Inspection·August 23, 2023

F 0578 -#3 Witness Section had no date when it was signed by the 2nd witness signature. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/22/23 at 02:08 p.m. the DON said the OOH-DNR was incomplete like it was. She said the resident would be a full code because the OOH-DNR was null and void. She said it was hers and nursing responsibility to ensure the OOH-DNR was complete and accurate to be valid. Residents Affected - Few Record review of the Out-of-Hospital Do-Not-Resuscitate Order nstructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, managing conservator, or a qualified relative, the guardian, agent, a qualified relative, or parent of a minor child may execute the OOH-DNR Order by signing and dating it in Section B . In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in section B. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 2 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for 1 of 6 residents reviewed for PASRR (Resident #3) Residents Affected - Few The facility did not have an accurate PASRR level 1 screening for Resident #3. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 08/21/23 indicated Resident #3 admitted [DATE], and readmitted [DATE] was an [AGE] year-old female, with diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) and anxiety (intense, excessive, and persistent worry and fear about everyday situations) Record review of PASRR level 1 screening completed by the transferring facility dated 05/15/22 indicated Resident #3 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record from 05/18/22 through 8/21/23. Record review of an annual MDS dated [DATE] indicated Resident #3 had a BIMS score of 11 indicating she had moderately impaired cognition, was negative for PASRR, and had a diagnosis of depression and received medication for depression 7 of 7 days. Record review of a care plan revised 03/21/23 indicated Resident #3 was currently taking psychotropic medication for depression and anxiety and required monitoring for side effects, behaviors, and mood problems. Record Review of physician orders dated August 2023 indicated Resident #3 had a diagnosis of major depressive disorder. The orders indicated Resident #3 was prescribed Remeron (an antidepressant medication) 15 mg daily for major depressive disorder with a start date of 02/26/23; sertraline (a medication to treat depression and anxiety) 100 mg at bedtime for depression related to major depressive disorder with a start dated of 02/26/22; and buspirone (an antianxiety medication) 10 mg three times a day for anxiety with a start date of 07/18/23. During an interview on 08/21/23 at 2:06 p.m., the MDS nurse said she was responsible for PASRR forms. She said when the facility had a social worker the social worker would help with PL1s. She said no one double checked the PASRR forms. The MDS nurse said she received education on PASRR including webinars and training with the most recent training in May or June 2023. The MDS nurse said Resident #3's PL1 was negative and should have been corrected. She said it was missed. The MDS nurse said she reviewed the residents' admission documentation and diagnoses to ensure the PL1s were correct. She said the risk of an incorrect PL1 was a resident may not receive needed services. During an interview on 08/21/23 at 2:12 p.m., the DON said Resident #3's PL1 was negative and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 3 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should have been positive. She said it was just missed. The DON said the MDS nurse was responsible for PASRR forms. She said the MDS nurse was educated on completing PASRR forms. The DON said her expectation was PASRR form be completed correctly and timely. She said the risk of an incorrect PL1 was a resident could miss needed services. During an interview on 08/22/23 at 12:14 p.m., Corporate Nurse F said the facility did not have a policy on PASRR, they followed best practice and the RAI. During an interview on 08/22/23 at 2:30 p.m., the administrator said the MDS nurse was responsible for making sure the PL1 was correct and uploaded into the system. She said her expectation was for all residents to receive the required services. She said Resident #3's PL1 was just missed. The administrator said she expected PASRR forms to be completed timely and correctly. She said the potential risk was a resident might not receive services they deserved. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 4 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to have a final summary of the resident's status at the time of the discharge that is available for release to authorized persons for 1 of 3 residents reviewed for discharge summary (Resident #50). The facility did not have a physician signed Discharge Summary within 20 business days after Resident #50 discharged from the facility and did not return. This failures could place discharged residents at risk for a lack of continued care and services. Findings included: Record review of the face sheet printed 08/23/23 indicated Resident #50 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), benign neoplasm of cerebral meninges (non-cancer tumor that arises from the membranes that surround the brain), obstructive hydrocephalus (any condition that blocks the flow of fluid in the brain or spinal cord), hypertension (elevated/high blood pressure), and convulsions (burst of uncontrolled electrical activity between brain cells). The face sheet also indicated he was discharged to the hospital on [DATE]. Record review of Nurse Notes indicated on 06/07/23 Resident #50 had with issues of penile swelling and pus drainage; he had an elevated potassium level of 6.9; and the physician ordered the resident to be sent to the hospital for evaluation. The ambulance arrived and the resident was sent to the hospital due to lab values. Record review of the EMR indicated Resident #50 had a Discharge Summary with effective date of 06/07/23. The form had no information filled out on it and was not signed by the physician. During an interview on 08/23/23 at 12:15 p.m. the DON said she and the MR staff were responsible for filling out the Discharge Summary reports and either sending or taking over to the physician office for him to sign. She said Resident #50 was sent and admitted to the hospital on [DATE]. She said when she reviewed Resident #50's Discharge Summary it was blank and so she filled it out today and it was taken to the physician for him to sign. According to the Texas Administration Code §554.1202(4) The physician must: (4)write, sign, and date a physician's discharge summary within 20 working days of being notified by the facility of the discharge, except as specified in §19.1912(e) of this title (relating to Additional Clinical Record Service Requirements), if the resident has been temporarily discharged for 30 days or less, and readmitted to the same facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 5 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 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, and the residents' goals and preferences for 1 of 13 residents reviewed for respiratory care and services. (Resident #29) Residents Affected - Few The facility failed to administer the correct dose of oxygen to Resident #29. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated August 2023 indicated Resident #29, admitted [DATE], was [AGE] years old with a diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood adequately). The orders indicated the resident received oxygen at 3 liters per minute via nasal cannula continuously effective 05/01/22. Record review of the most recent MDS assessment dated [DATE] indicated Resident #29 was alert, oriented with a BIMS of 9 (indicates moderate cognitive impairment) and received oxygen therapy in the last 14 days. Record review of a care plan updated 08/02/23 indicated Resident #29 was short of breath with exertion/activity secondary to congestive heart failure. One of the interventions was to administer oxygen at 3L NC continuously. During the following observations, Resident #29's oxygen was administered at 4.5L NC. The resident's speech was garbled and was not comprehensible for interview. *on 08/21/23 at 9:43 a.m., *on 08/21/23 at 11:55 a.m., *on 08/22/23 at 9:35 a.m., *on 08/22/23 at 3:11 p.m., and *on 08/23/23 at 9:42 a.m. During observation and interview on 08/23/23 at 9:42 a.m., after observing Resident #29's oxygen setting, LVN C said Resident #29's oxygen was in progress via NC at 4.5 L NC. She said the resident's oxygen should be set at 3L NC and the resident received the incorrect dose of oxygen. She said she was responsible for checking to ensure the resident received the correct dose, but she had not checked it. She said the possible negative outcome of the resident receiving oxygen at 4.5L could be the resident would receive too much oxygen and it would cause increased confusion. During an interview on 08/23/23 at 10:00 a.m., the DON said her expectations were for the oxygen to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 6 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete be administered as prescribed. She said administering too high of a dose of oxygen could cause Resident #29 to become dependent on it. She said it was the charge nurses' responsibility to check the resident's oxygen dosage to ensure they received the correct dose, and they should be checking it every shift. Record review of an Oxygen Administration policy revised October 2010 indicated: . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Event ID: Facility ID: 675220 If continuation sheet Page 7 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0759 Ensure medication error rates are not 5 percent or greater. 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 a medication error rate of less than 5 percent. There were 4 errors out of 30 opportunities, resulting in an 13.33% percent medication error involving 2 of 4 residents reviewed for medication pass. (Residents #43 and #18) Residents Affected - Some -LVN B failed to administer 2 scheduled medications (Metoprolol and Spironolactone) and 1 prn medication (clonidine) (all to treat high blood pressure) as ordered by the physician for Resident #43 -LVN C did not administer 1 scheduled medication (ascorbic acid 500mg) (used to treat wound healing) as ordered by the physician for Resident #18. This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life. Findings included: 1. Record review of the face sheet dated indicated Resident #43 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain (stroke)), hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), convulsions (burst of uncontrolled electrical activity between brain cells), and atrial fibrillation (a type of irregular heartbeat). Record