Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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 89 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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 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 | — | 8 | 0 |
| Greenhill Villas | 13.9 mi | — | 5 | 0 |
| Capstone Healthcare Of Daingerfield | 14.3 mi | — | 0 | 0 |
| Capstone Healthcare Of Hughes Springs | 14.9 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Pittsburg.
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 August 2026) and official state health department websites.