Avalon Place Kirbyville
Kirbyville, Texas · CCN 675220
26 surveys since 2012, 14 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 124
- Surveys
- 26
- Harm or worse
- 14
- Immediate jeopardyall corrected before survey
- 7
Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 114
- Ownership
- Government - Hospital district
- Chain
- CREATIVE SOLUTIONS IN HEALTHCARE
- County
- Jasper · rural
- Medicare-certified since
- 1993
CMS ratings
- Overall
- 4
- Health inspection
- 4
- Staffing
- 2
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 104 government-run facilities of 100–127 beds in Texas.
Last survey on record
Dec 3, 2025
341 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.42 | 3.25 |
| Registered-nurse hours per resident day | 0.43 | — |
| Annual nurse turnover | 97.8% | 48.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $9,113 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J15.9% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1058.8% | E317.6% | F211.8% |
| No harm, potential for minimal | A— | B15.9% | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6612×
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- F6952×
Provide safe and appropriate respiratory care for a resident when needed.
- F8802×
Provide and implement an infection prevention and control program.
- F5781×
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.
- F6001×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
In the surveyor’s words
From the most serious findings on record at Avalon Place Kirbyville, in the surveyor’s own words.
- Immediate jeopardy, patternF600Apr 15, 2022
Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse was provided for 4 of 11 residents reviewed for abuse. (Resident #s 1, 2, 4, and 5) 1. The facility did not provide required monitoring and supervision to prevent Resident #1 from sexually abusing Resident #2 on 04/11/22. Resident #2 wandered into Resident #1's room. Resident #2 was heard yelling. Resident #1 was found behind Resident #2, his hand on her shoulder, holding his partially erect penis while thrusting toward Resident #2. Residents #1 and #2's briefs were down. 2. The facility staff did not intervene and protect Resident #5 from Resident #4's verbal and physical abuse. On 4/9/22 Resident #4 was found hovering over Resident #5 yelling at him. […]
- Immediate jeopardy, patternF689Apr 15, 2022
Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent abuse for 4 of 11 residents (Resident #s 1, 2, 4, and 5) reviewed for supervision. 1. The facility staff did not provide supervision to prevent Resident #1 from sexually abusing Resident #2 on 04/11/22. Resident #2 wandered into Resident #1's room. Resident #2 was heard yelling. Resident #1 was found behind Resident #2, his hand on her shoulder, holding his partially erect penis while thrusting toward Resident #2. Residents #1 and #2's briefs were down. 2. The facility staff did not separate and supervise Resident #5 to prevent his continued verbal and physical abuse of Resident #4. On 04/9/22 Resident #4 was found hovering over Resident #5 yelling at him. […]
- Immediate jeopardy, patternF726Apr 15, 2022
Based on observation, interview and record review, the facility failed to ensure nursing staff demonstrated competencies and skill sets necessary to care for resident needs for 4 of 11 residents (Resident #s 1, 2, 4, and 5) reviewed for competent nursing staff. The facility did not ensure LVN A, NA B and CNA F were trained to supervise and intervene for residents with behaviors. The facility did not provide required monitoring and supervision to prevent Resident #1 from sexually abusing Resident #2 on 04/11/22. Resident #2 wandered into Resident #1's room. Resident #2 was heard yelling. Resident #1 was found behind Resident #2, his hand on her shoulder, holding his partially erect penis while thrusting toward Resident #2. […]
- Immediate jeopardy, isolatedF689Sep 10, 2025
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. […]
- Immediate jeopardy, isolatedF600Sep 4, 2022
Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse was provided for 3 of 5 residents reviewed for abuse. (Resident #s 1, 2, and 3) The facility did not prevent Resident #1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was seen walking out of Resident #2's room. Resident #1 had blood on his thumb. Resident #2 was found with blood in her brief. Resident #1 was heard trying to get Resident #3 to go to his room. An Immediate Jeopardy (IJ) situation was identified on 9/3/22 at 2:59 p.m. […]
Read 30 findings in full →The most serious and the most recent: 30 of 124 on record.
Every survey on record
FindingsAt actual harm or above
- Dec 3, 2025Standard4 findings
- Sep 10, 2025Complaint2 findings · 1 harm
- Sep 11, 2024Standard3 findings
- Aug 23, 2023Standard8 findings
- Sep 4, 2022Complaint3 findings · 2 harm
- Jun 22, 2022Standard and complaint6 findings
- Apr 15, 2022Complaint3 findings · 3 harm
- Apr 6, 2022Complaint1 finding · 1 harm
Show the 18 earlier surveys
- Dec 12, 2021Infection control1 finding
- May 12, 2021Standard7 findings
- Sep 11, 2019Standard13 findings
- Jul 18, 2019Complaint3 findings
- May 21, 2019Complaint2 findings · 1 harm
- Apr 24, 2019Complaint1 finding · 1 harm
- Oct 4, 2018Standard18 findings
- Jul 25, 2018Complaint3 findings · 3 harm
- Dec 14, 2017Standard11 findings
- Oct 5, 2016Standard10 findings
- Feb 2, 2016Complaint1 finding
- Dec 3, 2015Standard9 findings
- Nov 12, 2014Standard7 findings
- Oct 29, 2014Complaint1 finding · 1 harm
- Oct 30, 2013—2 findings
- Dec 12, 2012—1 finding
- Jun 19, 2012—1 finding · 1 harm
- Jan 4, 2012—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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