Inspection·September 11, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #48 on discharge. She said when Resident #48 discharged floor nurses did not complete the discharge summary. She said that was before the change in management companies. The ADON said she was not responsible for completing the discharge summary for Resident #48. During an interview on 09/11/24 at 12:10 p.m., the DON said at the time of Resident #48's discharge on [DATE] she was on vacation and RN A was responsible for ensuring discharge summaries were completed and signed by the physician. She said at that time the policy was the medical records person, was responsible for opening the discharge summary in the computer system and notify the IDT (interdisciplinary team) of a discharge and the IDT were responsible for completing their sections and then physician came in and signed the discharge summary in the system within 20 days. She said as of 07/01/24 they had a change in management and the staff and physicians were unable to access the old computer system. The DON said Resident #48 should have had a completed discharge summary, she said all residents discharged home should have a discharge summary completed. She said the IDT was responsible for ensuring the discharge summary was completed. The DON said the risk for the resident with a discharge summary not completed and signed by the physician was potential improper education or instruction given to the resident at the time of discharge and a potential delay in care or treatment. The DON said her expectation was she would be trained next week on the requirements of discharge summaries. Attempted phone interview with RN A on 09/11/24 at 12:20 p.m., with no return call or answer. Attempted phone interview with medical records person on 09/11/24 at 12:24 p.m., with no return call or answer. During an interview on 09/11/24 at 12:30 p.m., the Administrator said the DON was now responsible for completing the discharge summary and ensuring the physician signed it. She said the ADON would now be her back up to ensure the discharge summary was completed and signed by the physician. She said the DON and ADON would be educated on the completion and signature by physician for discharge summaries this week. She said Resident #48 should have had a discharge summary completed and they were completing a 100% audit of all discharges for June 2024. She said there was a change in management on 07/01/24 and the staff were unable to access the previous records. She said the resident risk of a discharged resident with an incomplete discharge summary not signed by the physician was a Resident may not receive continued proper care. She said her expectation was all discharge summaries be completed timely. Record review of a facility policy titled, Discharge Summary/ Discharge Plan effective before 7/1/24 dated 2015 indicated 1. The entire discharge summary will be completed with each resident that discharges regardless of where they discharge to, or if they expire in house. For electronic discharge summaries, once completed, the DC summary will be printed on blue paper, a white copy made to be placed in the medical record and the original will be sent out for physician's signature. The white copy will remain in place until the signed original returns. Record review of a facility policy effective after 07/01/24 titled, Discharge Summary/ Discharge Plan dated 2015 indicated1. The entire discharge summary will be completed with each resident that discharges regardless of where they discharge to, or if they expire in house. For electronic discharge summaries, once completed, the DC summary will be printed on blue paper, a white copy made to be placed in the medical record and the original will be sent out for physician's signature. The white copy will remain in place until the signed original returns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 2 of 4 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 09/11/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings included: During an interview on 09/9/24 at 8:30 a.m., the DM said she had taken her food handler test, however had not been sent to classes for certified dietary manager. She said the company had talked about sending her for certification classes but did not send her to classes. She said she had worked as the Dietary Manager for almost a year. During an interview on 09/11/24 at 10:00 a.m., the Administrator said she had tried to send the DM to become certified and the class was canceled. She said the next class would be in February 2025. The Administrator said she was trying to help the DM become certified. During an interview on 09/11/24 at 12:30 p.m., the HR staff said the DM was not certified and thought she had been hired as the DM about a year ago was rehired by their new managing company. The HR staff said the Administrator had tried to send the DM to class and said the class was canceled. Record review of an email addressed to the Administrator dated 09/11/24 indicated the dietary manager class would be February 22, 2025. Record review of a list provided by HR staff dated 09/11/24 indicated the DM was hired on 04/22/21, then promoted to DM on 09/15/23. The HR staff said the Administrator had tried to send the DM to class and said the class was canceled. Record review of training indicated the dietary manager had completed a food handler for DM and had 8 hours of training dated 09/10/23. Record review of the undated job description indicated Clinical Dietary Manager The following is a non-exhaustive criteria that relates to the job of clinical dietary manager, and it is consistent with the business needs of the facility. These are legitimate measure of the qualifications, and are related to the functions that are essential to the job of a Clinical Dietary Manager. Base Knowledge: Must obtain and maintain Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP) credential from ANFP (Association of Nutrition and Foodservice Professionals). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 3 of 4 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 09/11/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. Residents Affected - Many The facility did not ensure the gas stove, and the convection ovens were in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner. Findings included: During an observation and interview on 09/09/24 at 7:50 a.m., [NAME] A turned on the burners on the stove. 2 of 6 burners did not light using their pilot lights and she picked up a long lighter and lit pilot. She turned the burners on and the burners lit. She said occasionally the pilot lights go out and we must light the pilots . She said the DM knew about the pilot lights going out. During an interview on 09/10/24 at 2:00 p.m., the Administrator said the portable AC in the kitchen might have blown out the pilot lights, but she would have the maintenance supervisor to check on the pilot lights. During an interview on 09/11/24 at 12:55 p.m. the DM said the pilot lights would have to be lit occasionally for the last month, but her staff knew to watch for the pilot lights and to light if needed. She said the pilot lights going out might have been related to the portable AC units. During an interview on 09/11/24 at 1:00 p.m., the Maintenance Supervisor said he would go to the kitchen and clean the pilot lights. He said the staff had not reported the pilot lights not being lit. He said the equipment should be in good working order and if not, the burner might not work as required. The maintenance supervisor said some pilot lights will leak small amounts of gas, and some do not, he said he was new and was unsure what type of pilots were on the stove. He said he would check the burners. Record review of the Preventive Maintenance dated March 2003 indicated The facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 4 of 4