Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Pittsburg during CMS and state inspections, most recent first.
Call Lights Not Within Reach for Two Residents: Two residents with cognitive impairment and fall risk had call lights placed out of reach during repeated observations. One resident's call light was found on the opposite side of the room or pinned to a cord, and the other resident's call light was repeatedly on the floor at the head of the bed. CNA, LVN, ADON, DON, and the Administrator all stated call lights should be accessible and within reach.
Inaccurate MDS Oral Assessment: A resident with COPD, dementia, and other chronic conditions was observed with broken and missing teeth and reported mouth pain, but the MDS and care plan did not document any dental issues or pain. Staff interviews confirmed the resident’s oral status was not accurately captured, and facility leadership stated missing teeth and dental issues should have been documented on the MDS.
Incomplete and Non-Individualized Care Plans: The facility failed to develop and implement comprehensive person-centered care plans for multiple residents with identified medical and functional needs. One resident with a stage 3 sacral wound did not have EBP included on the care plan, another resident with seizures, altered diet, and ADL dependence did not have those needs reflected, and a third resident with COPD, oxygen use, antiplatelet therapy, and pain concerns had only a minimal care plan. Staff interviews confirmed the plans were not individualized and did not fully reflect diagnoses, medications, diet, or interventions.
A resident with COPD and impaired cognition had oxygen care not provided as ordered. Staff observed a used oxygen concentrator with dirty filters, dirty machine surfaces, and tubing and water reservoir that were past the ordered change date, while another concentrator in the room also had dirty filters. The DON and Administrator stated nursing staff were responsible for changing tubing, water reservoirs, and cleaning or replacing filters per orders.
Improper Storage of Wound Care Chemical in Resident Room: A resident with Parkinsonism, vitamin deficiency, and anxiety disorder had intact cognition and was independent with most ADLs, yet a bottle of liquid chemical wound cleanser was found in his room and remained there on a later observation. An LVN, DON, and Administrator stated wound care chemicals and other medications or chemicals should be kept in the treatment cart, medication cart, or medication supply room rather than in a resident's room.
Failure to Provide Ordered Large Portions: A cognitively intact resident with Parkinsonism, vitamin deficiency, and anxiety disorder had a care plan and meal ticket for large portions due to prior weight loss concerns, but he reported that he often received regular-sized meals instead. During observation, he showed photos of small or standard portions, and the Dietary Mgr, DON, and Administrator acknowledged that he had been served the wrong portion size.
A resident with a stage 3 sacral pressure ulcer and other chronic conditions was observed receiving hair washing without staff wearing gowns, even though EBP signage and PPE were present in the room. An LVN and a CNA both used gloves but did not apply gowns during the high-contact hygiene task, and the resident stated staff had not been using gowns for care. Interviews with the CNA, LVN, ADON, DON, and Administrator confirmed staff were expected to follow EBP for residents with wounds.
Failure to post daily nurse staffing information: The facility did not keep the nurse staffing post current and readily accessible for residents and visitors. The posting at the entrance remained dated and was not updated over multiple days, and the ADON, DON, and Administrator all confirmed that the staffing post was supposed to be updated daily; the Administrator also stated there was no policy addressing the staffing post.
A resident with multiple chronic conditions did not receive several scheduled doses of baclofen because the medication supply ran out and was not available in the emergency kit. Nursing staff did not notify the physician and only informed the DON after the resident reported the missed doses. The pharmacy had previously delivered a full supply, but the medication was depleted early, and facility protocols for timely notification and administration were not followed.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive impairment was allegedly struck by a MA after an altercation, and the incident was witnessed by a family member. The event was not reported to the Administrator or state agency in a timely manner, and the MA continued to work with residents, including being reassigned to the same unit. The required immediate reporting and staff suspension procedures were not followed, resulting in noncompliance and Immediate Jeopardy.
A medication aide was alleged to have physically abused a resident with severe cognitive impairment, but after the incident was reported to the former ADON, the aide was not suspended and continued to work with residents, including being reassigned to the same unit. The former ADON did not report the allegation to the Administrator as required by facility policy, resulting in the aide maintaining resident contact until the incident was reported again by a family member nearly a month later.
The facility failed to deliver mail to residents on Saturdays due to the absence of the BOM, who was the only person with access to the mail lockbox. This affected 5 residents who reported not receiving mail on weekends, a violation of their right to timely communication. The DON and ADM were unaware of the issue, which contradicted the facility's Mail Distribution Policy requiring same-day delivery.
