Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Place Kirbyville during CMS and state inspections, most recent first.
Oxygen Reservoir Not Changed Per Order: A resident with dementia, COPD, and HTN had an order for oxygen humidifier changes every Sunday evening shift and PRN, but the humidifier/water reservoir was observed dated weeks earlier. The resident said she used O2 but rarely and did not know how often the tubing was changed. An LVN, the DON, and the ADM confirmed nursing staff were responsible for changing and labeling the reservoir per order, and the care plan did not include oxygen administration.
Unsanitary Condition Found in Resident’s Personal Refrigerator: A resident with Parkinson’s disease, type 2 DM, and severe cognitive impairment had a personal refrigerator checked after giving permission, and the freezer section contained a greenish/black substance. The ADON, DON, and Administrator stated the resident and/or RP were responsible for cleaning the refrigerator, with staff help available if needed, and the facility policy allowed housekeeping to assist with weekly inspections and removal of outdated food items.
Improper disinfectant used for a resident's C. difficile isolation room. A resident with dementia, schizophrenia, severe cognitive impairment, and frequent bowel incontinence was on contact isolation for C. difficile, but housekeeping staff reported using K-Quat Plus in the room and on bathrooms. The Housekeeping Supervisor said staff were expected to use K-Quat Select, while the facility policy referenced K-Quat Select or a 10% bleach solution for C. difficile; EPA review did not show either K-Quat product killed C. difficile spores.
Nurse Staffing Data Not Posted Daily: The facility failed to keep daily nurse staffing information posted and readily accessible for residents and visitors. Surveyors observed no staffing data posted during two observations, and the DON, ADON, and ADM stated there had been confusion about the posting requirement, with staffing having been stopped months earlier and no policy in place for daily posting.
A resident with severe cognitive impairment and a high risk for elopement was brought from a secured unit to a facility activity and left unsupervised due to unclear staff communication and lack of direct supervision. The resident exited through a door that did not alarm and was found outside the building before being returned to the secured unit without injury. The incident revealed failures in following care plan interventions and maintaining adequate supervision.
A resident with severe cognitive impairment and behavioral health diagnoses pushed a rolling bedside table into another cognitively impaired resident, causing a fall and a significant skin tear. The incident was witnessed by an LVN, and there were no prior behavioral issues or warning signs documented for either resident. Both residents' care plans noted cognitive and psychiatric conditions, but no history of aggression or altercations.
The facility failed to employ a qualified dietary manager, as the designated Dietary Supervisor lacked necessary certification. Despite attempts by the Administrator to enroll the DM in certification classes, the classes were canceled, leaving the DM uncertified for nearly a year. This deficiency could risk residents' nutritional needs and food safety.
The facility failed to maintain the gas stove and convection ovens in safe operating condition, as two burners did not light using their pilot lights and required manual lighting. Staff were aware of the issue, and the DM noted that the problem had persisted for a month. The Maintenance Supervisor, new to the facility, was unaware of the issue and acknowledged the need for equipment to be in good working order.
A resident with multiple chronic conditions was discharged without a complete discharge summary, lacking essential information and a physician's signature. The facility's staff, including the ADON and DON, were unclear about their responsibilities, and a change in management hindered access to previous records, contributing to the deficiency.
Oxygen Reservoir Not Changed Per Order
Penalty
Summary
The facility failed to ensure that Resident #48 received respiratory care as ordered when the oxygen humidifier, or water reservoir, was not changed weekly. Resident #48 was a female admitted with diagnoses including dementia, COPD, and hypertension. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and she required maximal assistance with ADLs. A physician’s order directed staff to change the oxygen humidifier every Sunday evening shift and as needed, and another order directed oxygen at 2 L/min via nasal cannula PRN to maintain O2 sats above 92%. During observation on 12/1/25, Resident #48’s oxygen humidifier was found dated 11/9/25. The resident stated she used her oxygen but rarely and did not know how often her tubing was changed. Interviews with an LVN, the DON, and the ADM confirmed that nursing staff were responsible for maintaining residents’ oxygen tubing, reservoirs, and machines, and that the reservoir should be changed weekly per order and labeled with the new date. The resident’s care plan dated 12/1/25 did not include oxygen administration care planning. The facility policy on Oxygen Administration stated that oxygen therapy is administered and monitored by the nurse and that the resident will be free from infection.
