirmed expectations for proper storage and weekly changes, which were not met, risking infection and disease transmission.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 19 days over a three-month period. This deficiency was due to challenges in hiring RNs, as confirmed by the DON and Administrator. The lack of RN presence was documented in the CMS' PBJ Staffing Data Report and timecard records.
The facility failed to maintain cleanliness in its kitchen and walk-in refrigerator, with observations revealing dust, food crumbs, and dried milk spills. The Dietary Manager admitted to an ineffective cleaning schedule, and no cleaning log was provided. The Administrator expected daily cleaning, but this was not adhered to, risking infection and pest issues.
A facility failed to maintain an effective infection control program, as staff did not use PPE when caring for a resident on contact isolation for MRSA. Additionally, contaminated laundry was not properly bagged or labeled, and staff did not wear PPE while handling it. Interviews revealed a lack of awareness and training on infection control policies, leading to potential infection risks.
A facility failed to maintain a safe environment due to ceiling damage and leaks in a resident's room and the dining area. The resident's room had a water-damaged ceiling with possible mold, causing difficulty in room navigation. The dining area ceiling was sagging and discolored. Despite identifying the issues and receiving repair bids, no work orders were logged, and repairs were delayed.
A resident with chronic respiratory conditions was not provided with appropriate respiratory care as their nasal cannula and tubing were not stored in a bag when not in use, contrary to the facility's policy. This oversight was observed multiple times, despite the resident's care plan requiring oxygen therapy and the facility's policy mandating proper storage to prevent infection and equipment damage.
A medication cart in the C/D hall was found unlocked and unattended, containing various medications including narcotics. Interviews with staff revealed a lack of awareness and adherence to the facility's policy requiring medication carts to be locked when not in use. The responsibility for securing the cart was attributed to the assigned nurse, with oversight expected from nursing management.
Failure to Ensure Proper Beard Restraint Use During Food Preparation
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices related to improper use of hair restraints by kitchen staff. During an observation of food preparation on 03/31/26 at 11:45 a.m., Cook A was seen working in the kitchen without a hair restraint covering his facial hair. A follow-up observation and interview on 04/01/26 at 12:25 p.m. again found Cook A preparing food without a beard restraint in place. During the interview, Cook A acknowledged that he should wear a hair restraint to cover his facial hair but stated he had forgotten to put one on. The Administrator, interviewed on 04/01/26 at 1:40 p.m., stated that her expectation was that staff wear hair restraints as soon as they enter the kitchen at any time. She indicated that failure to do so had the potential for residents to have hair in their food and raised infection control concerns. Review of the facility’s “Food Preparation and Service” policy, revised November 2022, showed that food and nutrition services staff are required to wear hair restraints, including beard restraints, so that hair does not contact food. Review of the 2022 FDA Food Code further specified that food employees must wear hair and beard restraints designed and worn to effectively keep hair from contacting exposed food and clean equipment, utensils, linens, and unwrapped single-service and single-use articles.
RN Coverage Not Provided as Required
Penalty
Summary
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 6 of 31 days in July 2025. During record review and interview on 01/15/2026, the Administrator acknowledged that there were days and weekends that were not covered as required and provided the staffing schedule and time sheets. Review of the Daily Staffing Hours vs. Daily Staffing Sign-in Sheets showed that RN coverage was not provided for at least eight consecutive hours on July 5, 6, 12, 13, 26, and 27, 2025. During interviews, the Corporate Nurse Consultant stated she knew RN coverage was supposed to be 7 days a week and 8 consecutive hours a day, and the Administrator stated the previous DON had a stroke at the end of June and was unable to help provide weekend coverage. The facility policy titled Staffing, Sufficient and Competent Nursing, revised August 2022, stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
Food Service Staff Failed to Follow Hand Hygiene, Glove Use, Hair Restraint, and Trash Container Requirements
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation on 01/13/2026, the dietary manager entered the kitchen and did not immediately wash her hands. Later that day, a staff member identified as [NAME] O was observed placing dinner rolls on plates, handling plates, and moving in and out of the kitchen without changing gloves. He was also observed using his cell phone while wearing gloves and then taking hall tray carts to the hallways without removing the gloves or washing his hands after re-entering the kitchen. He was not wearing a facial hair cover during these observations. During interview, [NAME] O stated his kitchen duties included washing dishes, placing plates and meal trays on carts, and delivering the hall tray carts. He acknowledged that he was placing the rolls on the plates at lunch and that he went in and out of the kitchen several times during meal service. When asked how many times he changed gloves and washed his hands after returning to the kitchen, he first said he did not know and then stated, "none I guess." He also stated he did not know the facility expectations for hand washing, changing gloves, or handling food, and ended the interview abruptly. On 01/15/2026, [NAME] O was observed rolling an open-top trash can from the kitchen through the dining room and down Hall B, and he stated he did not know where the lid was for the trash can. Another trash can in the dining room near the drink station was also observed without a lid. The dietary manager stated she was uncertain why the lids were not being used and that she would correct it. Record review showed the staff member attended a June 2025 in-service on handwashing, and facility policies required hand hygiene before serving food, handwashing after collecting soiled plates and food waste, changing gloves between tasks, wearing hair restraints, and keeping kitchen waste in clean, leakproof, tightly closed containers.
