Federal inspection record · CMS data as of October 1, 2026
Avalon Place Kirbyville
700 N Herndon Ave, Kirbyville, TX · (409) 423-6111
- Certified beds
- 114
- Residents per day
- 50
- Ownership
- Government
- Chain
- Creative Solutions In Healthcare
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- September 28, 1993
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Avalon Place Kirbyville carries 24 inspection points. That is fewer than 91% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
17 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Resident Assessment and Care Planning3D
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Pharmacy Service3E
- E
Ensure medication error rates are not 5 percent or greater.
- E
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.
- D
Ensure that residents are free from significant medication errors.
Quality of Life and Care2D
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Nutrition and Dietary2F
- D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- F
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.
Infection Control2E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Nursing and Physician Services1B
- B
Post nurse staffing information every day.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Environmental1F
- F
Keep all essential equipment working safely.
Resident Rights1D
- D
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.
Inspection history
2025-12-03
4 health deficiencies · 1 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2024-09-11
5 health deficiencies · 2 fire-safety deficiencies
Top issue: Environmental (1 deficiency)
2023-08-23
8 health deficiencies · 3 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 29 min of nursing staff time a day, 13 min of it from a registered nurse.
This home
3 h 29 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 49% of nursing staff and 60% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$9,113 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-09-10 | Fine | $9,113 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident daysAbout the same | 2.0 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.9 pts worse | 2.9 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.1 pts better | 99.5% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 100.0% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.4 pts worse | 4.6% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.7 pts better | 0.6% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts worse | 4.6% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication9.5 pts worse | 27.3% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.2 pts worse | 12.0% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.5 pts worse | 14.4% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.9 pts worse | 16.7% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts better | 0.5% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.5 pts worse | 14.0% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.6 pts better | 1.1% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine7.9 pts better | 96.6% | 88.7% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine14.6 pts better | 100.0% | 85.4% | 80.1% |
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Who owns and runs it
19 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Liberty County Hospital District No 1 | 5% Or Greater Direct Ownership Interest · Organization | 100% | 35 facilities |
| Blake, Gary | Operational/Managerial Control · Individual | 0% | 139 facilities |
| Blake, Gary | Adp Of The SNF · Individual | 0% | 139 facilities |
| Blake, Malisa | Operational/Managerial Control · Individual | 0% | 139 facilities |
| Blake, Malisa | Adp Of The SNF · Individual | 0% | 139 facilities |
| Burkhalter, Sheila | Adp Of The SNF · Individual | 0% | 1 facilities |
| Eamiguel, Christopher | Adp Of The SNF · Individual | 0% | 10 facilities |
| Fregia, Milton | Managing Control - Governing Body · Individual | 0% | 10 facilities |
| Gardner, Shannon | Managing Control - Governing Body · Individual | 0% | 10 facilities |
| Gardzina, Margaret | Managing Control - Governing Body · Individual | 0% | 10 facilities |
| Henry, Paul | Managing Control - Governing Body · Individual | 0% | 10 facilities |
| Huggins, Linda | Corporate Director · Individual | 0% | 138 facilities |
| Kirbyville I Enterprises, L.l.c. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Kirbyville I Enterprises, L.l.c. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Kirbyville I Realty, L.l.c. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Stratton, Charles | Managing Control - Governing Body · Individual | 0% | 35 facilities |
| Stratton, Charles | Corporate Officer · Individual | 0% | 35 facilities |
| Willig, Zachary | Corporate Director · Individual | 0% | 84 facilities |
| Xintavelonis, Elena | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
6 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Egress2E
- D
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.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke2E
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Services1D
- D
Have properly installed electrical wiring and gas equipment.
Emergency Preparedness1C
- C
Conduct testing and exercise requirements.
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