Unsanitary Condition Found in Resident’s Personal Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident’s food items in a personal refrigerator. During an observation and interview on 12/01/25 at 08:45 AM, Resident #46 was lying in bed in his room and gave permission for the refrigerator to be checked. The freezer section contained a greenish/black substance. The Administrator was present and stated she would have someone clean the refrigerator. Resident #46’s record showed he was an [AGE]-year-old male admitted on [DATE] with diagnoses including Parkinson’s disease and type 2 diabetes mellitus. His quarterly MDS assessment dated 09/04/25 showed a BIMS score of 6, indicating severe cognitive impairment. During interviews, the ADON, DON, and Administrator stated that the resident and/or responsible party were responsible for cleaning the refrigerator, with staff assistance available if needed. The facility’s Personal Refrigerators Policy stated that the resident and/or responsible party were responsible for care and maintenance of the refrigerator, and that housekeeping could assist by inspecting refrigerators at least weekly and helping remove outdated food items and maintain cleanliness.
Improper disinfectant used for a C. difficile isolation room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for a resident on contact isolation for clostridium difficile. Resident #49 was a female with dementia and schizophrenia, had severe cognitive impairment with a BIMS score of 03, and was frequently incontinent of bowel. Her physician ordered contact isolation for clostridium difficile beginning 11/24/25, and her care plan included contact precautions related to clostridium difficile with the goal that the infection would not spread to other residents. During observation and interview, housekeeping staff stated they used K-Quat Plus cleaner in rooms on clostridium difficile isolation and on bathrooms, and another housekeeper said she used K-Quat Plus for Resident #49's room and let it sit for 10 minutes. The Housekeeping Supervisor later stated staff were expected to use K-Quat Select disinfectant on clostridium difficile rooms and said she was not aware the K-Quat cleaner did not kill clostridium difficile. She also stated she would contact corporate to determine the correct cleaner. Record review of EPA information showed K-Quat Plus and K-Quat Select did not indicate activity against clostridium difficile spores, while the facility's policy for deep cleaning resident rooms with special precautions stated to disinfect all contact surfaces using K-Quat Select or a 10% bleach solution for clostridium difficile. The DON, ADON, and Administrator each stated staff were expected to use the proper disinfectant to kill clostridium difficile, and the Administrator stated bleach solution was expected for clostridium difficile.
Nurse Staffing Data Not Posted Daily
Penalty
Summary
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. During observations on 12/1/25 at 8:20 AM and 12/2/25 at 10:25 AM, no nurse staffing data was posted in the facility. During an interview on 12/2/25 at 11:00 AM, the DON stated the staffing data was not posted and said it had previously been posted near the nurse's station, but was no longer there. Later on 12/2/25, the DON said she would run the staffing report and post it, and during an observation at 11:25 AM the surveyor saw the daily nurse staffing posted behind the nurse's station. The DON, ADON, and ADM each stated there had been confusion about whether staffing needed to be posted, with corporate telling them it did not need to be posted. The ADON said she had stopped posting it about 6 months earlier, and the ADM said the facility did not have a policy for posting daily staffing.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a high risk for elopement was removed from a secured unit to attend an activity in the main dining room. The resident, who had diagnoses including catatonic schizophrenia, dementia, chronic obstructive pulmonary disease, hemiplegia, and anxiety, was known to wander and required secure unit placement as documented in his care plan and elopement risk assessment. Despite these precautions, the resident was brought to the dining room for a carnival event and left unsupervised, which was contrary to his care plan interventions that specified he should remain on the secured unit. During the event, the resident was left at a table in the dining room by a CNA, who believed the ADON had accepted responsibility for supervision. However, the ADON did not acknowledge taking over supervision and was already monitoring other residents from the secured unit. The resident was left unattended, and staff did not maintain direct supervision. The resident exited the facility through a dining room door that did not alarm, and his absence was not immediately noticed by staff. He was found outside the building walking on a sidewalk and was returned to the secured unit without injury. Interviews with staff revealed confusion and lack of clear communication regarding who was responsible for the resident's supervision while off the secured unit. The CNA who brought the resident to the activity was new and had not ensured a proper handoff of supervision. The charge nurse was unaware the resident had left the unit, and the ADON did not accept responsibility for the resident. The door alarm malfunctioned or was disabled, allowing the resident to exit undetected. The incident was identified as past non-compliance and resulted in an Immediate Jeopardy situation.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer's disease, dementia with psychotic disturbance, and anxiety disorder pushed a rolling bedside table into his roommate, who also had similar cognitive and psychiatric diagnoses. This action caused the roommate to fall to the ground and sustain a significant skin tear on his left forearm. The incident was witnessed by an LVN, who reported that there was no prior indication of aggression or conflict between the two residents, and no previous behavioral issues had been documented for either individual. Both residents were severely cognitively impaired, as indicated by their BIMS scores of 3, and were receiving psychotropic medications. The care plans for both residents noted their cognitive deficits and behavioral health diagnoses but did not document any prior behavioral problems or risk factors for resident-to-resident altercations. The incident was not preceded by any observable triggers, arguments, or changes in medical status, and staff reported that there were no signs that would have predicted such an event. The facility's policy states that residents have the right to be free from abuse, including resident-to-resident physical abuse. Despite this, the event resulted in physical harm to one resident due to the actions of another. The incident was reported and investigated, but the investigation concluded that the intent to harm was inconclusive, as the action was interpreted as an attempt to move the table rather than a deliberate act of aggression.
Deficiency in Dietary Management Qualifications
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not designate a qualified dietary manager who met the required qualifications. The designated Dietary Supervisor lacked a dietary manager's certification or any other qualifying credentials, which could potentially place residents at risk for the spread of foodborne illness and not having their nutritional needs met. Interviews and record reviews revealed that the Dietary Manager (DM) had taken a food handler test but had not been sent to classes for certified dietary manager training. The DM had been working in the role for almost a year without certification. The Administrator attempted to send the DM for certification, but the class was canceled, with the next available class scheduled for February 2025. The HR staff confirmed the DM's lack of certification and noted the Administrator's efforts to enroll the DM in the class. The job description for the Clinical Dietary Manager required obtaining and maintaining a Certified Dietary Manager (CDM) credential, which the current DM did not possess.
Failure to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove and convection ovens. During an observation, it was noted that two out of six burners on the stove did not light using their pilot lights, requiring manual lighting with a long lighter. Staff acknowledged that the pilot lights occasionally went out and needed to be manually lit, and the Dietary Manager (DM) was aware of this issue. The Administrator suggested that the portable AC in the kitchen might have caused the pilot lights to go out. Further interviews revealed that the DM had been aware of the pilot light issue for the past month, and staff were instructed to monitor and light them as needed. The Maintenance Supervisor, who was new to the facility, stated that the staff had not reported the issue and acknowledged that the equipment should be in good working order. He mentioned that some pilot lights might leak small amounts of gas and was unsure of the type of pilots on the stove. The facility's preventive maintenance records from March 2003 indicated a comprehensive preventive maintenance program should be in place for essential operating equipment.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a resident had a complete discharge summary at the time of a planned discharge. Specifically, the discharge summary for a resident did not include essential information such as the discharge date, discharge disposition, rehabilitation potential, admission and discharge diagnoses, summary of care, prognosis, or nursing documentation. Additionally, the discharge summary lacked a physician's signature and date, which are critical for ensuring continuity of care. The resident in question was a male with multiple chronic conditions, including diabetes mellitus type 2, respiratory failure, kidney failure, chronic obstructive pulmonary disease, and hypertension. He was discharged home with medication and oxygen, and arrangements were made for an oxygen supply company. However, the discharge summary was incomplete, and the necessary documentation was not provided to ensure proper follow-up care. Interviews with facility staff revealed that there was confusion and lack of responsibility regarding the completion of the discharge summary. The Assistant Director of Nursing (ADON) indicated that floor nurses did not complete the discharge summary, and the Director of Nursing (DON) was on vacation at the time of discharge. The facility had undergone a change in management, which resulted in staff being unable to access the previous records system, further complicating the completion of the discharge summary.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kirbyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shady Acres Health And Rehabilitation Center | 15.5 mi | ★★★★★ | 14 | 4 |
| Rayburn Health Care & Rehabilitation | 17 mi | ★★★★★ | 8 | 0 |
| Timberidge Nursing And Rehabilitation Center | 17.6 mi | ★★★★★ | 3 | 0 |
| Paradigm At The Pines | 26.3 mi | ★★★★★ | 18 | 1 |
| Silsbee Oaks Health Care Llp | 27.4 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.