Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Avir At Pilot Point during CMS and state inspections, most recent first.
A resident with urinary retention and an indwelling Foley catheter was observed sitting in a wheelchair with catheter tubing touching the floor, despite care plan interventions and physician orders requiring securement of the tubing and the facility’s catheter care policy mandating that catheter tubing and drainage bags be kept off the floor. An LVN confirmed the tubing was on the floor, was unable to locate the wheelchair clip intended to secure the tubing, and acknowledged the infection control concern. The DON also confirmed that the tubing should have been attached to a clip under the wheelchair and recognized the infection control issues associated with the tubing being on the floor.
A resident with COPD and moderately impaired cognition had physician orders and a care plan for nebulizer treatments, with the last documented treatment given per the MAR. Several days later, surveyors observed the nebulizer machine on the nightstand with the mask and tubing still attached and hanging unbagged, despite facility leadership and an LVN stating that respiratory items should be bagged and, per the DON, dated when not in use for infection control. The facility lacked a specific written policy on storing breathing masks and tubing.
Staff failed to provide privacy during a blood sugar check and insulin administration for a resident with diabetes and cognitive impairment, performing the procedure in a public hallway. Additionally, confidential medical information for several residents was left exposed on an unattended nurse's cart in the hallway, accessible to unauthorized individuals. These actions did not align with facility policies requiring privacy during care and secure handling of medical records.
The facility did not ensure that comprehensive care plans were developed, reviewed, and revised in a timely manner for several residents. Despite recent MDS assessments, care plans were not updated quarterly as required, and staff responsible for care planning acknowledged the oversight. This resulted in outdated care plans being available to staff, potentially impacting the delivery of appropriate care.
Surveyors found that dessert dishes containing cake with frosting were not covered during meal distribution, while main dishes and drinks were properly covered. Staff interviews confirmed that facility policy requires all food to be covered to prevent cross contamination, but desserts were left uncovered as they were transferred directly from the kitchen to the cart.
A resident with a urostomy and moderate cognitive impairment was observed with an uncovered catheter bag visible from the hallway, contrary to facility policy requiring privacy covers to maintain dignity. Staff interviews confirmed the expectation for catheter bags to be covered, but the oversight was not corrected during multiple rounds, resulting in a lapse in respectful and dignified care.
A resident with GERD and schizoaffective disorder was found with TUMS left at the bedside without a physician order or assessment for self-administration. Staff interviews confirmed that medications should not be left with residents and must be administered according to physician orders, but these protocols were not followed in this case.
A nurse's medication cart containing various medications and insulins was left unlocked and unattended in a hallway, accessible to staff, residents, and visitors. The cart was only secured after the nurse returned, and interviews with the ADON, DON, and Administrator confirmed that this was against facility policy, which requires medication carts to be locked when not in direct supervision.
Staff failed to follow infection control protocols during catheter care for a resident with an indwelling catheter by placing the catheter bag on the floor during transfer, and during incontinent care for another resident by not performing hand hygiene between glove changes and using gloves stored in a pocket. These actions did not align with facility policies designed to prevent cross-contamination and infection.
The facility failed to provide weekly changes of respiratory equipment for two residents with COPD, leading to deficiencies in care. One resident's nasal cannula was not changed weekly, and another's nebulizer had not been changed for over two months. These oversights were confirmed by the ADON and nursing staff, who acknowledged the importance of adhering to the facility's policy to prevent infection and ensure proper respiratory care.
A facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two incidents. An LVN did not perform hand hygiene between glove changes during colostomy care for a resident with multiple health conditions and an MDRO. Additionally, two CNAs failed to sanitize a mechanical lift before and after use with another resident, contrary to infection control protocols. These actions were inconsistent with the facility's policies and training materials.
