Avalon Place Kirbyville: Immediate Jeopardy Violations - TX
The facility's response included a comprehensive search protocol and same-day staff training on multiple security measures....
Latest reports, citations, and penalties from CMS data
The facility's response included a comprehensive search protocol and same-day staff training on multiple security measures....
The facility's own nursing schedules documented the gaps in coverage....
The September 9 incident at ALS Woodstock involved a resident with multiple medical conditions including diabetes, heart disease and a right leg amputation....
The resident had moderate cognitive impairment and was prescribed morphine for pain and restlessness....
Resident 69 had been hospitalized from August 8 through August 12 for metabolic encephalopathy and acute kidney failure....
The citation lasted from June 6 through June 7, when the facility corrected the problems before the formal investigation began three months later....
LPN #202 discovered Resident #70 smoking from a pipe while sitting in his wheelchair just inside the bathroom doorway....
Despite working with Resident 1 from July through September 2025, the resident's physical therapy goals had remained completely unchanged....
The resident, who has dementia and severe cognitive impairment, depends entirely on facility staff for basic activities like bathing, dressing and toileting....
Resident 2 told inspectors he immediately reported the incident to the charge nurse on duty....
The altercation began when one resident grabbed belongings from another resident's table....
Neither supervisor informed the regional administrator that thermostats weren't working properly in resident rooms....
Federal inspectors found the equipment violation during a September 11 complaint investigation at University Rehabilitation Center....
The administrator thought the infection preventionist had reported it....
The designation means inspectors found conditions that could cause serious injury, harm, impairment or death to residents....
That day, Resident 2 grabbed the harasser's neck and punched him in the stomach after being called names and having his personal space invaded....
The doctor's order, dated August 25, specified the resident must wear the collar until a follow-up appointment in six weeks....
The incident occurred on August 29, 2025, when LVN D observed Resident 87 tell Resident 49 "I'm going to hit you" during what she described as an argument....
Resident #1 fell in his room during the overnight shift on August 10....
Resident 1 began experiencing severe right hip pain on August 27, 2025....