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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicalodges Pittsburg during CMS and state inspections, most recent first.
A large rug at the facility entrance concealed a hole in the cement, creating a tripping hazard, while black, white, yellow, and green substances consistent with mold were observed throughout multiple areas, including resident rooms, laundry, and service areas. Staff reported ongoing symptoms such as headaches and sore throats, and a musty odor was noted. Despite widespread contamination, the facility did not test for mold or address the environmental hazards as the infection management policy lacked guidance on mold removal.
A cognitively impaired resident at high risk for elopement exited a facility unsupervised, crossing a lawn, parking lots, and a street before reaching a dentist office. The resident's care plan included monitoring for exit-seeking behaviors, but no alarm sounded when the resident left. Maintenance checks revealed a delay in the alarm on a frequently used exit door, contributing to the resident's unsupervised departure.
The facility failed to conduct annual performance reviews for CNAs and CMAs, with several employees lacking signed evaluations in their records. An interview with an administrative nurse confirmed the absence of these evaluations, and the facility did not provide a policy for completing them, resulting in a failure to ensure staff competency and training needs.
The facility failed to maintain sanitary conditions in food preparation, storage, and serving. Observations revealed dirty shelving in the ice room and dietary supplies stored on the floor. Staff had conflicting responsibilities for cleaning, and the facility's policy lacked guidance on proper storage practices.
The facility failed to submit accurate staffing data to CMS, missing 24-hour Licensed Nurse coverage on multiple dates. Despite having a policy for posting actual hours worked, the facility lacked a specific policy for PBJ submission, leading to discrepancies in reported staffing information.
The facility failed to track and trend infections effectively, with missing data in the Infection Control logbook and a lack of culture reports for infections. Administrative Nurse E was unaware of how to use the electronic monitoring program, and a COVID outbreak occurred in July 2024. The facility's policies required monitoring infections, but the facility did not determine trends to prevent their spread.
The facility failed to adhere to antibiotic stewardship principles, leading to a deficiency in monitoring antibiotic use. A resident was prescribed Cefdinir for health maintenance, but interviews with administrative nurses revealed a lack of training and completion of the computerized infection monitoring system. The resident had been hospitalized for pneumonia and returned with an antibiotic order, yet the facility's policy on antibiotic use was not followed.
The facility failed to maintain a sanitary environment in the ice room, with black grime on the floor, dirty shelving, and unclear cleaning responsibilities. Administrative and dietary staff were unsure who was responsible for cleaning, and no policy existed for maintaining the area.
A facility with 29 residents failed to maintain a clean and homelike environment on four of five resident halls. Issues included a strong urine odor in a resident room, rust and loose hair in a shower room, uncovered clean linen, loose handrails, and poor maintenance in various areas. These deficiencies were confirmed by staff, indicating a failure to follow housekeeping and maintenance policies.
A resident with schizoaffective disorder, diabetes, and severe cognitive impairment required assistance with personal hygiene but was observed with overgrown facial hair and long fingernails. Grooming was typically done on bath days, but the resident had issues with his electric razor and fingernail clippers. Staff interviews revealed a lack of awareness about the last grooming service, and the facility did not have a grooming policy, leading to the resident not being maintained in a dignified manner.
A resident with multiple medical conditions, including cerebral palsy and diabetes, experienced a skin tear after hitting their hand on a dining room table. The care plan was not updated to address this injury or prevent further incidents, and the table remained in use despite posing a risk. The facility's wound prevention policy was not followed, leading to a deficiency in care.
A resident with multiple health conditions, including cerebral palsy and diabetes, experienced repeated skin tears due to inadequate care and monitoring. The facility failed to update the care plan with necessary interventions and did not have a physician's order for the existing skin tear. The resident sustained injuries from a dining room table with a metal edge, which was not removed despite being identified as a hazard.
A facility failed to monitor a resident receiving antipsychotic medication for schizophrenia. Despite recommendations to conduct DISCUS assessments every six months, the last assessment was over eight months ago. The facility lacked a policy for these assessments, leading to a deficiency in care practices.
A facility failed to accurately complete a Significant Change MDS for a resident with dementia and severe cognitive impairment, who had multiple falls, including an injury fall. The Fall CAA lacked necessary fall information, and the care plan required specific interventions to prevent falls. An administrative nurse confirmed the documentation did not accurately reflect the resident's fall history and risk.
The facility failed to complete the Daily Staff Posting by not including the total and actual hours worked by direct care staff. A review of the Daily Staffing Sheet revealed missing actual hours for nursing staff. Interviews indicated that the business office was responsible for logging these hours but had not done so since June. The facility's policy required the charge nurse to fill in total hours and the business office to verify actual hours using payroll data.