Failure to Maintain Catheter Tubing Off the Floor for a Catheterized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident with an indwelling urinary catheter. The resident, an older female with urinary retention, had an MDS assessment and care plan identifying the presence of an indwelling urinary catheter, with care plan interventions that included ensuring a privacy bag and leg strap or anchor were in place. Physician’s orders directed staff to check the Foley catheter tubing secure device placement every shift and allowed use of a leg strap to secure the Foley catheter. Despite these orders and the facility’s urinary catheter care policy, which required that catheter tubing and drainage bags be kept off the floor, the resident’s catheter tubing was observed touching the floor while she was seated in her wheelchair in the hallway. During the observation, a LVN confirmed that the catheter tubing was on the floor and stated that it should have been attached to a clip under the wheelchair to prevent this. The LVN attempted to locate the clip but was unable to find it and did not know why it was not present. The LVN acknowledged that catheter tubing on the floor posed potential infection control issues. The DON, after being informed of the situation, also confirmed that the catheter tubing should have been attached to a clip under the wheelchair and acknowledged the infection control concerns associated with the tubing being on the floor. These observations and interviews demonstrated that the facility did not follow its own catheter care policy and physician’s orders regarding keeping catheter tubing off the floor.
Improper Storage of Nebulizer Equipment After Respiratory Treatment
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care and infection control for a resident requiring nebulizer treatments. The resident was an older female with COPD and hypertension, with moderately impaired cognition (BIMS score of 10). Her baseline care plan and MDS documented active treatment for COPD, including monitoring for respiratory distress, monitoring oxygen saturation as ordered, and administering medications per order. Physician’s orders directed Ipratropium-Albuterol nebulizer treatments every eight hours for two days, with a start date of 01/01/2026 and an end date of 01/02/2026. The MAR showed the last breathing treatment was administered on 01/02/2026. On 01/06/2026, during an observation, the resident was found lying in bed with the nebulizer machine on the nightstand approximately three feet from the head of the bed. The nebulizer mask and tubing were still connected to the machine and hanging from the side of the nightstand, not stored in a bag. The resident did not recall when she last received a breathing treatment. An LVN, who stated he had not provided the treatment, acknowledged that the nebulizer mask should have been bagged when not in use to prevent respiratory infection and that it appeared someone had given a treatment and failed to bag the mask. The Administrator and DON both stated that all respiratory items, including nebulizer masks, should be stored in a bag when not in use for infection control, and the DON added that the mask should be dated and that the nurse providing the treatment was responsible for proper storage. The facility did not have a written policy specifically addressing storage of breathing masks and tubing.
Failure to Maintain Resident Privacy and Confidentiality During Care and Record Handling
Penalty
Summary
The facility failed to maintain resident privacy and confidentiality for seven out of sixteen residents reviewed. One incident involved a nurse (LVN B) checking a resident's blood sugar and administering insulin in a public hallway rather than in a private setting. The resident, who had severe cognitive impairment and diabetes mellitus, was in her wheelchair in the hallway when the nurse performed the blood sugar check and insulin injection, exposing her abdomen in view of others. The nurse later acknowledged that the procedure should have been done in the resident's room or another private area. Another deficiency was observed when a nurse (LVN A) left a cart unattended in the hallway with a piece of paper on top containing confidential medical information about several residents. The paper included details such as diagnoses, blood sugar values, medication refusals, and other sensitive health information. The cart was left facing the hallway, unattended, while staff and residents passed by, making the information accessible to unauthorized individuals. The nurse admitted that the information should have been secured and not left exposed. Interviews with facility leadership, including the ADON, Administrator, and DON, confirmed that staff are expected to provide privacy during care and secure all resident medical information. Facility policies reviewed also emphasized the importance of protecting resident privacy and confidentiality during treatment and in the handling of medical records. The observed actions were inconsistent with these policies and expectations.
Failure to Timely Update and Review Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the timely development, review, and revision of person-centered, comprehensive care plans for five residents. Record reviews showed that for each of these residents, the last quarterly care plan was not completed in accordance with the required schedule, despite recent comprehensive MDS assessments being performed. Interviews with the Administrator, DON, and MDS Coordinator confirmed that care plans were not updated quarterly as required, and that the DON was responsible for this process. The facility's policy also requires the interdisciplinary team to review and update care plans at least quarterly, in conjunction with the required MDS assessment. Direct observations and interviews revealed that the lack of updated care plans could result in staff not having current information on the care needs of residents. The Administrator and DON acknowledged the oversight and confirmed that the care plans for the affected residents were outdated. The MDS Coordinator further clarified that care plans should be updated upon admission, quarterly, and with any change in condition, and that these should be accessible to staff. The deficiency was identified through interviews and record reviews, which demonstrated that the facility did not follow its own policy or regulatory requirements for care plan updates.
