Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, and record review, the facility failed to ensure residents received mail delivered to the
facility for 5 of 5 confidential residents reviewed for right to communication.
Residents Affected - Some
The facility failed to ensure residents received their mail within 24 hours of delivery by the postal service.
This failure could place residents at risk of potentially being denied their right and to receive and open mail
in a timely manner and a diminished quality of life.
Findings included:
During a confidential group interview on 11/19/24 at 10:08 AM, 5 of 5 residents interviewed said mail was
not being distributed on Saturdays. All 5 residents said they had not gotten mail on Saturdays in a long
time. One of 5 residents interviewed said, The business office lady was not here on Saturday's so we do not
get mail on weekends.
During an interview on 11/19/24 at 10:47 AM, the BOM said residents got mail Monday through Friday. She
said it was delivered in a lockbox outside the facility and she was the only one with a key to the lockbox.
She said no one had a key on the weekends to get the mail so it could be delivered to the residents. She
said she was hired in May of 2023 and the prior administrator gave her the key to the mailbox in June or
July 2023. She said since that time (June or July of 2023) no resident had received mail on Saturdays
because she did not work on weekends. She said residents were supposed to receive mail on Saturdays,
but the prior administrator knew they did not. She said she did not know if the (current) new administrator or
new DON knew residents were not getting mail on Saturdays.
During an interview on 11/20/24 at 10:57 AM, the ADON said it was important for residents to get their mail
on weekends because it was their right. She said not getting their mail could cause them to miss news and
information important to them, or cause residents' distress and worry.
During an interview on 11/20/24 at 12:33 PM, the DON said all residents should get mail Monday through
Saturday. She said it was their right to receive mail or something they ordered timely. She said if they were
waiting on an important document, they should be able to receive it timely. The DON said not receiving mail
timely was a violation of resident's rights. She said she did not know residents were not receiving mail on
Saturday, but the problem was fixed now. From now on, the facility will designate the weekend RN
supervisor who will have a key to the mailbox so she will be able to get and deliver the mail to the residents
on weekends. She said the weekend RN supervisor will also check the front door for packages. The DON
said she would be the back-up person for the weekend RN supervisor. If the weekend RN supervisor could
not deliver the mail, then she would.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 13
Event ID:
675037
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0576
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 11/20/24 at 12:41 PM, the ADM said all residents should receive mail on weekdays
and weekends because it was their right to receive their mail in a timely manner. She said she did not know
residents were not getting mail on Saturday. She said she took responsibility for not checking on that. She
said the BOM, was responsible for getting residents mail and delivering it, but she did not realize no one
was delivering mail on Saturday's. The ADM said the risk of residents not getting mail in a timely manner
was not hearing from their family, or they may have business type mail they needed. She said there was a
risk of worry or distress if residents' were waiting on something to come in the mail.
Record review of a Mail Distribution Policy dated 12/2020, provided by the DON indicated:
Policy:
To ensure that each patient's/resident/s personal mail (incoming and outgoing) is handled in a private and
confidential manner.
It is the facility's policy to:
1.Distribute all incoming mail to the addressed patient/resident unopened and within the same day on
which it was d delivered to the Activity Department. If the patient/resident is incapable of
receiving/managing his/her/personal mail, his/her mail should be promptly distributed to the
patient's/resident's qualified legal representative.
2.Develop a system of delivering mailing patient's/resident's personal mail, involving the Activity
Department and the person who receives the mail (i.e., the Receptionist, charge nurse, business office),
and including provisions whereby the Activity Department is either informed that mail has arrived or is
physically given the mail.
Procedures:
1.The Activity Staff or Designee:
A. Deliver personal mail to the patient's/resident's room within 24 hours of receipt .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 2 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review
(PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #32)
reviewed for PASRR Level I screenings.
Residents Affected - Few
The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #32. The PASRR
Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (major depressive
disorder and bipolar disorder) were present upon Resident #32's re-admission date on 04/20/23.
