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 Pickett Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with documented diagnoses of PTSD, Anxiety, and Depression, as well as ongoing psychiatric monitoring and interventions, was not coded with active mental health diagnoses on the MDS assessment. Staff interviews revealed a misunderstanding that only pharmacologically treated conditions should be considered active, leading to inaccurate MDS coding despite evidence of nonpharmacological interventions and nursing monitoring.
A resident with existing mental health diagnoses was later diagnosed with Bipolar Disorder, but the facility did not resubmit a PASSR to the state as required by policy. The resident's care plan and psychiatric notes reflected the new diagnosis, and the administrator confirmed the omission.
A prefilled Semaglutide insulin pen intended for a resident with diabetes was found on a medication cart without required labeling of the date opened or date removed from refrigeration, and was not stored according to facility policy or manufacturer instructions. Both the RN and DON confirmed the medication was available for use but not properly labeled or stored.
A dumpster outside the facility was observed without a required plug, resulting in improper containment of garbage and refuse. Facility policy requires all garbage to be safely and efficiently disposed of, and the absence of the plug was confirmed by the Dietary Manager.
The facility did not accurately document its resident population in the facility-wide assessment by failing to include a resident with PTSD, despite providing services for this diagnosis during the assessment period. The Administrator confirmed the omission of PTSD from the assessment.
Staff did not consistently wear required eye protection when entering the rooms of residents on isolation droplet precautions for COVID-19, despite facility policy and posted signage mandating its use. Multiple CNAs were observed entering rooms with only gowns, masks, and gloves, omitting eye protection, and confirmed this practice during interviews. The Infection Preventionist acknowledged the failure to follow infection control guidelines for residents with active COVID-19 infections.
A resident with moderate cognitive impairment exhibited aggressive behavior, requiring a one-time Haldol injection. The facility failed to notify the resident's family of this significant change in a timely manner, as per their policy. The family was informed the following morning, contrary to the expectation of notifying them as soon as the resident was safe.
A resident's medication was misappropriated by an LPN who took two Lasix pills for personal use. The resident was unaware of any missed doses and experienced no adverse effects. The incident was discovered by another nurse, leading to an investigation by the DON and Administrator. The LPN admitted to the misappropriation and was terminated.
Failure to Accurately Code Active Mental Health Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for one resident out of sixteen reviewed. The resident in question was admitted with diagnoses including Type 2 Diabetes, Anxiety, Major Depressive Disorder, and Post-Traumatic Stress Disorder (PTSD). Documentation in the medical record, including a PASRR Level 2 outcome, indicated active mental health diagnoses and recommended ongoing psychiatric monitoring, nonpharmacological interventions, and close observation of moods and behaviors. Physician orders and care plans reflected ongoing monitoring and interventions for these mental health conditions, and the resident was prescribed medication for anxiety. Despite this, the quarterly MDS assessment did not document active diagnoses of PTSD, Anxiety, or Depression for the resident. Interviews with the MDS LPN and Clinical Reimbursement Specialist revealed a misunderstanding of what constitutes an active diagnosis, with both staff members stating that only residents receiving medication for a diagnosis should be considered as having an active diagnosis. The staff did not recognize that nonpharmacological interventions and nursing monitoring, as recommended in the PASRR and care plan, also indicated active diagnoses. As a result, the MDS assessment failed to accurately reflect the resident's current health status and active conditions.
Failure to Timely Resubmit PASSR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASSR) in a timely manner after a new mental health diagnosis was added for a resident. According to the facility's policy, a referral for a PASSR Level II evaluation must occur promptly when a significant change in status, such as a new mental health diagnosis, is identified. The policy specifically states that the referral should be made as soon as the criteria are evident, without waiting for the completion of a significant change in status assessment (SCSA). Medical record review showed that the resident was initially admitted with a diagnosis of Depression and later diagnosed with Generalized Anxiety Disorder and Bipolar Disorder. Despite the addition of Bipolar Disorder as a new diagnosis, the facility did not submit a new PASSR to the state-designated authority. The resident's care plan and psychiatric notes reflected the updated diagnoses, and the administrator confirmed that the facility did not follow the expected process of resubmitting the PASSR after the new mental health diagnosis was identified.
Failure to Properly Label and Store Insulin Pen
Penalty
Summary
Surveyors identified a deficiency related to the labeling and storage of a prefilled Semaglutide insulin pen for a resident with Type 2 Diabetes, Anxiety, Major Depressive Disorder, and PTSD. The insulin pen, which was ordered to be administered weekly, was found on a medication cart with its packaging opened and the pen appearing full and unused. The insulin pen was not labeled with the date it was opened or the date it was removed from refrigeration, as required by both facility policy and the product's boxed warning. According to the product labeling, unopened insulin pens should be refrigerated, and once opened, they should be stored at room temperature with the date of opening clearly marked. During interviews, the RN responsible for the cart was unable to confirm how long the insulin pen had been out of refrigeration and acknowledged that it was not labeled or stored correctly. The DON also confirmed that the insulin pen was available for resident use and was not labeled or stored in accordance with policy or manufacturer instructions. These findings demonstrate a failure to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles and facility policy.