Unsafe Entrance and Widespread Mold Contamination
Penalty
Summary
The facility failed to ensure a safe and sanitary environment for residents, staff, and visitors. Observations revealed a large rubberized rug covering a sloped walkway at the front entrance, which concealed a large hole in the underlying cement. This rug created a tripping hazard, as evidenced when a surveyor stumbled on it. Multiple areas throughout the facility, including public restrooms, laundry areas, corridors, the kitchen, smoking lounge, medical records storage, boiler room, and HVAC room, were found to have black, white, yellow, and/or green substances on walls, floors, and ceilings. Staff interviews confirmed that these substances had been present for months, with reports of a musty smell and a recent ceiling leak that required a bucket to catch water. Several staff members reported headaches and sore throats in the weeks leading up to the discovery of the mold-like substances. Administrative staff confirmed that nearly all rooms in several hallways were contaminated with mold, and that the facility's infection management policy did not address mold treatment or removal. Despite the leadership team's identification of the need to evacuate residents due to the environmental concern, instructions from a consultant directed staff to resume their regular duties and to spray visible surfaces with a disinfectant. The facility did not test the substance to confirm the presence of mold, following consultant advice, and did not take immediate action to address the environmental hazards identified.
Resident Elopement Due to Inadequate Supervision and Alarm Delay
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for a cognitively impaired resident, identified as R31, who was at high risk for elopement. On the morning of 08/29/24, R31, who had been assessed with severe cognitive impairment and daily wandering behaviors, exited the facility unsupervised and without staff knowledge. The resident managed to walk approximately 248 feet, crossing a lawn, two parking lots, and a two-way street, before arriving at a nearby dentist office. The facility was unaware of the resident's absence until the dentist office contacted them about the resident's presence. R31's medical records indicated diagnoses of Alzheimer's disease and major depressive disorder, with a history of wandering and poor safety awareness. The resident's care plan included instructions for staff to monitor for exit-seeking behaviors and to redirect the resident as needed. Despite these measures, the resident was able to leave the facility without triggering any alarms, as staff did not hear any alarm sound when the resident exited. Interviews with staff revealed that the resident often sat near the front door but had not previously exited the facility. Maintenance checks revealed that the alarm on the exit door by the staff break room had a delay of approximately one minute before sounding, which may have allowed the resident to exit unnoticed. This door was frequently used by staff for taking out trash and led to an area with grass and a parking lot. The facility's elopement policy required staff to identify at-risk residents and develop individualized care plans, but the failure to ensure the security of the premises resulted in the resident's unsupervised departure, placing them in immediate jeopardy.
Removal Plan
- LN G completed a full body assessment of R31 upon return to facility.
- Resident placed on 1:1 monitoring for the remainder of the investigation.
- Maintenance and door alarm company provide door alarm testing.
- LN G notified R31's responsible party and his physician of his elopement.
- Administrative Nurse D documented an alert in the electronic software of any care plan changes.
- Administrative Nurse D notified the State Agency via email of the elopement.
- Administrative Nurse D reviewed the Medication Administration Record and progress notes that led up to R31 leaving unsupervised and without staff knowledge, to determine if other risk factors were present.
- Administrative Nurse D reviewed all residents for elopement risk, for accuracy, and updated the elopement book and care plans as needed.
- The facility provided Mandatory Elopement Policy training to all staff.
- Quality Assurance Performance Improvement (QAPI) meeting held with the medical director regarding the elopement.
- All staff completed the mandatory Elopement Policy Training.
Failure to Conduct Annual Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to conduct annual performance reviews for certified nurse aides (CNAs) and certified medication aides (CMAs) as required. The review of employee records revealed that several CNAs and CMAs, with hire dates ranging from 1999 to 2023, lacked signed evaluations. Specifically, CNA Q, CNA O, CNA/CMA NN, CNA P, and CNA MM did not have documented evaluations in their records. An interview with Administrative Nurse D confirmed the absence of these evaluations and indicated that annual evaluations were expected to be completed in a timely manner. The facility did not provide a policy for the completion of annual evaluations, resulting in a failure to ensure certified nursing staff received evaluations to assess competency and identify training needs.