This failure could place residents who had a mental illness at risk of not receiving a needed assessment
(PASRR Evaluation), individualized care, or specialized services to meet their needs.
Findings included:
Record review of Resident #32's face sheet, dated 11/18/24, indicated he was a [AGE] year-old male,
admitted to the facility on [DATE], and readmitted most recently on 04/20/23. His diagnoses included major
depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest) and
bipolar disorder(a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and
concentration).
Record review of Resident #32's annual MDS assessment, dated 09/10/24, indicated he had a BIMS score
of 14, which indicated intact cognition. The MDS further indicated he received an antipsychotic medication
and an antidepressant medication during the assessment window.
Record review of Resident #32's PASRR Level 1 Screening, dated 11/02/22, indicated that in Section C,
Mental Illness was marked as no, which indicated Resident #32 did not have a mental illness.
During an interview on 11/19/24 at 11:30 AM, the MDS Coordinator said she only found one PL1 form that
was completed for Resident #32. She said it was incorrect and Resident #32 had the diagnoses of major
depressive disorder and bipolar disorder at admission and the PL1 form should have indicated yes for
mental illness.
During an interview on 11/20/24 at 08:37 AM, the MDS Coordinator said that she completed a 1012 form
and a new PL1 form related to Resident #32's mental illness diagnoses. She said Resident #32 should
have had a positive PL1 on admit to the facility. She said it was unlikely he would qualify for PASRR
services because he had not had any psych hospitalizations or contact with the police.
During an interview on 11/20/24 at 12:47 PM, the Administrator said Resident #32 should have had a
positive PASRR Level 1 form. She said it was possible that he could have received PASRR Services this
entire time he had been in the facility. She said no one was responsible for checking over the PASRR forms
after the MDS coordinator.
Record review of the facility's undated policy, PASRR Services, stated:
.In Texas, nursing facilities are required to adhere to the Preadmission Screening and Resident Review
(PASRR) process, a federally mandated program designed to ensure that individuals with mental
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 3 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
illness (MI), intellectual disability (ID), or developmental disability (DD) are appropriately placed and receive
necessary services.
Level of Harm - Minimal harm
or potential for actual harm
Procedure:
Residents Affected - Few
1. PL1 Screening Form Completion:
*Before admitting any individual, the referring entity must complete the PASRR Level I (PL1) Screening
Form to identify potential MI, ID, or DD. The nursing facility should coordinate with the referring entity to
ensure this form is completed.
2. admission Protocols:
*If the PL1 indicates no suspicion of MI, ID, or DD, the nursing facility can admit the individual through the
routine admission process.
*If the PL1 indicates a suspicion of MI, ID, or DD, the facility must ensure that a PASRR Evaluation (PE) is
completed before admission, unless the admission qualifies as an expedited admission or an exempted
hospital discharge .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 4 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure a resident who was incontinent of
bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 residents
(Resident #33) reviewed for appropriate treatment and services to prevent urinary tract infections (an
infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine
leave your body).
The facility failed to ensure Resident #33's indwelling catheter (drains urine from your bladder into a bag
outside your body) had a catheter securement device to anchor the catheter to his leg on 11/19/24.
These failures could place residents at risk for urinary tract infections.
Findings included:
Record review of the undated face sheet indicated Resident #33 was a [AGE] year-old male that admitted
[DATE] and readmitted [DATE]. Resident #33 had diagnoses that included: Obstructive and reflux uropathy
(a blockage in the urinary tract that prevents urine from draining causing it to back up into the kidneys),
hypertension (the force of blood against the artery walls is too high), and dementia (impairment of at least 2
brain functions, such as memory loss and judgment.)
Record review of the significant change MDS dated [DATE] indicated Resident #33 had a BIMS score of 0,
indicating severe cognitive impairment. The MDS indicated he required substantial/maximal assistance with
toileting hygiene and partial to moderate assistance to roll left and right in bed. He had an indwelling
catheter.