The facility failed to ensure RN coverage for at least 8 consecutive hours daily, as required. Time sheets revealed that on multiple occasions, the RN worked less than the mandated hours, leading to a lack of supervisory support for RN-specific activities. Interviews with staff highlighted miscommunication and a lack of awareness regarding duty hours.
The facility failed to follow professional standards for food safety, as expired food was not disposed of, and frozen chicken lacked proper labeling. Meats were improperly thawed without continuous water flow. Interviews with staff confirmed these practices did not meet facility policies, posing a risk for foodborne illness.
A facility failed to ensure the accuracy of a PASRR Level I assessment for a resident with major depressive disorder and bipolar disorder. The assessment incorrectly indicated no mental illness, despite the resident receiving antipsychotic and antidepressant medications. The MDS Coordinator and Administrator acknowledged the error, and it was noted that there was no process to verify the accuracy of PASRR forms after completion.
A facility failed to ensure a resident with an indwelling catheter received appropriate care to prevent UTIs. The resident, with severe cognitive impairment and a history of urinary issues, was observed without a catheter securement device, contrary to physician orders and facility policy. Staff interviews confirmed the importance of securing the catheter to prevent complications, but the oversight was only corrected after being pointed out.
A facility failed to secure a resident's lorazepam, a controlled medication, with the required double locks. The medication room was locked, but both the refrigerator and the lockbox inside were unlocked, allowing unauthorized access. The DON and ADON confirmed the expectation for double locks to prevent drug diversion, as outlined in the facility's policy.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had call lights within reach. Resident #8 had diagnoses including senile degeneration of the brain, schizoaffective disorder, depression, and anxiety disorder. His MDS reflected severe impaired cognition with a BIMS score of 7, dependence on toileting and bathing, moderate assistance needed with all ADLs, and total incontinence of bowel and bladder. His care plan identified him as high risk for falls related to incontinence and lack of safety awareness, and included interventions to keep his call light within reach and encourage use for assistance. Resident #38 had diagnoses including unspecified dementia, cognitive communication deficit, extrapyramidal movement disorder, history of falling, muscle wasting and atrophy, difficulty walking, muscle weakness, and lack of coordination. Her MDS reflected that she was understood and understood others, was independent with toileting, and required partial assistance with ADLs. Her care plan identified her as a fall risk due to unsteady gait, decreased balance, medications, and poor safety awareness, and included interventions to keep her call light in reach and answered promptly. During multiple observations, Resident #38's call light was found on the floor at the head of the bed and not within reach, including when she was in bed resting and when she was not in the room. Resident #8's call light was observed on the other side of the room, pinned to a cord across the room, and on the opposite side of the room while he was in bed resting or asleep. Staff interviews confirmed that the call lights were not accessible, that all staff were responsible for ensuring accessibility, and that the residents could not call for help if needed. The facility policy stated that each resident is provided with a means to call staff directly for assistance from bed, toileting/bathing facilities, and from the floor.
