Inspection·September 10, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/09/25 indicated he was a [AGE] year-old-male admitted on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, hallucinations and anxiety disorder. Record review of Resident #50's quarterly MDS assessment dated [DATE] indicated he had a BIMS of 3 which indicated that he was severely impaired of cognition. The assessment indicated Resident #50 diagnoses of Alzheimer's disease and received an antidepressant and antipsychotic medication received during the last 7 days. Record review of Resident #50's Care plan updated 09/08/25 indicated he had impaired cognition, refused care and had a communication problem, and had difficulty understanding some verbal content related to Alzheimer's disease and dementia. The care plan indicated Resident #50 had a fall on 03/20/25, he was knocked down by a bedside table pushed into him by his roommate. The care plan did not indicate any other behavior problems. Record review of Resident #50's nursing note dated 03/20/25 indicated Resident #50 received a skin tear to left upper arm. During an observation and interview on 09/08/25 at 12:20 pm, Resident #50 was sitting in a chair and denied any residents were rough, hit or pushed him. Resident #3 denied he pushed or hit Resident #50 with a bedside table or anything. Record review of the investigation worksheet for Resident #3's dated 03/20/25 indicated the allegation was made on 03/20/25 at 3:00 p.m. and was reported to state on 03/20/25 at 4:32 p.m. Record review of Resident #3's Provider Investigation Report dated 03/20/25 indicated a resident-to-resident altercation in which Resident #3 pushed a bedside table into Resident #50 causing a skin tear and Resident #50 to fall to the floor. The findings indicated inconclusive for the allegation of abuse. Investigation Summary indicated the intent of Resident #3 was not to hurt Resident #50 by pushing the table out of the way, but pushing the table caused Resident #50 to fall and resulted in a skin tear. Resident #3 was monitored one on one with documentation every 15 minutes until discharged from the facility to inpatient hospice. During an interview on 09/08/25 at 11:45 a.m., LVN A said she was providing care for Resident #3 and #50 today and she witnessed the incident between the residents on 03/20/25. She said on 03/20/35 she was sitting in the nurse's office looking at them. LVN A said Resident #50 was inside the room in her view with a rolling bedside table in front of him and Resident #3 was standing in front of him just talking. She said there was no yelling, arguing or aggression. She said there was no indication anything was wrong. LVN A said Resident #3 told Resident #50 he was looking for his suitcase, I know you took it and pushed the rolling bedside table into Resident #50 causing a skin tear and fall. She said there were no previous or prior incidents. LVN A said she immediately separated them, Resident #3 was immediately placed on one-on-one monitoring with documentation of every 15 minutes but watched constantly. LVN A said she provided wound care to Resident #50 and had him x-rayed with results of no fractures. She said Resident #3 was sent to the behavior hospital the next morning. LVN A said she was educated on abuse and neglect and notified the Administrator immediately. During an interview on 09/10/25 at 10:30 a.m., the DON said her expectation was all residents be free from abuse and neglect. She said all staff had been educated frequently on abuse and neglect and elopement prevention. She said related to the incident with Resident #3 and #50 there was no sign of a problem, no urinary tract infection or lab problems, or no new medication that could have caused behaviors. She said the residents had no prior signs or symptoms that would lead us to suspect an incident and no triggers or suspected behavior that could lead up to an incident. The DON said there was no way we could have predicted an incident would happen between these roommates. She said we addressed the situation, removed Resident #3 and monitored him one on one until he was sent to the hospital. The DON said when Resident #3 returned to the facility he had a different roommate. She said Residents #3 and #50 have not had any incidents since. During an interview on 09/10/25 at 10:45 a.m., the Administrator said her expectation was all residents be free (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 2 of 9 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 09/10/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete from abuse and neglect and stay safe and secure in the facility. She said all staff were educated frequently on abuse and neglect. She said the incident with Resident #3 and #50 was unable to be predicted. She said there no signs of a problem; the residents had no prior incidents or behaviors. She said there have been no incidents since and the residents were no longer roommates. The Administrator said the residents were immediately separated; Resident #3 was placed on one-on-one monitoring until sent to the hospital and Resident #50 was assessed and x-rayed with no fracture. She said the facility investigated the incident, in-serviced staff, interviewed staff and residents and notifications as required. The Administrator said there was nothing to predict an incident would happen. Record review of and undated facility policy titled, Abuse/ Neglect indicated, The resident has the right to be free from abuse, neglect, . Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, . 5. Physical Abuse: Includes, hitting, slapping.Resident to Resident The above policy will apply to potential resident-to-resident abuse. Event ID: Facility ID: 675220 If continuation sheet Page 3 of 9 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 09/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #101) reviewed for accidents and supervision. The facility failed to provide adequate supervision for Resident #101 on 05/12/25 when the resident was removed from the secured unit and brought out to the main dining room for an activity. The resident exited the facility through a door that did not alarm and without staff knowledge and was found walking outside the back of the facility walking down a sidewalk. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions which could lead to residents sustaining serious injury or harm. Findings include: Record review of a face sheet dated 09/09/25 indicated Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included catatonic schizophrenia (severe mental condition combined with pronounced psychomotor disturbances) dementia (loss of cognitive functioning), chronic obstructive pulmonary disease (lung disease that causes difficulty breathing by blocking airflow from the lungs), hemiplegia (paralysis of one side of the body associated with varying degrees of abnormal muscle tone, impaired sensation, visual impairment and loss of movement control on the affected side) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS, dated [DATE], indicated Resident #101 had a BIMS score of 3 indicated severely impaired cognition and cognitive patterns of inattention and disorganized thinking continuously. Diagnoses were dementia, schizophrenia, anxiety, and chronic obstructive pulmonary disease. The assessment indicated Resident #101 wandered 1 to 3 days of the look back period and was independent of sitting to stand and walking 150 feet in a corridor or similar space. Record review of Resident #101's care plan, with a target date of 12/04/25, indicated Resident #101 was at risk for wandering related to impaired safety awareness and required secure unit placement due to being a wander threat, elopement risk, disorientation and impaired safety awareness. The care plan indicated Resident #101 had an actual elopement attempt; he wandered outside the facility unattended initiated on 05/12/25. Resident #101's care plan interventions included resident will reside in the secure unit. Record review of Resident #101's Elopement Risk assessment dated [DATE], indicated Resident #101 was a high elopement risk and resided on a secure unit. Record review of a progress note dated 05/12/25, LVN G indicated it was reported to the DON that Resident #101 was brought off the secured unit to attend a facility activity in the dining room and when staff were returning residents to the unit Resident #101 was not readily available. The progress note indicated staff immediately made a thorough search of the facility and surrounding premises and noted Resident #101 walking along the sidewalk. Resident was returned to the secure unit with no injury or pain noted. The progress note indicated a family member and physician were notified Resident #101 had wandered outside unsupervised. Record review of an Event Nurses' Note Elope or Attempt dated 05/12/25 indicated Resident #101 was brought off the secured unit to attend a facility activity in the dining room and when staff was returning residents to the secured unit, Resident #101 was not readily available. The note indicated staff immediately made a thorough search of the facility and surrounding premises and noted the resident outside the facility walking along the sidewalk. Resident was returned to the secured unit. The note indicated he exited the left side dining room door, was missing less than 5 minutes, and was discovered on the sidewalk at the left side rear of the building. The note indicated Resident #101 was cognitively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 4 of 9 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 09/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few impaired, wandered, and required cueing and acquired no injury. Record review of the investigation worksheet for Resident #101's dated 05/12/25 indicated the allegation was made on 05/12/25 at 3:00 p.m. and was reported to state on 05/12/25 at 5:14 p.m. Record review of Resident #101's Provider Investigation Report dated 05/12/25 indicated the nursing facility was hosting a carnival in the dining room. Several residents from the Secured unit were brought out to enjoy the festivities. Resident #101 was sitting on the left side of the dining room with several residents from the secure unit. Resident #101 was not at the table. The facility began a search and called code orange. The DON located Resident #101 as he was walking on the sidewalk. She asked why he was outside and his response was not clear, but the DON walked Resident #101 back inside with no hesitation. Resident #101 was assessed with no injury or pain. The investigation summary indicated Resident #101 was outside for 1-2 minutes at most. Resident 101 was returned to the Secured unit and not noted exit seeking. The facilities findings were inconclusive. Staff were in-serviced on Elopement prevention, Elopement prevention of secured unit resident attending activities away from the secured unit, Resident Rights, Abuse/ Neglect, color code system, no alarms are to be turned off and no doors propped open, demonstration for operation of doors in dining room and secured unit. The facility performed environmental rounds, reviewed Resident #101's care plan and MDS. The facility notified the family, physician, ombudsman and HHSC. A new mag-lock keypad alarm system was installed on exit door on left side of dining room and the Incident was presented during QAPI. Record review of Resident #101's Elopement Risk assessment dated [DATE], indicated Resident #101 was a high elopement risk, resided on a secure unit and had an elopement attempt. During an interview on 09/08/25 at 11:55 a.m., CNA L said on 05/12/25 CNA Y took Resident #101 out to the carnival and left him with a nurse. She said she was unsure which nurse. She said she was taking her dirty laundry barrel out to the end of Hall 200 to laundry and as she passed the dining room, she saw Resident #101 sitting at the table in front of the window in the dining room about 8 to 10 steps from the door to exit the dining area to the outside of building. CNA L said she took her barrel to the laundry at the end of Hall 200 when she came back, Resident #101 was not sitting in his chair and she asked the DON where Resident #101 was. She said she notified the Administrator who called for a Code Orange and she went down Hall 200 and exited to the left. CNA L said Resident #101 was brought back to the secured unit and started on q 15-minute checks for a few days. She said Resident #101 wandered but did not push on the doors. CNA L said the secured unit residents now attend activities on the unit only. During an Interview on 09/08/25 at 1:55 p.m., the AD said it was nursing home week, and the facility was having a carnival in the dining room on 05/12/25. She said she and the ADON went to the secured unit and chose 3 appropriate residents from the unit to enjoy the carnival. She said she was taking pictures of residents when she saw CNA Y bring Resident #101 into the carnival. The AD said she assisted the 3 residents from the secured unit playing games and did not see Resident #101 exit the facility. She said the last time she saw Resident #101 CNA Y was with him. The AD said when she was returning the 3 residents from the secured unit back to the unit, she asked CNA Y if Resident #101 was back there, and CNA Y said she had left him at the carnival. The AD said she immediately notified the Administrator to call a Code Orange, but the DON had already found and returned him into the building. The AD said CNA Y did not ask her to monitor Resident #101 before she left him. The AD said the residents on the secured unit were now enjoying on the unit activities at this time. She said after the incident, she was educated on abuse/ neglect, resident rights, and elopement prevention. She said she was educated on removing secured unit resident off the secured unit to include notifying the charge nurse when staff removed the resident from the unit, stay with them the whole time, and notifying the charge nurse when the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 5 of 9 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 09/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few returned to the unit. The AD said if a resident eloped, she would notify the charge nurse, the DON, the Administrator and whole team, a Code Orange would be announced, and everyone would start looking for the missing resident inside and outside. The AD said she would start looking where the resident was last seen and spread out including resident rooms, closets, bathrooms in every room, the kitchen, and outside of the facility. During an interview on 9/8/25 at 3:50 p.m., CNA Y said she was educated on abuse/ neglect, resident rights and elopement prevention on hire. She said after the incident she was educated if a resident eloped, she would notify the charge nurse, a Code Orange would be called, and everyone would start looking for the resident inside and outside of the facility. She said she had been there 2 weeks when the incident with Resident #101 happened. She said a carnival was going on in the main dining room off the secured unit and some staff had come to the unit and asked if any residents wanted to go to the carnival. CNA Y said Resident #101 wanted to go, so she told LVN G on the secured unit at the time and she said to take him to the carnival, but she would have to come back to the unit. She said she and Resident #101 stayed in the main dining room for about 15 to 20 minutes and she handed him over to the ADON. CNA Y said, I asked the ADON do you have him I have to go back to the Unit. I had to say do you have him twice before she agreed. She said the ADON took a picture of Resident #101 and then CNA Y said she left Resident #101 sitting at a table by himself. She said after she returned to the secured unit, within a few minutes, she heard a Code Orange called. CNA Y said she believed the alarm was disabled on the door to exit the dining room and Resident #101 walked out the door and was found on the driveway behind the building. CNA Y said she verified with the ADON twice before she left Resident #101. She said when she left the carnival area, the ADON was taking Resident #101 to get popcorn. During an Interview on 09/08/25 at 3:40 p.m. the ADON said it was nursing home week and on 05/12/25, the facility was having a carnival in the main dining room. She said she and the AD went to the secured unit and chose 3 appropriate residents to come off the unit to enjoy the carnival. She said she noticed Resident #101 was in the dining room with CNA Y who was a new CNA to the facility. She said during the event she gave Resident #101 some popcorn while he was at the table at the corner of the main dining room with CNA Y with him. The ADON said when the residents from the secured unit were being taken back to the secured unit, she noticed Resident #101 was not there. The ADON said a Code Orange was called, and Resident #101 was found outside the back of the building. She said she was aware CNA Y said she left Resident #101 with her but she said she did not accept supervision of Resident #101 from CNA Y; she already was monitoring 3 residents from the secured unit that