Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Failure to provide foot care for a resident with severe cognitive impairment and diagnoses including acute kidney failure, dysphagia, and difficulty walking. Facility policy required daily nail observation and toenail care by an LPN or podiatrist, but the resident had thick, dark toenails, caked debris under toenails, and a damaged toenail, and was not on the podiatry list when reviewed by the DON and SSD.
Two residents had medications left unsecured at the bedside instead of being stored in locked medication areas as required by facility policy. One resident with hemiplegia, hemiparesis, and anxiety had a tube of hydrocortisone ointment on the bedside table that the resident said was not his, while another resident with COPD and a cerebral infarction had nystatin antifungal powder left on the bedside table. RNs and the DON confirmed the medications were not properly stored.
Failure to follow contact precautions and PPE requirements for a resident with ESBL UTI and severe cognitive impairment. The resident had positive urine cultures for ESBL organisms and was placed on contact precautions with signage requiring gloves and gown before room entry. A housekeeper, CNAs, and the SSD entered the room and handled items without PPE, while staff stated they believed PPE was only needed for direct care or high-contact activities.
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 Provide Foot Care
Penalty
Summary
Provide appropriate foot care was not provided for one resident who was reviewed for foot care. The resident was admitted with diagnoses including acute kidney failure, dysphagia, and difficulty walking, and an admission MDS showed a BIMS score of 0, indicating severe cognitive impairment. The care plan directed staff to provide the amount of assistance needed with ADL care, float heels while in bed, and inspect skin during repositioning, toileting, and ADL assistance. A nursing progress note documented that the resident's toenails were thick and dark in color. The facility policy titled Nail Grooming stated nursing staff would provide observation and care of nails daily and as necessary, and that toenail care would be performed by a licensed nurse or podiatrist. A review of the podiatry appointment list showed the resident was not scheduled for podiatry services on the listed date. During observation, the resident had very thick, yellow and brown toenails, with a brownish black substance caked under the fourth and fifth toenails of the right foot and a hole appearing in the third toenail of the right foot. The DON confirmed the resident was not on the podiatry list, and the SSD confirmed the resident had not been added to the list until later.
Improper Medication Storage at Bedside
Penalty
Summary
The facility failed to properly store and secure medications for two residents. The report states that facility policy required medication supplies to be accessible only to licensed nursing personnel, pharmacy personnel, or other staff authorized to administer medications, and that medications could be kept in locked medication carts, rooms, or cabinets. Resident #51, who had diagnoses including hemiplegia, hemiparesis, and anxiety disorder and was cognitively intact with a BIMS score of 15, had Triamcinolone Acetonide Cream 0.1% ordered as needed for itching and dry skin. However, during observation, a 1-pound container of Hydrocortisone Ointment 2.5% was found on the bedside table in the resident's room, and the resident stated it was not his and had not been applied to his skin. RN C later observed the ointment in the room and confirmed it had not been stored properly. Resident #18, who had diagnoses including COPD, cerebral infarction, and intervertebral disc degeneration and was also cognitively intact with a BIMS score of 15, had an order to apply nystatin antifungal powder under both breasts each shift. During observations, a bottle of antifungal powder was seen on the resident's bedside table on two separate occasions. RN D stated she was unaware the resident had antifungal powder at the bedside, and the DON confirmed the medication was at the bedside and should not have been there. The DON further confirmed that the medications for both residents had been left at bedside and should have been stored in the appropriate locked location.
Failure to Follow Contact Precautions and PPE Requirements
Penalty
Summary
The facility failed to follow infection control practices for one resident with ESBL urinary tract infections and severe cognitive impairment. Resident #13 was admitted with diagnoses including dementia, osteoporosis, and UTI. The resident’s record showed urine cultures positive for Klebsiella pneumoniae ESBL on 2/3/2026, Klebsiella pneumoniae on 5/15/2026, and Proteus mirabilis ESBL on 6/8/2026. A physician order dated 6/8/2026 ordered ertapenem 1 gram daily for 7 days for ESBL, and a subsequent order dated 6/9/2026 initiated contact precautions for ESBL. The care plan also identified contact precautions related to ESBL with PPE as indicated. Observations at the resident’s room showed contact precaution signage stating that everyone must put on gloves and a gown before room entry, and PPE was available outside the door. Despite this, Housekeeper A entered the room with laundry, opened the closet door, placed the laundry in the B bed closet, and exited without PPE. Housekeeper A stated she did not have to wear PPE for residents on contact precautions and said there was no difference between Enhanced Barrier Precaution and contact precautions because she did not provide high-contact activities. Additional observations showed CNA A entered the room to bring ice and placed a cup of ice on the resident’s bedside table without PPE, stating PPE was not needed because she was not providing direct care. CNA A and CNA B later stated they were not sure what the PPE differences were between EBP and contact precautions and then stated they only needed PPE for high-contact activities regardless of the precaution type. The Social Service Director also entered the room and moved items on the resident’s bedside table without donning PPE, and confirmed she had not worn PPE before entering. The Infection Preventionist confirmed the expectation was for staff to wear appropriate PPE when entering rooms of residents on EBP and contact precautions and confirmed the observations of staff entering the room without appropriate PPE.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 0 | 0 |
| Celina Health And Rehabilitation Center | 20.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pickett Care And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.