01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-03 | 6 | 2025-12-03 | 1 |
| Cycle 2 | 2024-09-11 | 3 | 2024-09-11 | 2 |
| Cycle 3 | 2023-08-23 | 8 | 2023-08-23 | 3 |
CMS CCN 6752202026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Avalon Place Kirbyville
700 N Herndon Ave · Kirbyville, TX 75956 · Jasper County
Certified beds114CMS provider file
Recent citation rows23current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-03 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-12-042025-12-03 · HEALTHF0732Severity B · pattern; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-12-042025-12-03 · HEALTHF0813Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Correction field: Deficient, Provider has date of correction · 2025-12-042025-12-03 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-12-042025-12-03 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2025-12-052025-09-10 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-09-11 · complaint2025-09-10 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2025-09-05 · complaint2024-09-11 · HEALTHF0661Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-09-11 · HEALTHF0801Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-09-11 · HEALTHF0908Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Keep all essential equipment working safely.
Correction field: Deficient, Provider has date of correction · 2024-10-082024-09-11 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2024-10-112024-09-11 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-09-122023-08-23 · FIREE0039Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-08-282023-08-23 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0661Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-09-012023-08-23 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-09-222023-08-23 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-08-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-09-10 | Fine | $9,113 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2017
- FREGIA, MILTONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/07/2022
- GARDNER, SHANNONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/22/2022
- GARDZINA, MARGARETIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/26/2024
- HENRY, PAULIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/09/2009
- STRATTON, CHARLESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2005
- HUGGINS, LINDAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/09/2024
- WILLIG, ZACHARYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2025
- STRATTON, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/01/2005
- KIRBYVILLE I ENTERPRISES, L.L.C.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/09/2024
- BLAKE, GARYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/09/2024
- BLAKE, MALISAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/09/2024
- KIRBYVILLE I ENTERPRISES, L.L.C.Organization · ADP OF THE SNFNOT APPLICABLE · since 04/12/2025
- KIRBYVILLE I REALTY, L.L.C.Organization · ADP OF THE SNFNOT APPLICABLE · since 07/09/2024
- BLAKE, GARYIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/09/2024
- BLAKE, MALISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/09/2024
- BURKHALTER, SHEILAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/12/2025
- EAMIGUEL, CHRISTOPHERIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/09/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.42per resident day
RN hours0.43per resident day
Weekend nurse hours2.97per resident day
Staff turnover97.8%CMS reported field
06 / LOCAL RECORDS
Open the Texas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.