Unsafe and Unsanitary Room Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 16 of 52 rooms observed for cleanliness and condition. Surveyors observed missing doorway transition strips in multiple resident rooms, broken and/or missing square vinyl floor tiles in several rooms and near the nurse's desk in Hall C, and soiled restroom floors with dark-colored buildup along toilet bases, cove-base, and door frames in rooms 3, 4, and 6. A fly paper glue strip with dead flies and yellow residue was hanging on the wall above the head of Bed A in one resident room. Additional observations included a resident room with chewing tobacco clumps on the floor and an open dresser drawer containing a pizza box with dried slices of pizza that the resident said had been there for at least a week. In another room, a wash basin was positioned on the floor beneath the sink and the drainpipe was soiled with a dried brown substance. Surveyors also observed a restroom with a urine odor, dark stains behind the toilet, and dirt buildup along the door frame. A resident stated the room had not yet been cleaned that day, and another resident stated housekeepers had not emptied the trash and had not yet been in the room that day. During interviews, the Housekeeping Director stated rooms were cleaned daily and one room per hall was deep cleaned each day, while the Maintenance Director stated she repaired damaged flooring when supplies were available and had been applying concrete to some floor areas to make them flush. She also stated she was aware of dirty bathrooms and doorways and that transition strips were being addressed through corporate bids. The Administrator stated floors were expected to be cleaned daily and damaged flooring should be reported for repair as soon as possible. Facility policy required a clean, sanitary, orderly environment and identified obstacles in the footpath as a fall risk factor.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in the storage and maintenance of respiratory equipment. The resident, a female with a history of hemiplegia, shortness of breath, nasal congestion, and other medical conditions, was observed with her nebulizer and oxygen equipment improperly stored. The nebulizer tubing and cannula were found lying on the nightstand without being bagged, and the oxygen concentrator's tubing and nasal cannula were not in use and improperly stored between the concentrator handle without a bag. This improper storage practice was against the facility's policy, which required that such equipment be bagged when not in use to prevent contamination. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that their expectations were for the nebulizer and oxygen equipment to be stored in a bag when not in use and to be changed weekly. The facility's policy on oxygen administration also stipulated that the equipment should be changed weekly and documented in the electronic health record. The failure to adhere to these standards could potentially place residents at risk for infections and the transmission of communicable diseases.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 3 of the 12 months reviewed. Specifically, during April, May, and June 2024, there were 19 days where the facility did not have RN coverage for the required hours. This deficiency was identified through a review of the CMS' PBJ Staffing Data Report and confirmed by the facility's Administrator, who provided timecard reports showing the lack of RN coverage on specific dates. The Director of Nursing (DON) acknowledged the facility's policy requiring an RN to be on staff for 8 hours daily but cited difficulties in hiring RNs as a reason for the lapses in coverage. The DON mentioned being available by phone and living nearby to address any urgent needs, but this did not fulfill the regulatory requirement for on-site RN presence. The Administrator also noted the challenge of finding RN staff in the area, although they had recently hired three RNs to improve staffing levels.
Failure to Maintain Cleanliness in Kitchen and Refrigerator
Penalty
Summary
The facility failed to maintain cleanliness and adhere to professional standards for food service safety in its kitchen, specifically in the walk-in refrigerator and on the kitchen floors. During an initial observation, surveyors noted that the walk-in refrigerator contained dust, food crumbs, and dried, spilled milk on the floor and underneath the shelves. Additionally, the kitchen floors were observed to be dirty, with dirt, food particles, and trash present underneath the shelves and along the walls. These conditions were confirmed in a follow-up observation, where no improvements were noted. Interviews with the Dietary Manager revealed that the refrigerators were supposed to be cleaned weekly by the evening cook, but this had not been done the previous week. The manager acknowledged that the cleaning schedule was not effective, and the current system of cleaning after the last meal was not ideal. The Administrator expressed that it was her expectation for the kitchen to be cleaned daily and that any spills should be addressed immediately to prevent infection and pest issues. Despite these expectations, no dietary cleaning log was provided upon request, indicating a lack of documentation and adherence to the facility's cleaning policy.