Sanitation Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in the preparation, storage, and serving of food to its residents. During a facility tour, it was observed that the wood shelving unit used for stacking dishes and glasses in the ice room had loose chunks of dirt, with plates and glasses stored upside down in direct contact with the dirty shelves. Administrative Staff A confirmed the need for housekeeping and maintenance in the ice room but was unaware of who was responsible for cleaning it. Dietary staff BB and Housekeeping staff W had conflicting understandings of who was responsible for cleaning the ice room, with dietary staff using the plates and glasses stored there for holiday dinners. Further inspection revealed that dietary supplies, including foam cups, insulated bowls, and cup lids, were stored directly on the floor of the southeast storage room, which is against sanitary storage practices. Maintenance Staff U and Dietary staff BB acknowledged that supplies should be stored off the floor on appropriate racks. The facility's dietary services policy did not address the proper storage of dietary supplies and dishware to ensure sanitary food service, contributing to the deficiency in maintaining sanitary conditions.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour Licensed Nurse (LN) coverage on four dates between July 1, 2023, and September 30, 2023, and on six dates between October 1, 2023, and December 31, 2023. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for the relevant fiscal quarters, which revealed gaps in 24-hour LN coverage on specified dates. During an interview, Administrative Nurse D indicated that she believed the PBJ was submitted correctly and was unaware of the discrepancies noted in the report. The facility's policy for Benefits Improvement Protection Act (BIPA) Nurse Staff Posting, revised in December 2019, instructed staff to post actual hours worked for licensed and unlicensed nursing staff. However, the facility lacked a specific policy for the submission of the PBJ to CMS, contributing to the inaccurate reporting of staffing information.
Inadequate Infection Tracking and Trending
Penalty
Summary
The facility failed to effectively track and trend infections among its residents, as evidenced by missing data in the Infection Control logbook for August and September 2024. The logbook for June 2024 documented two wound infections, three urinary tract infections, and two oral infections, but lacked culture reports to identify causative organisms. Administrative Nurse E admitted to documenting infections on a map of resident rooms to identify trends but was unaware of how to use the facility's electronic monitoring program. A COVID outbreak occurred in July 2024, affecting four residents and subsequently staff, although no current cases were reported. Administrative Nurse D expected staff to utilize the electronic data collection tool for tracking infections. The facility's policy on Antibiotic Use Protocol and Antibiotic Stewardship required staff to monitor infections and instruct on managing residents with infections, but the facility did not monitor infections to determine trends and prevent their spread.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to ensure adherence to antibiotic stewardship principles, which are crucial for preventing antibiotic resistance and the spread of multidrug-resistant organisms. A physician's order dated 07/26/24 instructed staff to administer Cefdinir, an antibiotic, to a resident twice a day for five days for health maintenance. However, interviews with administrative nurses revealed a lack of training and completion of the facility's computerized infection monitoring system. Specifically, Administrative Nurse E admitted to lacking training in the system, while Administrative Nurse D confirmed the absence of antibiotic stewardship and the incomplete monitoring system. The resident in question had previously been hospitalized for pneumonia and returned to the facility with an antibiotic order, yet the facility's policy on antibiotic use and stewardship was not followed, leading to the deficiency.
Facility Fails to Maintain Sanitary Ice Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the ice room, as observed during a facility tour. The floor was covered with black grime, and the wood shelving unit used for stacking dishes and glasses had loose chunks of dirt. Used crumpled paper towels were found on the floor, and the walls had missing paint. Additionally, the floor was unsanitizable due to missing paint or sealant in front of the ice machine. These conditions were confirmed by Administrative Staff A, who was unaware of who was responsible for cleaning and repairing the ice room due to recent staff changes. Dietary staff BB believed that housekeeping was responsible for cleaning the ice room, while Housekeeping staff W stated that the dietary staff was responsible, indicating a lack of clarity regarding cleaning responsibilities. The facility did not have a policy addressing the maintenance and cleaning of the ice machine/storage room, contributing to the unsanitary conditions observed. This lack of policy and clear responsibility led to the failure in ensuring a safe and sanitary environment for residents and staff.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility, with a census of 29 residents, failed to maintain a clean, comfortable, and homelike environment on four of five resident halls. During an environmental tour, several areas of concern were identified. A resident room on the northeast hall had a strong urine odor, indicating inadequate cleaning or maintenance. Additionally, a shower room on the same hall had rust around the drain and a large amount of loose hair, with a clean linen cart stored uncovered, and loose handrails on each side of the toilet. Further observations included a beauty shop on the central hall with a large glob of cut hair in the sink drain, and a laundry room handwashing sink containing dead bugs and small pieces of trash. On the southeast hall, a shower room had a toilet riser stored directly on the floor next to the toilet, with the cove base underneath the handwashing sink peeling from the floor, and the wall leading into the shower corner in poor repair with peeling and broken tile. These findings were confirmed by Maintenance/Housekeeping Staff U, highlighting the facility's failure to adhere to its housekeeping and maintenance policy.
