Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Medicalodges Frontenac during CMS and state inspections, most recent first.
A resident with depression, limited mobility, and a history of impaired safety awareness exited the facility unattended in a motorized wheelchair. The care plan and elopement risk assessments did not initially identify the resident as at risk, and staff were unaware of the exit when a family member deactivated the door alarm without notification. The resident was found and returned without injury after being outside for approximately 20 minutes.
The facility did not accurately post daily nurse staffing information, as required, by failing to record the actual hours worked by licensed and unlicensed nursing staff on the daily staffing sheets. This deficiency was confirmed by an administrative nurse and was not in accordance with the facility's policy.
The facility did not conduct annual performance reviews for three CNAs employed for over a year, as required by their Employee Handbook. The CNAs lacked documented evaluations in their personnel files, and Administrative Nurse D acknowledged that the evaluations were not current.
The facility failed to submit accurate direct care staffing information to CMS for Quarters 1, 2, and 3 of 2024. The PBJ Staffing Data Report showed low weekend staffing levels, despite schedules indicating similar staffing to weekdays. Administrative Staff A confirmed the inaccuracy, and the facility lacked a policy for PBJ reporting.
A facility failed to provide a sanitary dressing change for a resident with a stage three pressure ulcer, as a nurse placed supplies on an unsanitized surface. The facility also inadequately tracked infections, lacking culture results and compliance with McGeers criteria. Additionally, PPE and COVID-19 testing supplies were improperly stored on the floor, with no policy in place for storage.
The facility failed to ensure safe transfer practices for two residents with severe cognitive impairment, leading to unsafe transfers due to inadequate weight-bearing and improper use of assistive devices. Additionally, an unlocked janitor's closet containing harmful chemicals was found in a resident hall with confused residents, posing a safety risk. The facility lacked policies for safe transfers and chemical security.
The facility failed to maintain a safe, sanitary, and homelike environment in two resident rooms and one hallway. A strong urine odor was detected in the west hallway and inside a resident room. Black streaks were observed on a wall beside a resident's bed, caused by a positioning bar scraping against it. Another room had yellow-brown stains on the ceiling. These issues were confirmed by staff during an environmental tour, indicating a lapse in following the facility's housekeeping policy.
A facility failed to obtain a signed bed hold for a resident admitted to a hospital with a UTI and sepsis. The resident's EMR lacked documentation of a signed bed hold, which was confirmed by an administrative nurse. The facility's policy requires a written notice of bed hold policies at the time of transfer to a hospital.
A facility failed to create a comprehensive care plan for a resident with incontinence issues, leading to frequent urine saturation of the bed and a strong urine odor in the room. The resident, who requires maximum assistance and often refuses care, was not provided with specific instructions for check and change frequency or interventions for care refusal. Staff were unaware of the resident's care refusals, and the facility lacked a policy for care plan development.
A resident with dementia, dependent on staff for personal hygiene, was not regularly shaved, despite being unable to communicate his needs. Observations showed the resident with long, unshaven facial hair, and interviews revealed staff only shaved residents on shower days. The facility lacked a specific ADL policy, contributing to this oversight.
A resident with a history of urinary tract infections and incontinence was not provided adequate toileting opportunities, leading to frequent incontinence episodes and a strong urine odor in the room. Despite being able to communicate needs, the resident often refused care, and staff were not fully informed or equipped to manage the situation effectively. The facility failed to conduct a thorough assessment and develop an optimal toileting plan, increasing the risk of further infections.
A facility failed to follow antibiotic stewardship principles, leading to inappropriate antibiotic use for a resident with a history of UTIs. Despite a physician's order for cefdinir based on a culture report, a subsequent urine sample showed no UTI. Macrodantin was later prescribed without a supporting culture report, and cefuroxime axetil was administered based on susceptibility to proteus mirabilis. The facility did not adhere to its policy requiring review of lab results to support antibiotic use.
The facility failed to ensure adequate staff for safe mechanical lift transfers, leading to single-staff transfers for 12 residents, contrary to professional standards and safety guidelines. This practice placed the residents in immediate jeopardy.
The facility failed to ensure nursing personnel had the necessary competencies to safely transfer residents using mechanical lifts, often conducting transfers with only one staff member instead of the required two. This practice was against professional standards, OSHA guidelines, FDA guidelines, and manufacturers' recommendations, posing a significant safety risk to the residents.