review of an MDS dated [DATE] indicated Resident #43 had moderately impaired cognition with a BIMS score of 08 out of 15 and had diagnoses of hypertension and stroke. Record review of a care plan reviewed on 04/29/23 indicated Resident #43 was at risk for complications related to hypertension and included interventions of give medications as ordered and monitor/document/report prn any headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, or difficulty breathing (signs/symptoms of elevated blood pressure). During an observation and interview on 08/22/23 (Tuesday) at 07:27 a.m. LVN B administered medications to Resident #43. Prior to administering his medications she obtained vital signs of BP and P. She said his BP was elevated at 231/180 (normal BP level was 120/80). She then obtained his medications and administered hydralazine (medication used to treat high blood pressure) 50mg, Losartan (to treat high blood pressure) as well as his other medications and administered them with a glass of water. She did not ask the resident any questions about how he was feeling or anything else. Record review of the August 2023 physician order summary on 08/22/23 at 11:45 a.m. indicated Resident #43 was to also receive medications to help treat high blood pressure to include: Metoprolol 75 mg at 08:00 AM; Spironolactone 25 mg on Tuesdays, Thursdays, and Saturdays on Day; and a prn order for Clonidine 0.1 mg every 8 hours prn for BP 170/90 or greater. During a record review and interview on 08/22/23 at 11:55 a.m. with LVN B and the DON the August 2023 MAR for Resident #43 indicated he was to receive Metoprolol 75 mg at 08:00 AM, Spironolactone 25mg was to be administered on 08/22/23 on Day, and Clonidine 0.1 mg every 8 hours as needed for BP 170/90 or greater; there was no indication the medications were administered by LVN B. LVN B said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 8 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asked Resident #43 if he wanted his prn medication and he said no. The DON said a resident should not be asked if they want a prn blood pressure medication because the medication should be administered if the parameters warrant it to be given. 2. Record review of the face sheet dated 08/22/23 indicated Resident #18 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (elevated/high blood pressure), vitamin deficiency, and gastroesophageal reflux disease (GERD) stomach contents leak backward from the stomach into the esophagus (food pipe)). Record review of an MDS dated [DATE] indicated Resident #18 had moderately impaired cognition with a BIMS score of 08 out of 15 and had diagnosis of vitamin deficiency. Record review of a care plan dated 03/08/23 indicated Resident #18 had vitamin deficiency with interventions including to give medications as ordered. During an observation and interview on 08/22/23 at 08:10 a.m. LVN C administered medications to Resident #18. Prior to administering her medications she obtained vital signs of BP and P. She said her BP was low at 94/42. She said because Resident #18's BP was below the parameters to administer the blood pressure medications she was to hold them.She then administered aspirin 325mg, Ducolax 5mg, Calcium 600mg + Vitamin D 5mcg, Cetirizine 10mg, Colace 100mg, Vitamin B12 1000mcg, Famotadine 20mg, Magnesium oxide 400mg, Miralax 17 gm with 5 ounces of water, multivitamin with minerals, Protonix 20mg, sodium chloride 1 gm, Vitamin D3 125mcg, zinc 50 mg, and Nitro Bid apply 2 inches to each leg. Record review of the August 2023 physician order summary on 08/22/23 at 11:25 a.m. indicated Resident #18 was to receive the medications administered by LVN C. The orders also indicated she was to receive ascorbic acid (Vitamin C) 500mg for wound healing. During a record review and interview on 08/22/23 at 11:35 a.m. with LVN C she said there was an order on the August 2023 physician orders dated 07/03/23 for Resident #18 to have ascorbic acid 500mg for wound healing. She said she did not see the ascorbic acid order on the August MAR for Resident #18. Reviewing the EMR MAR LVN C said it listed on the wrong MAR and was missed by the staff including her to administer the medication since the first of August. During an interview on 08/22/23 at 02:06 p.m. the DON said she expected all staff to administer medications as ordered by the physician. She said missed doses of the ascorbic acid ordered for wound healing could result in the wound not healing or worsening. An Administering Medications policy and procedure revised December 2012 indicated Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed In Accordance with Orders: 3. Medications must be administered in accordance with orders, including any required timeframe FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 9 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free from significant medication errors for 1 of 2 residents (Resident #43) reviewed for significant medication errors. Residents Affected - Few -LVN B failed to administer 2 scheduled medications (Metoprolol and Spironolactone) and 1 prn medication (clonidine) (all to treat high blood pressure) as ordered by the physician for Resident #43 when his blood pressure was elevated at 231/180. This failure could place residents at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. Findings included: Record review of the face sheet dated indicated Resident #43 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain (stroke)), hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), convulsions (burst of uncontrolled electrical activity between brain cells), and atrial fibrillation (a type of irregular heartbeat). During an observation and interview on 08/22/23 (Tuesday) at 07:27 a.m. LVN B administered medications to Resident #43. Prior to administering his medications, she obtained vital signs of BP and P. She said his BP was elevated at 231/180 (normal BP level was 120/80). She then administered Hydralazine (medication used to treat high blood pressure) 50mg, Jardiance (to treat elevated blood sugar) 25mg, Eliquis (to treat a type of irregular heartbeat) 5 mg, Keppra (to treat seizures (a burst of uncontrolled electrical activity between brain cells)) 750mg, Losartan (to treat high blood pressure) 100mg, Metformin (to treat elevated blood sugar) 1000mg, and Vitamin D3 (to treat vitamin deficiency) 125mcg with a glass of water. She did not ask the resident any questions about how he was feeling or anything else. Record review of the August 2023 physician order summary on 08/22/23 at 11:45 a.m. indicated Resident #43 indicated Resident #43 was to receive medications to help treat high blood pressure to include: Metoprolol 75 mg at 08:00 AM; Spironolactone 25 mg on Tuesdays, Thursdays, and Saturdays on Day; and a prn order for Clonidine 0.1 mg every 8 hours prn for BP 170/90 or greater. These medications were not administered to the resident. During a record review and interview on 08/22/23 at 11:55 a.m. with LVN B and the DON the August 2023 MAR for Resident #43 indicated there was no indication the Metoprolol, Spironolactone, or Clonidine were administered by LVN B on the eMAR. LVN B said she asked Resident #43 if he wanted his prn Clonidine and he said no. She said she did not realize she missed the Metoprolol and Spironolactone. The DON said a resident should not be asked if they want a prn blood pressure medication when their blood pressure level was elevated and required the medication per orders and parameters. The DON said not administering the blood pressure medications could result in the resident having a stroke or dying. An Administering Medications policy and procedure revised December 2012 indicated Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed In Accordance with Orders: 3. Medications must be administered in accordance with orders, including any required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 10 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0760 timeframe Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 11 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment and not left on top of the medication cart for 1 of 3 medication carts (400 hall medication cart); failed to ensure expired medications were not stored with current medications for 1 of 3 medication carts (200 hall) and 1 of 1 medication room (Secured Unit); and medications of different routes were not stored together for 2 of 3 medication carts (400 hall and Secured Unit) observed for medication storage. -The facility did not ensure the 400 hall medication cart was secured and unable to be accessed by unauthorized personnel, residents, or visitors. -The facility did not ensure medications were not stored on top of the 400 hall medication cart when unattended. -The facility did not ensure expired medications were not accessible and available for use on the 200 hall medication cart and the Secured Unit medication room. -The facility did not ensure medications of different routes were not stored together on the 400 hall medication cart and the Secured Unit medication cart. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used past their effective or expiration date, and drug diversion. Findings include: 1. During an observation on 08/22/23 at 7:27 a.m., LVN B performed FSBS and drew up insulin to administer to Resident #43. LVN B left the 400 hall medication cart outside of the resident room with the drawers facing the hallway, the cart was unlocked, and a vial of Lantus insulin was left on top of the cart while she entered the resident room and administered his insulin. LVN B was in the resident's room with her back to the doorway. LVN B then went back to the medication cart and obtained Resident #43's medications. LVN B again she left the medication cart outside of the resident room with the drawers facing the hallway, the cart was unlocked, and a vial of Lantus insulin was left on top of the cart while she entered the resident room and administered his insulin. LVN B was in the resident's room with her back to the doorway. During an interview on 08/22/23 07:45 a.m. LVN B said she did not think leaving the insulin on top of the cart unlocked was an issue because the medication cart was within her eyesight, and it was at the end of the hall. She said she forgot to lock the cart before walking away from it. During an interview on 08/23/23 at 01:10 p.m., the DON said medications were not to be left on top of medication carts and medication carts were to be locked when staff walked away from them because any confused resident or visitor could access the cart. 2. During an observation and interview on 08/23/23 at 10:50 a.m. of the 200-hall medication cart, the CN indicated there was a card of Allopurinol 100 mg with an expiration date of 05/23/23. The CN said expired medications should not be on the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 12 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 08/23/23 at 01:10 p.m. the DON said expired medications were not to be on the medication carts available for use; they were to be pulled to be destroyed. 