Record review of the undated care plan indicated Resident #33 had dementia with behavioral disturbances.
The care plan indicated he had a diagnosis of a bladder disorder for difficulty starting, stopping urinary flow,
urinary retention, and UTI. Resident #33 had an indwelling catheter and was at risk for UTI, complications.
The care plan indicated to provide catheter care per facility policy and PRN.
Record review of Resident #33's physician's orders dated 6/5/24 indicated:
Foley catheter strap in place every shift.
Record review of Resident #33's MAR for October 2024 indicated:
Foley catheter strap in place every shift. The MAR was initialed for every day of October 2024.
Record review of Resident #33's MAR for November 2024 indicated:
Foley catheter strap in place every shift. The MAR was initialed November 1-19, 2024. LVN B had initialed
for the foley catheter strap for the day shift and evening shift on 11/19/24.
During an observation and interview on 11/19/24 at 2:03 PM, CNA A provided catheter care for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 5 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Resident #33. LVN B assisted with catheter care. Resident #33 did not have his foley catheter tubing
anchored or secured to his leg. LVN B said she had not checked today to see if the foley had been
anchored. She said it was important for the catheter to be anchored to his leg to prevent UTI's and so that it
did not pull on his penis. She said the catheter tubing secured to his leg prevented friction to his penis. LVN
B anchored the catheter to Resident #33's leg after catheter care.
Residents Affected - Few
During an interview on 11/20/24 at 10:20 AM, CNA C said if a resident had a catheter they should have an
anchor on their leg to prevent the catheter from tugging or pulling or coming out. She said the nurse was
responsible for making sure the catheter securement device was in place. She said if a resident had a
catheter and did not have it secured, she would tell the nurse.
During an interview on 11/20/24 at 10:30 AM, LVN D said the nurses were responsible for making sure
residents with a catheter had it secured. She said regarding Resident #33, it was especially important for
him because he had pulled his catheter out in the past. She said the catheter securement helped to prevent
tugging, UTI's, and backflow of urine (into the bladder.) She said she usually checked his catheter and
placement once per shift. She said if a CNA noticed a resident with a catheter did not have it secured, the
CNA should tell the nurse immediately.
During an interview on 11/20/24 at 10:57 AM, the ADON said the nurses were responsible for making sure
the catheter was secured and the nurse had to check off on the MAR that it was done. She said the
catheter securement was for protection because it prevented UTI's, protected the flow of urine by gravity,
and prevented pulling.
During an interview on 11/20/24 at 12:33 PM, the DON said the nurse was responsible for making sure any
catheter was secured. She said the LVN B should have checked to make sure the catheter was secured,
and especially with Resident #33 because he would pull the catheter out. She said catheter securement
should be checked periodically throughout the shift because of Resident #33 removing it from his leg. She
said any nurse for him should check placement of the catheter securement device when they get start their
shift. The DON said it was important for the catheter to be secured to prevent infection, dislodgement, and
harm to the resident from pulling and/or tugging. She said the catheter tubing could get tangled on
something, or the resident could pull on it. She said this was the only catheter she had in the building. She
said she was in the process of doing an in-service for all nurses to check for placement at the start of their
shift.
During an interview on 11/20/24 at 12:41 PM, the ADM said it was the responsibility of the charge nurse or
nurse to make sure a catheter was secured to a resident's leg. She said it was important because it would
help it to stay in place and help prevent tugging and discomfort. She said the catheter being secured could
help prevent Resident #33 from pulling it out. She said the risk of not having the catheter secured was
injury, discomfort and maybe a UTI. She said she did not know if nurses had to sign off on the MAR
regarding checking for the catheter securement.
Record review of A Catheter Care, Urinary Policy dated 7/1/2020 provided by the DON indicated:
Purpose
The purpose of this procedure is to prevent catheter-associated urinary tract infections .