Uncovered Dessert Dishes During Meal Service
Penalty
Summary
Surveyors observed that the facility failed to ensure all food items, specifically dessert dishes containing slices of cake with frosting, were covered during storage, preparation, distribution, and service in accordance with professional food service standards. During lunch service, test trays presented to investigators showed that while main dishes were covered with cloches, the dessert dishes were left uncovered. Additionally, on the South Hall, trays in an opened meal cart had covered main dishes and drinks, but the dessert dishes remained uncovered while the cart was open for approximately two minutes as a CNA distributed trays to residents' rooms. Interviews with dietary staff, CNAs, the Dietary Manager, the Administrator, and the DON confirmed that facility policy requires food to be covered to prevent cross contamination and exposure to airborne contaminants. However, the Dietary Manager stated that desserts were not covered because they were transferred directly from the kitchen to the cart, and staff were expected to keep the carts closed after removing each tray. The facility's policy on food preparation and service also specifies that covering foods is appropriate when meals are assembled in the kitchen and delivered to residents' rooms or dining areas.
Failure to Provide Privacy Bag for Catheter Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a male resident with a history of bladder cancer and a urostomy was not provided with a privacy bag for his catheter bag, which collects urine. On multiple occasions, the catheter bag was observed hanging on the side of the resident's bed without a privacy cover, making its contents visible from the hallway. The resident reported that the catheter bag had been without a privacy bag since the previous day and expressed a preference for it to be covered to prevent others from seeing his urine when the door was open. Staff interviews confirmed that the catheter bag should have been inside a privacy bag to maintain the resident's dignity and prevent embarrassment, but staff failed to notice and address the exposed catheter bag during their rounds. Facility policy requires that urinary catheter bags be covered to promote and enhance residents' well-being and self-esteem, and to prohibit demeaning practices that compromise dignity. Despite this policy, the resident's catheter bag remained uncovered and visible for an extended period, as confirmed by observations and staff interviews. The failure to provide a privacy bag for the catheter bag resulted in the resident not being treated with the respect and dignity required by facility policy and regulatory standards.
Failure to Ensure Safe Medication Administration and Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and safe medication administration practices for one resident. A male resident with diagnoses of gastro-esophageal reflux disease and schizoaffective disorder was observed with a cup containing two pills, identified as TUMS, left on his bedside table. The resident stated that the night nurse left the pills for him to take later for heartburn. Review of the resident's records showed no physician order for TUMS, and there was no assessment or care plan intervention allowing the resident to self-administer medications. Interviews with nursing staff, including LVNs and the ADON, confirmed that medications should not be left with residents and that all medications administered must have a physician order. Staff also stated that the resident had not been assessed for self-administration of medications, and there were no instructions or documentation supporting self-administration. The facility's policies require medications to be administered as prescribed and in accordance with physician orders, and only by licensed personnel. The incident was further corroborated by interviews with the DON and Administrator, who both stated that medications should not be left unattended with residents and that staff are expected to ensure residents take their medications before leaving the room. The lack of a physician order for TUMS and the practice of leaving medications at the bedside constituted a failure to meet pharmaceutical service requirements for the resident.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A nurse's medication cart was observed parked in front of the nurses' station with its centralized metal lock protruding and not engaged, leaving the drawers unlocked and accessible. The cart, facing the hallway, contained various over-the-counter medications, blister packs, and insulins, and was left unattended while several staff and residents passed by. The cart could be easily opened, and it was only locked after the nurse returned to the area. Interviews with the ADON, Administrator, DON, and the nurse involved confirmed that the cart should not have been left unlocked and unattended, as this allowed unauthorized individuals, including residents, staff, and visitors, to potentially access the medications. The facility's policy requires medication carts to be locked when out of sight of the medication nurse or aide, which was not followed in this instance. The nurse admitted to leaving the cart unlocked due to being in a hurry, acknowledging that it was not an acceptable reason.