3. During an observation and interview on 08/23/23 at 11:15 a.m. of the 400-hall medication cart with the CN indicated there was a box of acetaminophen 650mg rectal suppositories and an enema stored with oral medications. The CN said the rectally administered items should not be stored with oral medications; they should be stored separately. During an observation and interview on 08/23/23 at 11:40 a.m. of the Secured Unit medication cart with the CN indicated a bottle of nitroglycerin oral medication, a box of Exelon topical patches, and a vial of Vitamin B-12 injectable medication were stored together in the top drawer of the medication cart. LVN D said she did not know the medications were not supposed to be stored together on the cart. During an interview on 08/23/23 at 01:10 p.m. the DON said medications of different routes should not be stored together on the medication carts. 4. During an observation and interview on 08/23/23 at 01:55 p.m. of the Secured Unit medication room with LVN D indicated a box of prescribed promethegan suppositories expired 11/2022. LVN D said expired medications should be pulled to be destroyed and not available for use. An Administering Medications policy and procedure revised December 2012 indicated Safety of Medication Cart 16. During administration of medications, the medication cart will be kept closed and locked when out of the sight of the medication nurse of aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to resident or others passing by A Storage of Medications policy and procedure revised April 2007 indicated Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: Unusable Drugs or Biologicals 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed Marking Drugs for External Use/Poisons: 4. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications Orderly Storage and Dispensing: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 13 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain infection control prevention and practices for point of care equipment by 3 of 3 LVNs reviewed for infection control. (LVN A, LVN B, and LVN C) Residents Affected - Some * The facility failed to ensure LVN A, LVN B, and LVN C cleaned and disinfected glucometers appropriately after resident use. This failure could place residents at risk of infections or diseases from blood borne pathogens. Findings included: 1. During an observation and interview on 08/21/23 at 10:55 a.m. LVN A pulled a glucometer out of the top drawer of the medication cart. She cleaned the glucometer with a wipe from a red topped container for less than a minute. She performed a FSBS test on a resident. She then cleaned the glucometer again with the wipe from the red topped container and cleaned the glucometer for less than a minute and placed the glucometer into the top drawer of the medication cart. LVN A said she would not have done anything differently. 2. During an observation and interview on 08/21/23 at 11:20 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. During an observation and interview on 08/22/23 at 07:27 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. 3. During an observation and interview on 08/22/23 at 11:10 a.m., LVN C pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. She then placed the glucometer on top of the medication cart. LVN C said she would not have done anything differently. LVN C said the glucometer was to be cleaned before and after the resident's FSBS was done. LVN C said the glucometer was supposed to be cleaned with an alcohol wipe. LVN C said she had been trained in the proper cleaning/disinfecting of a glucometer but did not remember all the steps to be done or what to clean with. LVN C pulled the red top container (Micro Kill +) on the medication cart out of the bottom drawer. She said the contact time on the container was 2 minutes for most pathogens so the glucometer needed to be cleaned for 2 minutes with the wipe before the next use. During an interview on 08/22/23 at 11:50 a.m., the DON said staff were to use the purple top container of wipes to clean the glucometers. She said staff staff were provided with 2 glucometers on each medication cart so that one was wrapped with the wipe while the other one could be used. She said the glucometers were to be cleaned before and after each resident use. An Obtaining a Fingerstick Glucose Level Policy and Procedure revised December 2011 indicated Equipment and Supplies: .3. Disinfected blood glucose meter (glucometer) Steps in Procedure: 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 14 of 15 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 675220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon Place Kirbyville 700 N Herndon Kirbyville, TX 75956 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice An undated manufacturer guide indicated on page 46 Cleaning and Disinfecting Your Meter and Lancing Device: 4. To clean your meter, clean the meter with one of the validated disinfecting wipes listed below Medline Micro Kill + Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use Event ID: Facility ID: 675220 If continuation sheet Page 15 of 15