Infection Control Deficiencies in PPE Use and Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by clinical staff when caring for a resident on contact isolation precautions. The resident, a male with a history of MRSA in a wound culture, was observed receiving care from a nursing assistant who did not wear any PPE or perform hand hygiene upon entering or exiting the resident's room. Despite the presence of a contact isolation sign and a PPE station outside the room, the nursing assistant was unaware of the necessary precautions and the potential risks of not following them. Additionally, the facility did not adhere to proper laundry handling precautions for residents on contact isolation. Linens and personal items from the resident's room were not bagged or labeled as contaminated, and were mixed with other residents' laundry. Staff responsible for handling the laundry did not wear PPE or treat the items as contaminated, contrary to the facility's policy and CDC guidelines. The Director of Nursing and the Administrator had differing expectations regarding the handling and labeling of contaminated laundry, leading to confusion and non-compliance with infection control protocols. Interviews with staff revealed a lack of awareness and training regarding the facility's infection control policies, particularly concerning the handling of laundry and the use of PPE for residents on transmission-based precautions. The Administrator and Director of Nursing acknowledged the deficiencies and the potential risk of infection spread due to the failure to follow established protocols. The facility's policy on transmission-based precautions and CDC guidelines emphasize the importance of using PPE and proper handling of contaminated laundry to prevent infection transmission.
Ceiling Damage and Leaks in Resident Room and Dining Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the condition of the ceiling in a resident's room and the dining area. In the resident's room, a 2x2-foot area of the ceiling showed water damage, with discolored sheetrock and a black substance present, indicating possible mold. The resident reported that the ceiling had been in poor condition since moving into the room, with leaks occurring during rain, and that the facility staff would place a bucket under the leak. The resident also mentioned that the location of the leak made it difficult to navigate the room with a walker. In the dining area, the ceiling was sagging with watermark discoloration around an air vent, and the texture was flaking off. The Maintenance Director acknowledged the issue, stating that the dining room had been leaking since late September and that repair bids were being collected. However, no work orders for these repairs were found in the facility's maintenance logbook for September. The Administrator confirmed that the ceiling issues were identified in September, and while bids for repairs were received, the repairs had not yet been completed. The Administrator emphasized the expectation for ceilings to be intact and functional, and for residents to be in an environment free of hazards.
Failure to Properly Store Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required such care, consistent with professional standards of practice and the resident's comprehensive person-centered care plan. Specifically, the facility did not ensure that the nasal cannula of a resident, who was dependent on supplemental oxygen due to chronic respiratory conditions, was stored in a bag when not in use. This oversight was observed during multiple instances where the nasal cannula and tubing were found hanging on the handle of the resident's wheelchair instead of being stored in the designated storage bag. The resident in question was an elderly female with a history of chronic respiratory failure with hypoxia, chronic bronchitis, and dependence on supplemental oxygen. Her care plan included orders for oxygen therapy at 2 liters per minute as needed for shortness of breath or when oxygen saturation fell below 90%. Despite the facility's policy requiring oxygen equipment to be stored in a clear plastic bag when not in use, observations revealed that the equipment was not stored properly, potentially exposing the resident to risks of infection and equipment damage. Interviews with the facility's administrator and DON confirmed the requirement for proper storage of oxygen equipment, highlighting a lapse in adherence to the facility's own policies and procedures.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured in locked compartments, as observed with the C/D hall medication cart. On the specified date, the medication cart was found unlocked and unattended near the nurse's station, with no nurse in sight. The cart contained various medications, including prescription drugs, over-the-counter medications, and narcotics. This oversight was confirmed through interviews with RN B, who was unaware of the cart being unlocked, and acknowledged the importance of keeping the cart secured to prevent unauthorized access. Further interviews with the Administrator and the Director of Nursing (DON) revealed that the expectation was for medication carts to remain locked when not in use by the nurse. Both the Administrator and DON emphasized the potential risks of leaving medication carts unsecured, which could allow residents or staff to access medications. The facility's policy on Medication Labeling and Storage, revised in February 2023, mandates that compartments containing medications must be locked when not in use, and carts should not be left unattended if open. The responsibility for ensuring the security of the medication cart was attributed to the nurse assigned to it, with nursing management also responsible for oversight through observation and rounds.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jacksboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgeport Medical Lodge | 23.4 mi | ★★★★★ | 5 | 1 |
| Graham Oaks Care Center | 25.5 mi | ★★★★★ | 4 | 2 |
| Avir At Graham | 26.1 mi | ★★★★★ | 15 | 0 |
| Advanced Rehabilitation And Healthcare Of Bowie | 28.4 mi | ★★★★★ | 2 | 0 |
| Palo Pinto Nursing Center | 29 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.