Avalon Place Kirbyville
AVALON PLACE KIRBYVILLE in KIRBYVILLE, TX — inspection on September 10, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Avalon Place Kirbyville
700 N Herndon Kirbyville, TX 75956
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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.
Facility ID: