Cycle 1
Health 2026-01-21 · Fire 2026-01-21
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Jasper, TX
Rayburn Health Care & Rehabilitation
4-star overall rating with 4-star inspections with 7 recent health deficiencies
144 Bulldog Avenue, Jasper, TX
(409) 381-8500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-01-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.12
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.14
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,212
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9987
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.19
Baseline 20.48% · Performance 19.49% · Measure score 4.19 · Achievement 4.19 · Improvement 2.37
Healthcare-associated infections
2.90
Baseline 9.25% · Performance 7.80% · Measure score 2.90 · Achievement 0 · Improvement 2.90
Total nurse turnover
7.11
Baseline 37.21% · Performance 34.62% · Measure score 7.11 · Achievement 7.11 · Improvement 1.60
Adjusted total nurse staffing
3.97
Baseline 2.55 hours · Performance 3.99 hours · Measure score 3.97 · Achievement 3.22 · Improvement 3.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 14.29% · Lower 95% interval 7.51% |
| Discharge to community | 51.97% |
50.57%
1.4 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 45.9% · Lower 95% interval 40.8% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 20 · Denominator 40 |
| Discharge mobility score | 65% |
50.94%
14.1 pts better
|
Numerator 26 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 4.48% |
2.29%
2.2 pts worse
|
Numerator 3 · Denominator 67 · Adjusted rate 4.18% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 13.22% |
42%
28.8 pts worse
|
Numerator 16 · Denominator 121 |
| Discharge function score | 67.5% |
56.45%
11 pts better
|
Numerator 27 · Denominator 40 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 6 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.3%
2.5 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
3.3%
4.7 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.9% · Q3 8.9% · Q4 9.6% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
18.9%
12 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 30.8% · Q3 29.8% · Q4 29.3% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
10.8%
2.9 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.1% · Q3 8.3% · Q4 6.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.5% |
15.4%
19.1 pts worse
|
16.3%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.6% · Q2 36.4% · Q3 16.7% · Q4 36.3% · 4Q avg 34.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
16.1%
8.5 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 28.6% · Q3 15.1% · Q4 25.9% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.5%
1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.2% |
0.8%
5.4 pts worse
|
1.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.3% · Q3 2.9% · Q4 8.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
15.0%
7.5 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 28.8% · Q3 22.1% · Q4 20.9% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.2%
1.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.7% · Q3 3.5% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
89.7%
6.1 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 90.3% · Q3 100.0% · Q4 100.0% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.0%
1.3 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 11.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
88.0%
1.3 pts worse
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
25.9%
5.5 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 21.2% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-23 · Fire 2024-10-23
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-08-30 · Fire 2023-08-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-10-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-30
F · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-03-07
E · Potential for more than minimal harm
2026-01-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-03-07
E · Potential for more than minimal harm
2026-01-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-03-07
E · Potential for more than minimal harm
2026-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-03-07
D · Potential for more than minimal harm
2026-01-21
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2026-03-07
D · Potential for more than minimal harm
2026-01-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-03-07
D · Potential for more than minimal harm
2026-01-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-03-07
F · Potential for more than minimal harm
2024-10-23
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-10-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-10-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-30
F · Potential for more than minimal harm
2023-08-30
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-30
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-30
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-09-30
Penalties and ownership
What sits behind the stars
Ownership
Cryer, Shannon
5% Or Greater Indirect Ownership Interest · Individual
Darden, Dawn
5% Or Greater Direct Ownership Interest · Individual
Reynolds, Jeanie
5% Or Greater Indirect Ownership Interest · Individual
Fann, Ashley
5% Or Greater Direct Ownership Interest · Individual
Darden, Dawn
Operational/Managerial Control · Individual
Janus Gp Ii, LLC
General Partnership Interest · Organization
Nearby options
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#2
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1-star overall rating with 1-star inspections with abuse icon flag with $167,925 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Avalon Place Kirbyville
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