were chosen due to appropriateness to be removed from the secured unit. She said CNA Y did not ask her to monitor Resident #101. The ADON said the DON found Resident #101 and returned him to the unit, but she was not sure how long he was missing. She said the secured unit residents were now only attending activities on the secure unit and not leaving the unit for activities at this time. She was educated on abuse/ neglect, resident rights, elopement prevention, the procedures for removing residents from the secured unit, and on demonstration of operating the doors of secured unit and dining room exit doors, to remain locked and alarmed at all times. She said if a resident eloped, she would notify the charge nurse, the DON, the Administrator, a code orange would be announced, and everyone would start looking for the missing resident inside and outside of the facility. During an Interview on 09/08/25 at 3:35 p.m., the Maintenance Director said on 05/12/25 he was outside of the facility right outside Hall 100 talking to a painter and heard the DON outside. He said he then saw Resident #101 walking down the sidewalk behind the facility at the side of the building and the DON met Resident #101 and walked him back into the facility. He said before and after the incident he was educated on abuse/neglect, resident rights, and elopement prevention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 6 of 9 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 09/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 09/08/25 at 5:25 p.m., the DON said she was down Hall 100 and ran out hall 100 exit door and toward the back of the building, she reached the driveway in the back of the building, she could see Resident #101 on the sidewalk and called for the Maintenance Director to get to him. She said the Maintenance Director was standing at the end of Hall 100. She said she ran past the Maintenance Director and met Resident #101 and walked him around the building and entered through the end of Hall 100. The DON said Resident #101 was outside the back of the building about 45 steps from the external exit door of kitchen. She said he walked out the door by the left side of the kitchen. She said a new keypad was installed on 05/12/25 to the dining room and new alarms on both exit doors. The DON said she sat in the kitchen all day on 05/12/25 with her laptop monitoring the exit doors to the dining room until the lock was installed and both door alarms were functioning. The DON said the facility had only on the secured unit activities at this time. She said she in-served staff on elopement prevention and resident rights before and after the incident. She said she in-serviced staff on doors not to be propped open and no alarms to be turned off after the incident. The DON said CNA Y did not come back to the facility after the incident and self-termed. The DON said she was unable to do a one-on-one training with CNA Y. The DON said she in-serviced all staff including ADON on the process of bringing residents off the secured unit, if they remove a resident from the unit they notify the charge nurse before and when they return the resident to the secured unit and to stay with the resident at all times when the resident was off the secured unit. During an interview on 09/08/25 at 3:45 p.m., HR said CNA Y no longer worked at the facility and she self-terminated after the incident on 05/12/25. During an interview on 09/08/25 at 5:00 p.m., the Administrator said on 05/12/25, she was notified Resident #101 was missing and she called a Code Orange. She said the DON ran down Hall 100 and out of Hall 100's exit door toward the back of the building and found Resident #101 on the sidewalk about 45 steps from the door by the kitchen at the back of the building. She said they determined the left side dining room exit door did not alarm when Resident #101 went out of it while at the carnival. She said the resident was found within 1 to 3 minutes and was about 20 feet from the Maintenance Director and a painter who were looking at the building roof. The Administrator said after the incident, they installed a new keypad on the left door to the dining room and new alarms on 05/12/25. She said the facility would do activities directly on the unit with residents who resided on the secured unit. The Administrator said the facility in-served staff on elopement prevention, alarms, doors not to be propped open, resident rights, no alarms to were to be turned off and if they removed a resident from the unit, they were to notify the charge nurse before and upon returning the resident to the unit. While off the unit, staff were instructed to stay with the resident at all times. She said she thought the alarm had malfunctioned. During an observation and interview on 09/08/25 at 12:05 p.m., Resident #101 was in his room on the secured unit lying in bed. He was confused and only able to answer simple questions. Resident #101 said he did not remember going outside on carnival day. During an observation on 09/08/25 at 3:15 p.m., with the Administrator the dining room exit doors were tested. The left side of the dining room exit to the outside door was pressed on the door and held for 15 seconds, the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside of the facility opened with a loud alarm after pushing on the door. During an observation on 09/09/25 at 2:00 p.m., residents in the main area were participating in BINGO. There were no residents from the secured unit participating in BINGO off the secured unit. During an observation on 09/09/25 at 3:45 p.m., the left side of the dining room exit door to the outside was pressed and held for 15 seconds, and the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 7 of 9 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 09/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few opened with a loud alarm on pushing door. During an observation on 09/10/25 at 8:00 a.m., the left side of the dining room exit door to the outside was pressed and held for 15 seconds, the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside opened with a loud alarm on pushing door. During an Interview on 9/10/25 at 8:30 a.m., LVN G said on 05/12/25 she was the charge nurse responsible for the secured unit the day Resident #101 got out. She said CNA Y, a new CNA, took Resident #101 to an activity off the unit. She said she was unaware Resident #101 had left the unit until the facility staff started looking for him, but he was found within minutes. She said a Code Orange was called. LVN G said she was educated on abuse/ neglect, resident rights, elopement prevention and removing secured unit resident off the secured unit before and after the incident. During an interview on 09/10/25 at 10:30 a.m., the DON said her expectation was all residents be free from abuse/ neglect and stay safe and secure in the facility. She said all staff have been educated frequently on abuse/ neglect and elopement prevention. She said they now re-educate monthly on abuse/ neglect and elopement prevention. During an interview on 09/10/25 at 10:45 a.m., the Administrator said her expectation was all residents be free from abuse/ neglect and stay safe and secure in the facility. She said all staff have been educated frequently on abuse/ neglect and elopement prevention. Record review of an undated facility policy, titled Elopement Prevention indicated, .Every effort will be made to prevent elopement episodes while maintaining the lease restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The resident's care plan will be modified to indicate that the resident is at risk of elopement episodes.7. If a resident is discovered to be missing, a search shall begin immediately. Intervention Strategies .keypad exit magnetic locks, Keyed Alarms, Secured Unit.Staff will receive training during their orientation process and then annually regarding Elopement prevention. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., 7 LVNs (4 days and 3 from nights shift- LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G), 2 RNS, RN H and RN J were educated on abuse/neglect, resident rights, elopement prevention, removing secured unit residents off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON, Administrator, a code orange would be announced, and everyone would immediately start looking for the missing resident inside and outside the facility. They said during the search all resident rooms, closets, bathrooms and all other rooms were searched, including outside the facility. They said the responsible party, physician, ombudsman and HHSC were notified. If the resident was not found the police would be notified. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., 16 CNAs (from each shift- CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA T, CNA U, CNAV, CNA X, CNA Z, CNA HH) were educated on abuse/ neglect, resident rights, elopement prevention, removing secured unit residents off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON and Administrator and a code orange would be announced. They said everyone would immediately start looking for the missing resident inside and outside the facility. They said all resident rooms, closets, bathrooms and all other rooms were searched. They said outside area around the facility would also be searched. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., HR, DM, [NAME] AA, Dietary Aid BB, Dietary aid GG, Maintenance director, Laundry CC, HK Supervisor, HK DD, HK DD, HK EE, Floor Tech FF were educated on abuse/ neglect, resident rights, elopement prevention, removing a secured unit resident off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON and Administrator and a code orange would be announced. They said everyone would immediately start looking for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675220 If continuation sheet Page 8 of 9 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 09/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete missing resident both inside and outside the facility. They said the search would include all resident rooms, closets, bathrooms and all other rooms were searched. They said the outside the facility would also be searched. Record review of an in-service sign in sheet titled, No Alarms are to be turned off and no doors are to be Propped Open dated 05/12/25 for department Maintenance indicated 1 staff member Maintenance Director signature. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) in the dining room dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) on the secure unit dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for policy on Color code program dated 05/12/25, indicated it was important to know the color code when an emergency happened, and code orange indicated a resident elopement. 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for new policy on Elopement Prevention (Secured Unit Residents attending Activities away from the Secured Unit), dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of an AD Hoc QAPI Contributors form, dated 05/12/25, indicated there was a meeting held on 09/15/25 consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, Laundry Worker CC, Rehab Director and BOM. The following interventions were put in place: New Policy: Elopement Response. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/2025. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 675220 If continuation sheet Page 9 of 9