Failure to Prevent Unattended Exit of Resident at Risk for Elopement
Penalty
Summary
A resident with a diagnosis of depression, limited range of motion in one upper extremity, and who used a motorized wheelchair, exited the facility unattended. The resident was assessed as having intact cognition but required substantial to maximal assistance for transfers. The care plan was not updated to reflect the resident's risk for elopement until after an incident where the resident attempted to exit the facility. Prior to this, the resident's elopement assessment did not indicate risk, and there was no documentation of wandering behavior. On the day of the incident, the resident was last seen in the dining room awaiting dinner. Video surveillance showed the resident leaving through the front doors in his wheelchair, triggering the door alarm. A family member of another resident deactivated the alarm and did not notify staff. Staff were unaware of the resident's exit until notified by an external party, and the resident was retrieved approximately 20 minutes later without injury. The facility's elopement book, which contained information on at-risk residents, did not include this resident at the time of the incident.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to display accurate, publicly accessible, and identifiable daily nurse staffing information for its 38 residents. Review of the Daily Staffing Sheets from 01/01/25 through 03/19/25 showed that the actual hours worked by nursing staff were not completed on the forms as required. On 03/20/25, an administrative nurse confirmed that the forms did not include the actual hours worked. The facility's policy, revised in 12/19, requires that the actual hours worked by licensed and unlicensed nursing staff responsible for resident care be recorded on the Daily Staff Posting form.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nurse Aides (CNAs) who had been employed for over a year. Specifically, CNA R, hired on October 18, 2019, CNA MM, hired on December 15, 2022, and CNA NN, hired on May 17, 2022, did not have documented annual performance evaluations in their personnel files. The facility's Employee Handbook states that annual performance evaluations are necessary to assist employees in improving their performance and identifying areas of excellence and improvement. On November 18, 2024, Administrative Nurse D confirmed that the staff's annual evaluations were not up to date.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Quarters 1, 2, and 3 of 2024. The deficiency was identified through interviews and record reviews, revealing that the facility's Payroll Base Journal (PBJ) Staffing Data Report showed excessively low weekend staffing levels. Despite the staffing schedules indicating that weekend staffing was the same as during weekdays, the PBJ reporting was found to be inaccurate. Administrative Staff A acknowledged the inaccuracy of the PBJ reporting, and it was noted that the facility lacked a policy for reporting PBJ hours. This failure to report accurate staffing information occurred from January 1, 2024, through December 31, 2024.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide a sanitary dressing change for a resident with a stage three pressure ulcer. During an observation, a licensed nurse placed dressing supplies directly onto the resident's overbed table without sanitizing it first. The nurse confirmed the oversight during an interview, acknowledging that the supplies should have been placed on a sanitized surface. The facility's policy required staff to clean a surface and provide a clean field for dressing supplies, which was not followed in this instance. The facility also failed to adequately track and trend infections and causative organisms. The Infection Surveillance Monthly Reports from May to October 2024 documented multiple residents with urinary tract infections (UTIs) but lacked culture results and compliance with McGeers criteria. Interviews revealed that the facility had three different infection preventionists over the past year, and the current one was new to the role. The facility's policy required staff to analyze infection data routinely and base antibiotic initiation on specific organisms identified in lab results, which was not consistently done. Additionally, the facility did not store personal protective equipment (PPE) and COVID-19 testing supplies in a sanitary manner. During an environmental tour, several open and unopened boxes of PPE and COVID-19 tests were found resting directly on the floor in the utility room. Administrative staff confirmed that the boxes should not be stored on the floor, but the facility lacked a policy regarding the storage of supply boxes.
Unsafe Transfer Practices and Unsecured Chemicals in LTC Facility
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, leading to potential safety hazards. Resident 15, who had severe cognitive impairment and required maximum assistance for transfers, was observed being transferred without non-skid footwear, contrary to her care plan. Despite the use of a gait belt and assistance from two CNAs, the resident's inability to bear weight fully during transfers was not adequately addressed, as confirmed by the CNAs and the administrative nurse. The facility did not provide a policy regarding safe transfers, contributing to the unsafe transfer of this resident. Similarly, Resident 32, who also had severe cognitive impairment and required maximum assistance for transfers, was transferred using a sit-to-stand lift. However, the resident was unable to hold onto the lift handles properly, causing the lift belt to slide up into her armpits, placing her in a precarious position. This issue was noted during multiple transfers, and staff confirmed the resident's inability to bear full weight or hold onto the handles consistently. The facility again failed to provide a policy regarding safe transfers, resulting in unsafe transfer practices for this resident. Additionally, during an environmental tour, it was observed that a janitor's closet on the East Hall was unlocked, containing harmful cleaning chemicals. This area housed eight confused residents, posing a significant risk due to the accessibility of these chemicals. The facility did not provide a policy for managing unlocked chemicals, failing to ensure the safety of these residents by leaving potentially dangerous substances unsecured.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment in two resident rooms and one hallway. During an observation, a strong urine odor was detected in the west hallway near a resident room and inside the room itself. Additionally, there were multiple arched black streaks on the wall beside a resident's bed, caused by the positioning bar scraping against the wall. Another resident room on the west hall had two yellow-brown irregular circle-like stains on the ceiling, each measuring approximately 10 inches. These findings were confirmed by Administrative Staff A and Housekeeping Staff V during an environmental tour. The facility's policy on housekeeping, laundry, and maintenance, reviewed in February 2024, instructed staff to provide basic housekeeping services to resident living areas and utility and public areas, which was not adequately followed.
