Avalon Place Kirbyville

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 15 residents (Resident #48) reviewed for respiratory care. The facility failed to change the oxygen reservoir weekly for Resident #48. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 4 resident personal refrigerators reviewed for food safety (Resident #46). The facility failed to ensure the refrigerator for Resident #46 did not contain a greenish/black substance in the freezer section. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 14 residents (Resident #49) reviewed for infection control practices. The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #49's isolation room with clostridium difficile (bacteria that causes infection in the large intestine). This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (12/1/25 and 12/2/25) for nurse staffing posting. The facility failed to post the required current daily staffing information on 12/1/25 and 12/2/25. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #50) reviewed for resident abuse. The facility failed to ensure Resident #50's was free from physical abuse when Resident #3 pushed a rolling bedside table into his roommate Resident #50 causing a skin tear and Resident #50 to fall to the ground on 03/25/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on interviews and record review the facility failed to ensure that when the facility anticipated discharge, a resident must have a discharge summary that included, but was not limited to, the following: A recapitulation of the resident's stay that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 residents reviewed for discharge summary (Resident #48). The facility did not furnish a completed and physician signed Discharge Summary at the time of discharge for Resident #48. These failures could place discharged residents at risk for a lack of continued care and services.

Inspectors wroteBased 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) -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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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) * 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for advanced directives. (Resident #7). - The facility did not have a valid OOH-DNR for Resident #7. This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased 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) 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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) 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.

Inspectors wroteBased 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. -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.