Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 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 August 2026) and official state health department websites.