Failure to Obtain Signed Bed Hold for Hospitalized Resident
Penalty
Summary
The facility failed to provide a signed bed hold for Resident 14 upon their admission to an acute care hospital. The resident was admitted to the hospital with a diagnosis of a urinary tract infection and sepsis. Upon review of the resident's electronic medical record, it was found that there was no signed bed hold related to the hospitalization. Administrative Nurse D confirmed that the facility did not obtain a signed bed hold for the resident, despite the facility's policy requiring a written notice of bed hold policies to be provided to residents, family members, or legal representatives at the time of transfer to a hospital.
Failure to Develop Comprehensive Care Plan for Incontinent Resident
Penalty
Summary
The facility failed to develop a personalized comprehensive care plan for Resident 22, who has a history of cardiomyopathy, depression, and urinary tract infections. The resident, who is always incontinent of bowel and bladder, requires maximum assistance for care and often refuses incontinence care. Despite being able to communicate her needs, the care plan lacked specific instructions on the frequency of check and change programs, interventions for refusal of care, and enhancements to incontinence products to prevent frequent urine saturation of the bed. Observations revealed that the resident's room consistently had a strong urine odor, and the resident was often found in a slumped position in bed. The call light was out of reach and disconnected, which hindered the resident's ability to request assistance. Certified Nurse Aides reported that the resident's bed was frequently soaked with urine, and the resident did not always notify staff of the need for incontinence care. The resident was cooperative with care but often reported not needing to be changed when she was incontinent. Interviews with staff indicated a lack of awareness regarding the resident's refusal of incontinence care and the adequacy of the current check and change schedule. The facility did not provide a policy for the development of a comprehensive care plan, and there was no assessment of the urinary incontinence pattern or the effectiveness of the incontinence products used. This deficiency in care planning and execution compromised the resident's well-being and comfort.
Failure to Provide Regular Shaving for Dependent Resident
Penalty
Summary
The facility failed to provide regular shaving for a resident diagnosed with dementia, who was dependent on staff for personal hygiene. The resident's electronic medical record indicated moderate cognitive impairment and a need for substantial to maximum assistance with activities of daily living (ADLs), including facial shaving. Despite the resident's inability to communicate his needs, observations on multiple occasions revealed that the resident had long, unshaven facial hair, indicating a lack of regular shaving. Interviews with Certified Nurse Aides (CNAs) and an Administrative Nurse revealed that the facility's practice was to shave residents on their shower days. However, the resident in question was unable to request additional shaving due to his cognitive impairment. The facility did not have a specific policy for ADLs, which contributed to the oversight in ensuring the resident was shaven regularly, as he did not refuse care and was dependent on staff for his personal hygiene needs.
Inadequate Toileting Opportunities for Resident with Incontinence
Penalty
Summary
The facility failed to provide adequate toileting opportunities for a resident, identified as R22, who was always incontinent of bowel and bladder. R22 had a history of urinary tract infections and was on diuretics, which increased urine production. Despite being able to communicate her needs, R22 often refused incontinence care and was assessed to require maximum assistance from two staff members. Observations revealed that the resident's room frequently had a strong urine odor, and the resident was often found in a slumped position in bed, with the call light out of reach and disconnected. The facility's care plan instructed staff to encourage R22 to allow incontinence care and to notify the nurse if care was declined. However, staff interviews indicated that the resident did not consistently use the call light and often reported not needing to be changed, even when incontinent. Staff were instructed to check and change the resident every two hours, but observations showed that the resident's brief was often saturated, and urine had soaked through to the mattress. The facility's policy required a thorough assessment of the resident's urinary incontinence, including a three-day toileting diary, but it was unclear if this was completed. The facility's failure to conduct a thorough assessment of R22's urinary incontinence and to develop an optimal toileting plan contributed to the resident's frequent incontinence episodes and the strong urine odor in the room. The lack of a proper assessment and individualized care plan increased the risk of urinary tract infections, as evidenced by the resident's history of infections and recent antibiotic treatments. The facility did not ensure that staff were adequately informed or equipped to manage the resident's incontinence effectively.
