Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Katy Manor during CMS and state inspections, most recent first.
A resident received two Fentanyl patches due to a medication administration error. When the error was discovered, an LPN notified the DON, hospice, and the resident's family, but failed to notify the resident's physician. The DON confirmed the Medical Director was not informed, despite facility policy requiring physician notification for significant medication errors.
A resident with multiple health conditions received double the prescribed Fentanyl dosage after staff failed to follow medication administration and documentation protocols. Two Fentanyl patches were applied on consecutive days, with inconsistent documentation and lack of proper checks. The error was discovered when a nurse found both patches on the resident, who exhibited increased confusion and other symptoms. The Medical Director was not notified as required by policy, and staff interviews revealed lapses in following controlled substance procedures.
Facility staff failed to obtain necessary medical orders for catheter and colostomy care for three residents, despite facility policies requiring such orders. A resident with an indwelling catheter and another with both a catheter and colostomy lacked documented orders in their Physician's Order Sheets and Treatment Administration Records. Interviews with staff, including the ADON, LPN, DON, and administrator, revealed a lack of awareness and oversight regarding the missing orders.
Facility staff failed to ensure that a resident's code status was documented correctly throughout the medical record. The resident had conflicting documentation regarding their code status, with the face sheet indicating DNR and the physician order report and baseline care plan indicating Full Code. This discrepancy was discovered after the facility switched to a new electronic charting system.
Failure to Notify Physician After Significant Medication Error
Penalty
Summary
Facility staff failed to notify a resident's physician after a significant medication error involving the administration of Fentanyl patches. According to the facility's policy, staff are required to promptly consult the resident's physician in the event of changes such as adverse drug reactions or medication errors. Review of records showed that a resident, who had a physician order for Fentanyl 25 mcg/hour to be changed every 72 hours, was found with two Fentanyl patches with different dates applied. Documentation confirmed that staff signed out and administered a patch on consecutive days, resulting in the resident receiving two patches simultaneously. When the error was discovered, the LPN who found the two patches notified the DON, as well as hospice and the resident's family, but did not notify the resident's primary physician. Interviews with the Medical Director and DON confirmed that the Medical Director was not informed of the medication error, despite the DON acknowledging it as a significant error. The lack of physician notification following the medication error constituted a failure to follow the facility's policy and regulatory requirements.
Resident Received Double Dosage of Fentanyl Due to Medication Administration Errors
Penalty
Summary
Facility staff failed to ensure a resident remained free from significant medication errors when the resident was administered double the prescribed dosage of Fentanyl. The facility's policies required staff to ensure the right dosage, time, and documentation for medication administration, and to check the Medication Administration Record (MAR) and controlled substance logs. Despite these policies, a Fentanyl patch was placed on the resident on one day, and another patch was signed out and administered the following day, resulting in two patches being on the resident at the same time. Documentation was inconsistent, with the MAR not reflecting the administration of the second patch, and the nurse who signed out the patch did not administer it, instead allowing another nurse to do so without proper documentation. The resident involved had moderate cognitive impairment and multiple diagnoses, including Alzheimer's Disease, COPD, respiratory failure, and renal failure. The resident was receiving opioid therapy and oxygen. Staff discovered the error when a nurse observed two Fentanyl patches with different dates on the resident. The resident exhibited increased confusion, did not recognize family, and reported tingling in the arms. The resident also experienced a fall and vomiting during the period when the double dosage occurred. Staff interviews revealed that the error was not immediately reported to the Medical Director, and there was confusion among staff regarding the administration and documentation of the controlled substance. Interviews with staff and the Medical Director confirmed that the presence of two Fentanyl patches constituted a significant medication error. The Medical Director was not notified of the error, despite facility policy requiring such notification. Staff acknowledged that proper procedures were not followed, including checking for existing patches before applying a new one, ensuring the nurse who signed out the medication administered it, and documenting administration in the MAR. The error was only discovered after several days, and the resident's family and hospice were notified before the Medical Director.
Failure to Obtain Orders for Catheter and Colostomy Care
Penalty
Summary
The facility staff failed to meet professional standards by not obtaining necessary medical orders for catheter and colostomy care for three residents. Specifically, the staff did not secure orders for catheter care for three residents and colostomy care for one resident. The facility's policies require that medications, treatments, and care tasks be administered only upon the written order of a licensed professional. However, the Physician's Order Sheets (POS) and Treatment Administration Records (TAR) for these residents did not contain the required orders for catheter and colostomy care. Resident #1, who was cognitively intact and had an indwelling catheter, did not have orders for catheter care documented in their POS or TAR. Similarly, Resident #2, also cognitively intact with an indwelling catheter, lacked documented orders for catheter care in their POS and TAR. Resident #3, who had both an indwelling catheter and a colostomy, did not have orders for either catheter or colostomy care documented in their POS or TAR. The care plans for these residents included instructions for catheter care, but the absence of formal orders in the POS and TAR indicates a failure to adhere to the facility's policy. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN), Director of Nursing (DON), and the administrator, revealed a lack of awareness and oversight regarding the missing orders. The ADON and DON acknowledged that the charge nurse is responsible for entering orders into the system and that they are responsible for auditing and ensuring completion. However, they were unaware of the missing orders and could not explain why they had not been obtained. The administrator also confirmed that the charge nurses are responsible for entering orders, with the DON reviewing them, but was not aware of the deficiency.
Failure to Document Resident's Code Status Correctly
Penalty
Summary
Facility staff failed to ensure that a resident's code status was documented correctly throughout the medical record. The resident, who was admitted with diagnoses including spinal fracture, sacral fracture, heart failure, urinary tract infection, and diabetes, had conflicting documentation regarding their code status. The face sheet indicated a Do Not Resuscitate (DNR) status, while the physician order report and baseline care plan indicated a Full Code status. This discrepancy was discovered after the facility switched to a new electronic charting system, which led to inconsistencies in the resident's medical records. Interviews with facility staff revealed that the administrator goes over the admission packet, including advanced directives, due to the absence of a social service designee. The Administrator in Training (AIT) and the Director of Nursing (DON) acknowledged the discrepancy and its potential impact on the resident's care. The DON, who had been with the facility for about five weeks, was still learning and tailoring the charting system to the facility's needs. The administrator confirmed that all current resident records were reviewed and corrected to match the residents' wishes after the discrepancy was identified.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pilot Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashley Manor Health & Rehabilitation | 9.3 mi | ★★★★★ | 0 | 0 |
| Lakeview Health Care & Rehabilitation Center | 9.8 mi | ★★★★★ | 5 | 0 |
| Riverdell Care Center | 12 mi | ★★★★★ | 0 | 0 |
| Tipton Oak Manor | 16.2 mi | ★★★★★ | 0 | 0 |
| Four Seasons Living Center | 18 mi | ★★★★★ | 32 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.