Avalon Place Kirbyville
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
from abuse and neglect and stay safe and secure in the facility. She said all staff were educated frequently
on abuse and neglect. She said the incident with Resident #3 and #50 was unable to be predicted. She said there no signs of a problem; the residents had no prior incidents or behaviors. She said there have been no incidents since and the residents were no longer roommates. The Administrator said the residents were immediately separated; Resident #3 was placed on one-on-one monitoring until sent to the hospital and Resident #50 was assessed and x-rayed with no fracture. She said the facility investigated the incident, in-serviced staff, interviewed staff and residents and notifications as required. The Administrator said there was nothing to predict an incident would happen. Record review of and undated facility policy titled, Abuse/ Neglect indicated, The resident has the right to be free from abuse, neglect, . Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, . 5. Physical Abuse: Includes, hitting, slapping.Resident to Resident The above policy will apply to potential resident-to-resident abuse.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avalon Place Kirbyville
700 N Herndon Kirbyville, TX 75956
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
missing resident both inside and outside the facility. They said the search would include all resident rooms, closets, bathrooms and all other rooms were searched. They said the outside the facility would also be searched. Record review of an in-service sign in sheet titled, No Alarms are to be turned off and no doors are to be Propped Open dated 05/12/25 for department Maintenance indicated 1 staff member Maintenance Director signature. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) in the dining room dated 05/12/25, indicated 54 staff members signed the in-service
record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record
review of in-service sign in sheet titled, Demonstration for operating the door(s) on the secure unit dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for policy on Color code program dated 05/12/25, indicated it was important to know the color code when an emergency happened, and code orange indicated a resident elopement. 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for new policy on Elopement Prevention (Secured Unit Residents attending Activities away from the Secured Unit), dated 05/12/25, indicated 54 staff members signed the in-service
record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record
review of an AD Hoc QAPI Contributors form, dated 05/12/25, indicated there was a meeting held on 09/15/25 consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, Laundry Worker CC, Rehab Director and BOM. The following interventions were put in place: New Policy: Elopement Response. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/2025. The facility had corrected the noncompliance before the survey began.
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AVALON PLACE KIRBYVILLE in KIRBYVILLE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in KIRBYVILLE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVALON PLACE KIRBYVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.