Inaccurate MDS Oral Assessment
Penalty
Summary
The facility failed to ensure Resident #44’s assessment accurately reflected his oral status. The Annual MDS dated 1/30/2025 did not indicate that the resident had any missing or broken teeth, and the care plan dated 01/30/2026 also did not identify any dental issues or pain. The resident’s record showed diagnoses including COPD, dementia, hypertension, hyperlipidemia, GERD, pruritus, and pulmonary embolism with acute cor pulmonale, and the MDS documented that he was understood and understood others, had a BIMS score of 13, and was independent with ADLs. During an observation and interview on 2/9/2026, Resident #44 was sitting in a wheelchair with oxygen in his room and stated he was independent with most activities and no longer in therapy. He reported mouth pain from broken teeth and left ear pain, said he had reported tooth and left ear pain months earlier, and stated he wanted to see a dentist because of pain in the back of his mouth. He was not on a special consistency diet, and he was observed to have broken and missing teeth. Staff interviews showed the assessment information was not captured accurately. A CNA stated she was unaware the resident had missing teeth and had not heard him report mouth pain. An LVN stated that if something was missed on the MDS, it could negatively impact residents and delay care, and that missing teeth and dental issues should be documented. The ADON and DON stated the facility did not currently have an MDS nurse and that the MDS should match the resident’s current condition; the DON also stated missing teeth and dental issues should be documented on the MDS, but they were not.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 3 residents whose assessments identified ongoing medical, nursing, and functional needs. The report states that the care plans did not include measurable objectives and timeframes for the identified needs, and that the interdisciplinary team, including the DON, ADON, and corporate staff, were responsible for updating the plans. The facility’s policy required comprehensive care plans to be developed and revised when a resident’s condition changed, at least quarterly, and when desired outcomes were not met. For one resident with multiple sclerosis, psoriasis, protein-calorie malnutrition, bowel and bladder incontinence, dependence with ADLs, and a stage 3 sacral pressure ulcer, the care plan addressed the wound treatment but did not indicate that the resident was on enhanced barrier precautions related to the sacral wound. Staff interviews reflected that the wound had been thought to be cleared because the order included PRN wound care, and multiple staff members stated the resident should have been on EBP because he had a wound. The DON, ADON, and Administrator each acknowledged responsibility for care plan updates and stated that failure to update the plan could affect care and infection prevention. For another resident with Alzheimer’s disease, seizures, severe cognitive impairment, altered diet, and need for assistance with ADLs, the care plan did not include the resident’s seizure disorder, anticonvulsant medication use, altered diet, or impaired ADL performance. The resident’s records showed a diagnosis of seizure disorder, administration of levetiracetam, and a mechanically altered diet. Staff interviews stated that diagnoses, medications, diet, and interventions should be reflected in the care plan so staff would know what care to provide and what to monitor. For a third resident with COPD, dementia, hypertension, hyperlipidemia, GERD, pruritus, pulmonary embolism with acute cor pulmonale, oxygen use, nebulizer treatments, and antiplatelet therapy, the care plan only addressed code status and did not include COPD, pain, or antiplatelet medication. The resident was observed with oxygen in the room and reported mouth pain from broken teeth and left ear pain. Staff stated the care plan was insufficient and should have included diagnoses, medications, diet, and interventions so nursing staff would know how to care for the resident. The DON and Administrator acknowledged that the care plan should be individualized and updated when changes occurred.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD, schizophrenia, hypokalemia, and moderately impaired cognition. The resident’s care plan directed staff to administer oxygen therapy as ordered, and physician orders required the oxygen concentrator filter to be checked and cleaned weekly or as needed, and the oxygen tubing and water to be changed weekly and as needed. During observation and interview, the resident stated he used the black oxygen concentrator and did not use the white concentrator in his room. The black concentrator was plugged in, and its oxygen tubing and water reservoir were dated 12/22/25. On later observation, the black concentrator still had a dirty filter, dirty machine surfaces, and tubing and water reservoir dated 12/22/25; the white concentrator was not in use and both concentrators had dirty filters. Staff interviews confirmed that nurses were responsible for changing oxygen tubing, water reservoirs, and filters as ordered, and the DON and Administrator acknowledged that the tubing and filters should be changed or cleaned per orders.
Improper Storage of Wound Care Chemical in Resident Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for 1 of 13 residents reviewed for pharmacy services, involving Resident #26. Resident #26's face sheet reflected diagnoses including Parkinsonism, Vitamin Deficiency, and Anxiety Disorder. His quarterly MDS assessment reflected a BIMS score of 14, indicating intact cognition, and he was independent with most ADLs. During an observation and interview on 2/9/26, Resident #26 had a bottle of liquid chemical wound cleanser in his room and stated it was for his neck, where he previously had a wound that needed skin cleanser. The bottle remained in his room during a later observation on 2/10/26. An LVN stated wound care chemicals should be kept in the treatment cart or medication cart and should not be left in a resident's room. The DON and Administrator also stated that wound care chemicals, medications, or other chemicals should be kept in the medication cart or medication supply room and not left in residents' rooms.