Failure to Maintain Infection Control Practices During Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents reviewed for infection control. In the first instance, a resident with neuromuscular dysfunction of the bladder and an indwelling catheter was observed being transferred from a wheelchair to a bed by a CNA. During the transfer, the CNA placed the resident's catheter bag on the floor, outside of its privacy bag, before completing the transfer and then hanging the bag on the bed rail. The CNA later acknowledged that the catheter bag should not have been placed on the floor due to the risk of contamination. In the second instance, another resident with muscle weakness and total incontinence was provided incontinent care by two CNAs. During the care, one CNA changed gloves after cleaning the resident's perineal area and bottom but did not perform hand hygiene before donning a new pair of gloves, which she retrieved from her pocket. The CNA admitted that she did not sanitize her hands between glove changes and recognized that gloves stored in her pocket could be contaminated. Facility policy reviews confirmed that catheter bags should be kept off the floor and that hand hygiene must be performed after glove removal and before donning new gloves. The observed actions by staff were inconsistent with these policies, resulting in a failure to prevent potential cross-contamination and infection among residents.
Failure to Provide Weekly Respiratory Equipment Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their care. Resident #5, a female with chronic obstructive pulmonary disease (COPD) and dyspnea, was not provided with a weekly change of her nasal cannula as ordered. Observations revealed that her nasal cannula was dated 04/12/2024, indicating it had not been changed weekly as required. This oversight was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the failure to adhere to the care plan. Similarly, Resident #9, who also had COPD and acute respiratory failure with hypoxia, did not receive the necessary weekly change of her nebulizer. The humidifier bottle connected to her oxygen concentrator was dated 02/24/24, suggesting it had not been changed for over two months. The ADON confirmed this finding and recognized the need to change the equipment to prevent infection and ensure the resident's respiratory needs were met. Interviews with the nursing staff, including RN A and the Director of Nursing (DON), highlighted the importance of changing the humidifiers and nasal cannulas weekly to prevent bacterial growth and potential infection. The facility's policy on oxygen administration, which mandates weekly changes of oxygen tubing and humidifier bottles, was not followed, leading to these deficiencies in care for the residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene between glove changes while providing colostomy care to a resident. This resident, who was severely cognitively impaired and dependent on staff for self-care, had multiple health conditions including cancer, heart disease, diabetes, and dementia. The resident was also identified as having a Multi-Drug Resistant Organism (MDRO) related to her colostomy, necessitating Enhanced Barrier Precautions (EBP) during care. Despite these precautions, the LVN failed to perform hand hygiene after removing the soiled colostomy bag and before applying a new one, which was contrary to basic infection control practices. In the second incident, two Certified Nursing Assistants (CNAs) did not sanitize a mechanical lift before and after transferring another resident. This resident, also severely cognitively impaired, required assistance with mobility due to the effects of a cerebrovascular accident and was dependent on staff for toileting and bathing. The facility had identified the need for EBP for this resident as well. However, the CNAs neglected to sanitize the lift, which is a shared-use equipment, either before or after its use, thereby failing to adhere to infection control protocols designed to prevent the spread of bacteria. Interviews with the staff involved and the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed a lack of adherence to established infection control procedures. The facility's policies required hand hygiene between glove changes and the sanitization of shared equipment between uses, but these were not followed. The facility's documentation and training materials did not explicitly instruct staff to perform hand hygiene during colostomy care, which contributed to the oversight. These lapses in infection control practices could potentially lead to cross-contamination and the spread of infections among residents.
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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 Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Ridge Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 11 | 0 |
| Settlers Ridge Care Center | 11.7 mi | ★★★★★ | 1 | 0 |
| Cottonwood Nursing And Rehabilitation | 15.4 mi | ★★★★★ | 17 | 0 |
| Denton Village By Purehealth | 15.5 mi | ★★★★★ | 15 | 1 |
| University Rehabilitation Center | 16.8 mi | ★★★★★ | 7 | 1 |
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