Changing Catheters
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 6 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
.2.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the
insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 7 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to use the services of a registered nurse for at least
8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage.
Residents Affected - Some
The facility failed to provide RN coverage for 8 consecutive hours daily on 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.
This failure had the potential to place residents at risk by leaving staff without supervisory coverage for RN
specific nursing activities and for coordination of events such as emergency care and disasters.
Findings included:
Record review of the facility's time sheets for 04/01/24 through 06/30/24 for RN coverage indicated that RN
E worked the following days for the specified amount of time:
04/07/24 7.73 hours
04/14/24 7.65 hours
04/20/24 7.67 hours
4/21/24 7.60 hours
06/01/24 7.67 hours
06/02/24 7.37 hours
06/29/24 7.30 hours
06/30/24 7.65 hours
The time sheets did not indicate any other RN working the identified days.
During an interview on 11/20/24 at 09:29AM, the VP of operations said she was not aware of another RN
working on the identified days when RN E worked less than 8 hours.
During an interview on 11/20/24 at 12:30 PM, the ADON said she expected the RNs to stay on the clock for
8 hours. She said the RN clocked out for lunch and worked less than 8 hours. She said this was
miscommunication of how long the RNs should be on the clock.
During an interview on 11/20/24 at 12:43 PM, the DON said she expected the RN supervisor to be at the
facility for 8 hours on the clock. She said from now on the nurse will be expected to work the consecutive 8
hours. She said if the nurse had to leave, she expected the nurse to contact her and she would come up to
the facility and relieve her.
During an interview on 11/20/24 at 12:47 PM, the Administrator said she expected the facility to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 8 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
have RN coverage for 8 hours a day for 7 days a week.
Level of Harm - Minimal harm
or potential for actual harm
Record review of the facility's undated policy, Nurse Staffing Requirements, stated:
Residents Affected - Some
.The requirements for long-term care facilities require that nursing facilities provide 24-hour licensed
nursing, provide a Registered Nurse (RN) for eight (8) consecutive hours a day, seven (7) days a week, and
that there be a RN designated as Director of Nursing on a full-time basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 9 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to provide separately locked, permanently
affixed compartments for storage of controlled drugs in 1 of 1 medication rooms reviewed for storage of
medication (Front Medication Room).
The facility failed to ensure Resident #1's lorazepam medication (controlled anti-anxiety medication) was
locked behind 2 separate locks. The medication room was locked but the medication refrigerator and the
lockbox inside the medication refrigerator were both unlocked.
This failure could place residents who take narcotics that required refrigeration at risk of misappropriation of
drugs.
Findings included:
Record review of Resident #1's face sheet, dated 11/20/24, indicated she was a [AGE] year-old female,
admitted to the facility on [DATE].
Record review of Resident #1's physician's orders, dated 11/20/24, indicated this order:
*Lorazepam - Schedule IV concentrate; 2mg/mL; 0.5-1mL oral as needed. The start date was 10/02/24.
During an observation and interview on 11/19/24 at 01:25PM, RN E unlocked and opened the front
medication room door. She then opened the unlocked medication refrigerator. This surveyor then reached
inside the refrigerator and opened a lockbox in the refrigerator. The lockbox was not locked. Inside the lock
box was Resident #1's lorazepam concentrate medication. The DON was also present during this
observation, and she said the lorazepam medication should have been locked in the lock box.
During an interview on 11/20/24 at 12:30 PM, the ADON said she expected the controlled medications be
behind two separate locks. She said the risk was that someone could take the medication. She said there a
risk of a possible drug diversion.
During an interview on 11/20/24 at 12:43 PM, the DON said her expectation was for the controlled
medications to have two separate locks. She said the risk was that there could have been a possible drug
diversion.
During an interview on 11/20/24 at 12:47 PM, the Administrator said she expected the controlled
medications to have at least 2 separate locks. She said the risk was a possible drug diversion.