Failure to Provide Ordered Large Portions
Penalty
Summary
The facility failed to provide Resident #26 with a nourishing, palatable, well-balanced diet that met his daily nutritional and special dietary needs by not honoring his ordered and care-planned large portions. Resident #26 was a cognitively intact male with diagnoses including Parkinsonism, vitamin deficiency, and anxiety disorder. His comprehensive care plan identified a problem related to unplanned weight loss after recent hospitalization and included an intervention for large portions with all meals. His lunch meal ticket also indicated that he was to receive a large portion of food. During interview and observation, Resident #26 stated that his food portions were too small and that he did not consistently receive double portions, despite requesting them and seeing that his meal ticket reflected that need. He showed surveyors photographs of meals that appeared to be regular-sized portions, including a breakfast with a single fried egg and biscuit, a sandwich with one slice of bologna, and a lunch tray with a regular portion of spaghetti, green beans, and garlic toast. The Dietary Manager, DON, and Administrator each acknowledged that residents ordered or care-planned for large portions should not receive normal portions and confirmed that Resident #26 had been given the wrong portion size on his lunch tray.
Failure to Use EBP During Resident Hygiene Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 1 of 13 residents reviewed for infection control practices. Resident #4 was a male admitted to the facility with diagnoses including multiple sclerosis, psoriasis, and protein-calorie malnutrition. His MDS assessment reflected that he was usually understood, had a BIMs score of 15 indicating intact cognition, and was dependent on ADLs. His care plan documented a stage 3 pressure ulcer to the sacrum related to immobility, and the order summary reflected wound treatment ordered on 02/06/26. During an observation on 02/10/26, LVN A washed Resident #4's hair while wearing gloves but did not apply a gown. CNA B assisted by holding the resident's head with gloves on and also did not apply a gown. The resident had a sign in the room and PPE available for enhanced barrier precautions. The care plan did not include a specific plan related to enhanced barrier precautions. During interview, the resident stated that when staff changed him, gave him a bed bath, and did wound care, they did not put on gowns, and he said the gowns were put up only after state surveyors were present. During interviews, CNA B agreed she was supposed to have worn a gown while assisting with hair washing and stated staff were supposed to wear gown and gloves because the resident had a wound. LVN A stated she thought the wound had been cleared because the wound care order said PRN, but also agreed she should have worn PPE while providing care. The ADON, DON, and Administrator each stated staff were expected to follow enhanced barrier precautions, including gown and glove use for high-contact care, and that staff were responsible for applying PPE and following EBP. The facility policy stated that EBPs include targeted gown and glove use during high-contact resident care activities, including hygiene, and are indicated for residents with wounds.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed. The staffing information was not posted with the current daily data on 02/06/26, 02/07/26, and 02/08/26. During an observation on 02/09/26 at 8:48 AM, the nurse staffing data posted at the facility entrance was easily visible but was dated 02/05/26. During interviews on 02/11/26, the ADON stated she was responsible for updating the staffing posting and usually did it first thing in the morning, but she did not work on the weekend, so it had not been changed since Friday. The DON stated the ADON was responsible for updating the posting and that it should be updated daily where everyone could see it. The Administrator also stated the nurse staff posting should be updated every day and corrected if there was a change, and said there was no policy to address the staffing post.
Failure to Ensure Timely Administration of Ordered Medication Due to Supply Lapse
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple diagnoses, including spinal stenosis, dementia, and chronic obstructive pulmonary disease. The resident had a physician's order for baclofen 5 mg to be administered orally three times daily. However, the medication was not administered as ordered on four occasions over two consecutive days because the supply had run out and was pending arrival from the pharmacy. Documentation in the Medication Administration Record (MAR) and progress notes confirmed that the baclofen was not given at the scheduled times, and staff interviews revealed that the medication was not available in the emergency medication kit in the required dosage. The nurse involved stated that when medications were unavailable, she would check the emergency supply and notify the pharmacy and DON, but in this instance, the physician was not notified, and the resident missed several doses. The DON was only made aware of the issue after the resident reported it, and upon investigation, found that the medication had not been administered due to lack of supply and that the pharmacy had previously delivered a 30-day supply earlier in the month. Further review with the pharmacy confirmed that the medication had been delivered as scheduled, but the resident ran out of the medication several days early. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this case. The administrator stated that staff were expected to notify management immediately if a medication was unavailable so it could be reordered and administered by the next scheduled dose, but this protocol was not followed, resulting in missed doses for the resident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report and Respond to Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately as required. Specifically, an incident occurred in which a male resident with severe cognitive impairment and a history of dementia, psychosis, restlessness, agitation, and anxiety disorder was allegedly punched in the chest by a medication aide (MA) after the resident kicked the MA. The incident was witnessed by another resident's family member, who reported it to the former Assistant Director of Nursing (ADON) four days later. The former ADON did not report the allegation to the Administrator or the abuse coordinator, nor did he initiate the required notifications or immediate suspension of the accused staff member. The facility's records indicate that the alleged abuse was not reported to the state agency until a month after the incident, when the family member reported the event to the Administrator upon seeing the MA assigned to the same unit again. During this period, the MA continued to work in the facility, including being reassigned to the unit where the incident occurred. The facility's policy required immediate reporting of suspected abuse to the Administrator and other authorities, and for any employee accused of abuse to be placed on leave with no resident contact until the investigation was complete. These procedures were not followed in this case. Interviews with the former ADON revealed that he was aware of concerns regarding the MA's behavior but did not take the necessary steps to escalate or formally report the incident. The family member who witnessed the event expressed concern about the MA's continued presence on the unit, which prompted the eventual report to the Administrator. The delay in reporting and failure to remove the accused staff member from resident contact constituted noncompliance and resulted in a period of Immediate Jeopardy.
