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Avalon Place Kirbyville
700 N Herndon Ave, Kirbyville, TX 75956 · CMS Certification Number (CCN) 675220
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 17 in the last 3 inspection cycles (1 immediate jeopardy, 0 actual harm, 2 from complaints)
- Fire safety citations
- 6
- Fines (last 3 years)
- 1 fine, total $9,113
- Payment denials
- 0
- Most recent standard inspection
- December 3, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 2.7 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | Not published Not enough data available to calculate a star rating. | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | December 3, 2025 | 6 | 4 | 2 |
| Cycle 2 | September 11, 2024 | 3 | 3 | 0 |
CMS weighted health inspection score: 36 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
17 health citations across 4 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
December 3, 2025: 4 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/04/2025 |
| D | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/04/2025 |
| B | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/04/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/04/2025 |
September 10, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance Corrected 09/05/2025 |
| D | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/11/2025 |
September 11, 2024: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/08/2024 |
| F | F-0801 | 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/12/2024 |
| D | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/12/2024 |
August 23, 2023: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| D | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| D | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
| D | F-0578 | 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. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/01/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
6 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 12/03/2025 | D | K-0222 | 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. Egress Deficiencies | Deficient, Provider has date of correction Corrected 12/05/2025 |
| 09/11/2024 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/12/2024 |
| 09/11/2024 | E | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 10/11/2024 |
| 08/23/2023 | D | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 08/24/2023 |
| 08/23/2023 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/22/2023 |
| 08/23/2023 | C | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 08/28/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| September 10, 2025 | Fine | $9,113 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.42 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.43 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.05 | Not published | Not published |
| Nurse aide hours per resident per day | 1.94 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.97 | Not published | Not published |
| RN hours per resident per day, weekends | 0.25 | Not published | Not published |
| Total nursing staff turnover (%) | 97.8 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 100 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Liberty County Hospital District No 1
- Ownership type
- Government - Hospital district
- Chain
- Creative Solutions in Healthcare (149 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 114
- Average residents per day
- 48.9
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- September 28, 1993
- County/parish
- Jasper
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
19 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LIBERTY COUNTY HOSPITAL DISTRICT NO 1 | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| FREGIA, MILTON | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GARDNER, SHANNON | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GARDZINA, MARGARET | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HENRY, PAUL | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRATTON, CHARLES | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUGGINS, LINDA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILLIG, ZACHARY | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRATTON, CHARLES | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KIRBYVILLE I ENTERPRISES, L.L.C. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KIRBYVILLE I ENTERPRISES, L.L.C. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| KIRBYVILLE I REALTY, L.L.C. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BURKHALTER, SHEILA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| EAMIGUEL, CHRISTOPHER | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| XINTAVELONIS, ELENA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Avalon Place Kirbyville. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.