Avir At Kirbyville

Penalties

• Sep 10, 2025 — Fine ($9,113)

Inspection findings

1. Dec 3, 2025 Health · 5 findings
   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 4, 2025 · CMS health inspection

   • Not serious Scope/severity B

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Dec 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0813 Nutrition and Dietary Deficiencies

     Have a policy regarding use and storage of foods brought to residents by family and other visitors.

     Corrected Dec 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     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.

     Corrected Dec 5, 2025 · CMS fire safety

2. Sep 10, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Sep 11, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Sep 5, 2025 · CMS health inspection

3. Sep 11, 2024 Health · 5 findings
   • Not serious Scope/severity D

     F0661 Resident Assessment and Care Planning Deficiencies

     Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

     Corrected Sep 12, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     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.

     Corrected Sep 12, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Oct 8, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Oct 11, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 12, 2024 · CMS fire safety

4. Aug 23, 2023 Fire Safety · 11 findings
   • Not serious Scope/severity C

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Aug 28, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     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 Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0661 Resident Assessment and Care Planning Deficiencies

     Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 22, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Aug 24, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BLAKE, GARY — adp of the snf, NOT APPLICABLE, since 07/09/2024
• BLAKE, GARY — operational/managerial control, NOT APPLICABLE, since 07/09/2024
• BLAKE, MALISA — adp of the snf, NOT APPLICABLE, since 07/09/2024
• BLAKE, MALISA — operational/managerial control, NOT APPLICABLE, since 07/09/2024
• BURKHALTER, SHEILA — adp of the snf, NOT APPLICABLE, since 04/12/2025
• EAMIGUEL, CHRISTOPHER — adp of the snf, NOT APPLICABLE, since 07/09/2024
• FREGIA, MILTON — managing control - governing body, NOT APPLICABLE, since 05/07/2022
• GARDNER, SHANNON — managing control - governing body, NOT APPLICABLE, since 08/22/2022
• GARDZINA, MARGARET — managing control - governing body, NOT APPLICABLE, since 02/26/2024
• HENRY, PAUL — managing control - governing body, NOT APPLICABLE, since 05/09/2009
• HUGGINS, LINDA — corporate director, NOT APPLICABLE, since 07/09/2024
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 05/01/2005
• STRATTON, CHARLES — managing control - governing body, NOT APPLICABLE, since 05/01/2005
• WILLIG, ZACHARY — corporate director, NOT APPLICABLE, since 01/01/2025
• XINTAVELONIS, ELENA — adp of the snf, NOT APPLICABLE, since 04/12/2025
• KIRBYVILLE I ENTERPRISES, L.L.C. — operational/managerial control, NOT APPLICABLE, since 07/09/2024
• KIRBYVILLE I ENTERPRISES, L.L.C. — adp of the snf, NOT APPLICABLE, since 04/12/2025
• KIRBYVILLE I REALTY, L.L.C. — adp of the snf, NOT APPLICABLE, since 07/09/2024
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 04/01/2017