Failure to Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to protect residents from potential abuse after an allegation of physical abuse was reported against a medication aide (MA). The incident involved a male resident with severe cognitive impairment, including dementia, psychosis, and anxiety disorder, who was alleged to have been punched in the chest by the MA after the resident kicked her. The incident was witnessed by another resident's family member, who reported it to the former Assistant Director of Nursing (ADON) several days later. The former ADON did not report the allegation to the Administrator, nor did he suspend the MA from resident contact, but instead reassigned her to a different unit. Despite the family member's concerns and explicit request that the MA not work on the secured unit, the MA continued to work in the facility and was later assigned again to the same unit as the resident involved in the alleged abuse. The MA remained in contact with residents, including the alleged victim, until the family member reported the incident directly to the Administrator nearly a month later. The facility's own policies required immediate reporting of abuse allegations to the Administrator and suspension of the accused employee from resident contact pending investigation, but these procedures were not followed by the former ADON. Interviews and record reviews confirmed that the MA worked multiple shifts after the initial allegation was made and that the former ADON did not escalate the report as required. The Administrator stated that she was not informed of the incident until much later and that the MA should have been suspended immediately. The facility's policies and regulatory guidance clearly outlined the need for immediate action to protect residents and report allegations, but these were not adhered to, resulting in a period where residents were at risk for further abuse.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail within 24 hours of delivery by the postal service, affecting 5 of 5 residents reviewed for the right to communication. During a confidential group interview, residents reported not receiving mail on Saturdays, as the business office manager (BOM) was not present on weekends to access the mail lockbox. The BOM confirmed that since her hiring in May 2023, no mail had been distributed on Saturdays due to her absence and lack of a designated person to handle mail delivery on weekends. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that they were unaware of the issue, but acknowledged the importance of timely mail delivery as a resident right. The DON stated that residents should receive mail Monday through Saturday, and the failure to do so was a violation of their rights. The Administrator (ADM) also admitted to not realizing the oversight and emphasized the potential distress and worry caused to residents by not receiving mail timely. The facility's Mail Distribution Policy, dated December 2020, mandates that mail be delivered to residents within the same day of receipt, highlighting the facility's non-compliance with its own policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of the facility's time sheets, which showed that on several occasions, the RN worked less than the mandated 8 hours. Specifically, on dates such as 04/07/24, 04/14/24, 04/20/24, 04/21/24, 06/01/24, 06/02/24, 06/29/24, and 06/30/24, the RN worked between 7.30 and 7.73 hours, failing to meet the required coverage. The facility's policy mandates 24-hour licensed nursing and an RN on duty for 8 consecutive hours daily, which was not adhered to on these occasions. Interviews with facility staff, including the VP of operations, ADON, DON, and the Administrator, revealed a lack of awareness and miscommunication regarding the RN's duty hours. The ADON acknowledged that the RN clocked out for lunch, resulting in less than 8 hours of work, and attributed this to a misunderstanding of the expected work hours. The DON expressed an expectation for the RN supervisor to be present for the full 8 hours and indicated that she would personally cover if the RN needed to leave. The Administrator also confirmed the expectation of 8-hour RN coverage daily. This failure to provide adequate RN coverage had the potential to leave staff without necessary supervisory support for RN-specific activities and coordination during emergencies.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Expired food items, including milk and beef flavoring, were not disposed of, and frozen chicken was found without proper labeling or dating. Additionally, the process of thawing chicken, turkey, and ham did not comply with safety standards, as these meats were not submerged under water or had water running over them continuously. These practices were observed during specific times, indicating a lack of compliance with food safety protocols. Interviews with the Dietary Manager, Director of Nurses, and the Administrator confirmed that the facility's practices did not align with their expectations or the facility's policies. The Dietary Manager acknowledged that meat should be thawed with water running continuously and that all food should be labeled, dated, and expired items discarded. The Director of Nurses and the Administrator echoed these expectations, emphasizing the risk of foodborne illness if these standards were not met. The facility's document on food storage, revised recently, outlines the requirement to store food according to state, federal, and US Food Codes, maintaining specific temperatures for different food types.