Failure in Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to adhere to antibiotic stewardship principles, resulting in inappropriate antibiotic use for a resident with a history of urinary tract infections (UTIs). The resident, who had diagnoses including cardiomyopathy and depression, was assessed with no cognitive impairment and required significant assistance with incontinence care. Despite a physician's order for cefdinir based on a culture report showing susceptibility, a subsequent urine sample revealed no UTI. Later, Macrodantin was prescribed without a supporting culture report, and cefuroxime axetil was administered based on a culture report indicating susceptibility to proteus mirabilis. The facility's policy required staff to review clinical records for diagnostic or lab results supporting antibiotic use, but this was not followed for the Macrodantin order. An interview with the Administrative Nurse revealed that the antibiotic order came from an emergency room physician, and the facility did not receive the culture report. This oversight in obtaining culture results for the Macrodantin prescription compromised the facility's antibiotic stewardship efforts, potentially leading to multidrug-resistant bacterial infections.
Inadequate Staffing for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure adequate staff to safely transfer residents using mechanical lifts, as required by professional standards, OSHA guidelines, FDA guidelines, and manufacturers' recommendations. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift for transfers. Nursing staff reported that they often performed these transfers without a second staff member due to a lack of available staff, which was confirmed by interviews with six residents who regularly experienced single-staff transfers. This practice placed the 12 residents in immediate jeopardy. During an onsite survey, it was observed that staff did not utilize two staff members for mechanical lift transfers, contrary to best practices and safety guidelines. Interviews with alert and oriented residents revealed that they were frequently transferred by a single staff member, despite their care plans specifying the need for two staff members. For example, one resident reported being transferred with one staff member for several months, and another resident confirmed that one staff member regularly transferred them using a full body mechanical lift. Interviews with various staff members, including CNAs and licensed nurses, indicated that the practice of single-staff transfers was common and had been ongoing for approximately three months. Some staff members admitted to transferring residents alone because it was quicker than waiting for assistance. The facility lacked a policy on mechanical lift transfers, and staff education on the requirement for two staff members during transfers was only provided during orientation. The facility's failure to ensure the safe transfer of residents using mechanical lifts with the required number of staff members led to the identification of immediate jeopardy for the 12 affected residents.
Removal Plan
- A Quality Assurance and Performance Improvement (QAPI) meeting held with the Medical Director.
- All nursing staff will receive education from the Director of Nursing or designee on the requirement to have two staff present for mechanical lift transfers and the resident transfer requirements to have two staff present for mechanical lift transfers and the resident transfer requirements located in the plan of care/Kardex.
- All nursing staff will complete a skills demonstration on mechanical lift transfers before their start of their next shift.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that nursing personnel had the necessary knowledge, competencies, and skill sets to safely transfer residents using mechanical lifts, as per professional standards, OSHA guidelines, FDA guidelines, and manufacturers' recommendations. The facility identified twelve residents who required mechanical lifts for transfers, but staff frequently conducted these transfers with only one staff member present, contrary to the guidelines that mandate two staff members for safe operation. Interviews with six alert and oriented residents confirmed that staff regularly did not utilize two staff members for mechanical lift transfers, posing a significant safety risk to the residents involved. Resident 1, who required a sit-to-stand mechanical lift for transfers due to limited mobility, reported that nursing staff often transferred him with only one staff member. Similar reports were made by Residents 2 through 6, all of whom required either a full body or sit-to-stand mechanical lift and were supposed to be assisted by two staff members according to their care plans. These residents consistently reported that only one staff member was present during their transfers, which had been occurring for several months. Interviews with facility staff revealed a lack of awareness and adherence to the guidelines for mechanical lift transfers. Certified Nurse Aides (CNAs) admitted to transferring residents alone to save time, and there was no policy in place to ensure proper staffing for these transfers. Administrative and nursing staff were unaware of the single-staff transfers, and competencies for staff had not been updated for approximately a year. The facility lacked a staffing policy and failed to ensure staff competency and skill sets for the safe transfer of residents requiring mechanical lifts.
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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 Frontenac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pittsburg Care And Rehab | 4.8 mi | ★★★★★ | 8 | 0 |
| Via Christi Village Pittsburg | 4.8 mi | ★★★★★ | 0 | 0 |
| Medicalodges Pittsburg | 5.7 mi | — | 0 | 0 |
| Arma Operator, Llc | 6.3 mi | ★★★★★ | 1 | 0 |
| Medicalodges Columbus | 21.2 mi | ★★★★★ | 1 | 1 |
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