Improper Containment of Garbage in Dumpster
Penalty
Summary
The facility failed to properly contain garbage and refuse as required by its own policy, which states that all garbage and refuse must be collected and disposed of in a safe and efficient manner, with the Dining Services Director coordinating with the Director of Maintenance to maintain the exterior dumpster area. During an observation, it was found that one of the two dumpsters outside did not have a dumpster plug in place and secured. This was confirmed in an interview with the Dietary Manager, who acknowledged that the plug was missing and that a plug should be in place.
Facility Assessment Failed to Include Residents with PTSD
Penalty
Summary
The facility failed to ensure its facility-wide assessment accurately reflected the needs of its resident population, specifically by omitting residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD). Medical record review showed that a resident was admitted with PTSD, among other diagnoses, and received services for this condition during the assessment period. However, the facility assessment for the specified period did not include PTSD as a diagnosis present in the resident population, nor did it address the resources necessary to care for residents with this condition. During an interview, the Administrator confirmed that the facility had residents with PTSD and that this diagnosis was not included in the facility assessment.
Failure to Use Required PPE for Residents on COVID-19 Isolation Precautions
Penalty
Summary
Staff failed to consistently wear appropriate Personal Protective Equipment (PPE) when entering the rooms of residents on isolation droplet precautions for COVID-19. Facility policy required the use of masks, gowns, gloves, and eye protection for all staff entering rooms of residents with respiratory infections or during outbreak situations. Observations revealed that multiple Certified Nursing Assistants (CNAs) entered the rooms of residents with active COVID-19 infections wearing gowns, masks, and gloves, but without the required eye protection. Signage posted on the residents' doors clearly instructed that eye protection was mandatory, and staff confirmed during interviews that they did not use eye protection despite being aware of the isolation status. The residents involved had significant medical histories, including chronic respiratory conditions, cognitive impairment, and other comorbidities, and were under active isolation precautions for COVID-19 as documented in their medical records and care plans. The Infection Preventionist confirmed that staff were expected to wear full PPE, including eye protection, for residents on droplet precautions, and acknowledged that the facility failed to follow its own infection control guidelines for these residents.
Failure to Timely Notify Family of Resident's Significant Change
Penalty
Summary
The facility failed to provide timely notification to the Power of Attorney and/or resident representative for a significant change in condition of a resident. The deficiency involved a resident who experienced a significant mental status change, requiring a one-time injection of an antipsychotic medication, Haldol. The facility's policy on Notification of Change of Condition mandates that appropriate individuals, including the resident's representative, be informed of significant changes in the resident's status. However, in this case, the resident's son was not notified until the following morning, after the incident had occurred. The resident, who had a history of moderate cognitive impairment, exhibited increased agitation and attempted to enter other residents' rooms, displaying aggressive behavior towards staff. Despite the presence of the Medical Director and the administration of Haldol to manage the situation, the family was not informed in a timely manner. The Director of Nursing acknowledged that the family should have been notified as soon as the resident was safe, ideally before or immediately after the administration of the medication, which did not happen in this instance.
Misappropriation of Resident Medication by LPN
Penalty
Summary
The facility failed to prevent the misappropriation of property for a resident, specifically involving the medication Lasix. A Licensed Practical Nurse (LPN) was found to have taken two Lasix pills from a medication card belonging to a resident. The LPN admitted to taking the medication with the intention of using it for her father, who was suffering from congestive heart failure and experiencing fluid retention. The incident was discovered when another nurse found the medication card in the LPN's purse. The resident involved was cognitively intact and reported not being aware of missing any medication doses. The medical record indicated that the resident did not experience any adverse effects from the incident, and there was no evidence of harm or distress. The facility's investigation confirmed that the LPN had removed the medication card from the medication cart, taken two pills, and then returned the card to the facility for disposal. The Director of Nursing (DON) and the Administrator were notified of the incident and conducted an investigation. The LPN initially denied the allegations but later admitted to taking the medication. The facility substantiated the misappropriation of resident property, and the LPN was terminated as a result. The incident was reported to the Nurse Licensure Board, and the facility took steps to address the issue.
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Illustrative
What surveyors actually found near you
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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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Illustrative
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Nursing homes near Byrdstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clinton County Care And Rehabilitation Center | 8.4 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Fentress County | 14.4 mi | ★★★★★ | 10 | 0 |
| Overton County Health And Rehab Center | 16.9 mi | ★★★★★ | 0 | 0 |
| Cumberland Valley Nursing & Rehabilitation Center | 19.8 mi | ★★★★★ | 7 | 0 |
| Celina Health And Rehabilitation Center | 20.6 mi | ★★★★★ | 7 | 0 |
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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.