Inaccurate PASRR Level I Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident, which did not reflect the resident's mental illness diagnoses. The resident, who was readmitted to the facility, had documented diagnoses of major depressive disorder and bipolar disorder. However, the PASRR Level I screening incorrectly indicated that the resident did not have a mental illness. This discrepancy was identified during a review of the resident's records, which showed that the resident was receiving antipsychotic and antidepressant medications, further supporting the presence of mental illness. Interviews with the MDS Coordinator and the Administrator revealed that the PASRR Level I form was not completed accurately at the time of the resident's admission. The MDS Coordinator acknowledged the error and noted that a new form was completed to reflect the resident's mental illness diagnoses. The Administrator admitted that the resident should have had a positive PASRR Level I form and that there was no process in place to verify the accuracy of PASRR forms after they were completed by the MDS Coordinator. The facility's policy requires coordination with the referring entity to ensure the PASRR Level I form is completed accurately before admission.
Failure to Secure Indwelling Catheter Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections (UTIs). The deficiency was identified for a resident who was incontinent of bladder and had an indwelling catheter. The resident, a male with severe cognitive impairment and a history of obstructive and reflux uropathy, hypertension, and dementia, was observed without a catheter securement device on his leg, which is necessary to prevent UTIs and other complications. The resident's care plan indicated a risk for UTIs and required catheter care per facility policy. Despite physician orders and the Medication Administration Record (MAR) indicating that a Foley catheter strap should be in place every shift, the catheter was not secured during an observation. LVN B, who was responsible for the resident's care, acknowledged the importance of securing the catheter to prevent UTIs and other issues but had not checked the securement that day. The catheter was only anchored after the oversight was pointed out. Interviews with facility staff, including CNAs, LVNs, the ADON, and the DON, revealed that the responsibility for ensuring catheter securement lay with the nursing staff. The staff acknowledged the importance of securing the catheter to prevent UTIs, dislodgement, and harm to the resident. The DON noted that the catheter should be checked periodically throughout the shift, especially given the resident's history of pulling out the catheter. However, the failure to secure the catheter as required by policy and physician orders was evident during the surveyor's observation.
Failure to Secure Controlled Medications with Double Locks
Penalty
Summary
The facility failed to ensure that controlled drugs were stored in compliance with regulations requiring double locks. During an observation, it was found that the medication room was locked, but the medication refrigerator and the lockbox inside it were both unlocked. This allowed access to a controlled anti-anxiety medication, lorazepam, prescribed to a resident. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) both acknowledged that the lorazepam should have been secured behind two separate locks to prevent unauthorized access and potential drug diversion. The facility's policy on controlled medication storage, dated 11/13/18, mandates that medications classified under Schedules II, III, IV, and V be stored under double lock in a designated cabinet or safe. The policy also specifies that the access key to controlled medications should not be the same as the key for other medications, and that the medication nurse on duty should maintain possession of the key. Despite these guidelines, the surveyor was able to access the lorazepam without encountering any locked compartments beyond the initial room lock, indicating a lapse in adherence to the facility's own procedures and federal regulations.
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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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Nursing homes near Pittsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Springs Healthcare Center | 12.4 mi | ★★★★★ | 13 | 1 |
| Focused Care At Mount Pleasant | 12.4 mi | ★★★★★ | 10 | 0 |
| Greenhill Villas | 13.9 mi | ★★★★★ | 5 | 0 |
| Capstone Healthcare Of Daingerfield | 14.3 mi | ★★★★★ | 1 | 1 |
| Capstone Healthcare Of Hughes Springs | 14.9 mi | ★★★★★ | 1 | 0 |
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