A list of the most recent deficiencies for Avalon Place Kirbyville. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-22 | 2023-09-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-23 | 2023-09-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-23 | 2023-09-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-23 | 2023-09-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-23 | 2023-09-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-23 | 2023-09-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-23 | 2023-09-01 | N |
| 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. | Health | 2023-08-23 | 2023-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-23 | 2023-09-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-22 | 2023-08-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-22 | 2023-08-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-04 | 2022-09-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-04 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-04 | 2022-09-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-22 | 2022-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-23 | 2022-06-24 | N |
| 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. | Health | 2022-06-22 | 2022-06-23 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-06-22 | 2022-06-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-22 | 2022-06-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-22 | 2022-06-23 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-22 | 2022-06-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-15 | 2022-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-15 | 2022-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-06 | 2022-05-19 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-15 | 2022-04-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-12 | 2021-12-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-12 | 2021-06-30 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-12 | 2021-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-12 | 2021-06-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-12 | 2021-06-16 | N |
| 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. | Health | 2021-05-12 | 2021-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-12 | 2021-06-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-12 | 2021-06-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-11 | 2021-06-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-11 | 2021-06-16 | N |