Record review of the facility's policy, Controlled medication storage, dated 11/13/18, stated:
.Medications included in the Drug Enforcement Administration (DEA) classification as controlled
substances are subject to special handling, storage, disposal and recordkeeping in the facility in
accordance with federal, state and other applicable laws and regulations.
Procedures
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 10 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
a. The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and
state laws and regulations in the handling of controlled medications. Only authorized licensed/and or
certified nursing and pharmacy personnel have access to controlled medications.
b. Medications listed in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe
designated for that purpose, separate from all other medications. Alternatively, in a unit dose system,
Schedule III, IV, and V medications may be kept with other medications in the cart or in a separate locked
drawer on the cart. The access key to controlled medications in not the same key giving access to other
medications. The medication nurse on duty maintains possession of the key to controlled medication
storage areas. Back-up keys to all medication storage areas, including those for controlled medications, are
kept by the director of nursing .
Event ID:
Facility ID:
675037
If continuation sheet
Page 11 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and
serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for
kitchen sanitation in that:
1. Expired food, milk, and beef flavoring, was not disposed of.
2. Frozen chicken was not labeled or dated.
3. Chicken, turkey, and ham was being thawed without being submerged under water or without water
running.
These failures could place residents who received meals from the kitchen at risk for food borne illness.
The findings were:
During an observation on 11/18/24 at 8:52 a.m., it was observed that a large bowl of chicken meat was
being thawed in the kitchen sink without being submerged under water or running water running over the
top. It was observed that cultured buttermilk with an expiration date of 11/4/24 was still in the milk
refrigerator. It was observed that beef flavoring was out on a prep table with an expiration date of 2/15/24. It
was observed that tortillas and chicken was not labeled or dated. The chicken meat was in two, gallon sized
plastic bags, with no date or label, and copious amounts of ice buildup inside the bag on the chicken meat.
During an observation on 11/19/24 at 11:29 a.m., it was observed that two packages of turkey and one
package of ham were observed thawing partially submerged underwater with no water running
continuously.
During an interview on 11/20/24 at 11:05 a.m., the Dietary Manager said that meat should not be thawed in
a sink without being fully submerged and water running continuously to agitate the water. She said that food
should be labeled and dated. She said that expired foods should be thrown away. She said that residents
could be placed at risk for foodborne illness if these regulations were not followed .
During an interview on 11/20/24 at 12:28 p.m., the Director of Nurses said that she expects that all kitchen
staff follow facility policy and state regulations. She said she expects that if staff were to thaw meat it would
be submerged underwater with water continuously running. She said that all expired items should be
thrown out. She said that all food items should be labeled and date. She said that residents could be placed
at risk for foodborne illness from eating food that was not properly prepared or stored.
During an interview on 11/20/24 at 12:40 p.m., the Administrator said that she expects that her kitchen staff
follow regulations and facility policy. She said all expired foods should be thrown away. She said all foods
should be labeled and dated. She said that meats should be thawed properly and per regulations. She said
that residents could be placed at risk of foodborne illness if they eat food that was not handled properly.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675037
If continuation sheet
Page 12 of 13
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675037
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Pittsburg
123 Pecan Grove
Pittsburg, TX 75686
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of the facility document revised June 1, 2019, Food Storage provided by the Dietary Manager
revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food
will be stored according to the state, federal and US Food Codes and HACCP guidelines Keep fresh meat,
poultry, seafood, dairy products and most fresh fruit and vegetables in the refrigerator at an internal
temperature of 41°F or less Once frozen food has been thawed, it must be maintained at 41°F or
less prior to cooking.
Event ID:
Facility ID:
675037
If continuation sheet
Page 13 of 13
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the November 20, 2024 survey of AVIR AT PITTSBURG?
This was a inspection survey of AVIR AT PITTSBURG on November 20, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVIR AT PITTSBURG on November 20, 2024?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure residents have reasonable access to and privacy in their use of communication methods."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.