Failure to Provide Grooming Services for Resident
Penalty
Summary
The facility failed to provide grooming services for a resident, identified as R5, who required assistance with personal hygiene. R5 had a medical history that included schizoaffective disorder, diabetes, depression, and pneumonia due to COVID. The resident's cognitive status was assessed with a BIMS score of 12, indicating moderate cognitive impairment, which later declined to a score of five, indicating severe cognitive impairment. Despite having no impairment in upper or lower extremities, R5 required substantial assistance with personal hygiene. Observations revealed that R5 had several days' worth of facial hair, overgrown sideburns and eyebrows, hair in his ears and nose, and long fingernails, indicating a lack of grooming. Interviews with staff revealed that grooming was typically done on bath days, which were Sundays and Thursdays, but R5 expressed difficulty with his electric razor and fingernail clippers. Social Service Staff X was in the process of finding a beautician for grooming services and was unaware of the last grooming service provided to R5. Administrative Nurse D expected staff to provide grooming services per the standard of practice, but the facility did not have a grooming policy in place. This lack of grooming services resulted in R5 not being maintained in a dignified manner.
Failure to Update Care Plan for Skin Tear Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R3, to address skin tear prevention. R3 had multiple medical conditions, including cerebral palsy, osteoarthritis, diabetes, hypertension, sleep apnea, gout, anxiety disorder, and pain, which contributed to his risk for skin tears. The resident was non-ambulatory, dependent on staff for activities of daily living, and had contractures in his extremities. Despite these risks, the care plan did not include updated interventions for a current skin tear on R3's left hand or strategies to prevent further injuries. Observations and interviews revealed that R3 sustained a skin tear on his left hand after hitting it on a dining room table. The care plan lacked an intervention for this injury, and there was no physician's order or treatment administration record for the skin tear. Staff confirmed that the care plan should have been updated to guide care and prevent further injuries. Despite the incident, the table with a metal edge, which contributed to the injury, remained in the dining room, posing a continued risk to R3 and other residents. The facility's policy on wound prevention and management required staff to develop interventions for optimal care and healing of skin alterations. However, the facility did not adhere to this policy, as evidenced by the lack of immediate intervention and care plan updates following R3's skin tear. The failure to address the identified causes of injury and implement preventive measures placed R3 at risk for repeated skin tears.
Failure to Provide Adequate Skin Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, received appropriate treatment and care for a skin condition in accordance with professional standards of practice and the resident's care plan. R3, who has cerebral palsy, osteoarthritis, diabetes, hypertension, sleep apnea, gout, anxiety disorder, and experiences constant pain, was at risk for skin breakdown. Despite being identified as at risk for pressure ulcers, the resident's care plan lacked specific interventions for a current skin tear on the left hand and did not include updated measures to prevent further skin injuries. Observations and interviews revealed that R3 sustained multiple skin tears, including one on the left hand caused by hitting it on a dining room table with a metal edge. The facility's care plan did not reflect immediate interventions to prevent further injuries, and there was no physician's order or treatment administration record for the existing skin tear. Staff members confirmed that the care plan should have been updated to guide care and prevent further injuries, but this was not done. The facility's policy on wound prevention and management required the development of interventions to promote healing and prevent skin integrity concerns. However, the facility did not adhere to this policy, as evidenced by the lack of a physician's order for the skin tear, failure to update the care plan, and continued use of a hazardous table in the dining room. These oversights contributed to the resident's repeated skin injuries and inadequate monitoring and treatment of the skin condition.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to adequately monitor a resident, identified as R11, who was receiving antipsychotic medication for schizophrenia. The resident's electronic medical record indicated a diagnosis of schizophrenia and documented the use of antipsychotic medication, specifically Risperidone, prescribed at 1 mg twice daily. Despite the resident having intact cognition, as evidenced by a BIMS score of 14-15, the facility did not perform the required DISCUS assessments to monitor for tardive dyskinesia, a potential side effect of antipsychotic medications. The last recorded DISCUS assessment was completed on 01/10/24, and subsequent recommendations by Consultant Staff GG to conduct these assessments every six months were not followed. The facility lacked a policy regarding the completion of DISCUS assessments, which contributed to the oversight. Administrative Nurse D acknowledged the lapse, confirming that the DISCUS assessments had not been conducted for over eight months, despite the consultant's recommendations. This failure to monitor the resident's use of antipsychotic medication represents a deficiency in the facility's care practices, as it did not adhere to the recommended monitoring schedule to ensure the resident's safety and well-being.
Inaccurate MDS Completion for Resident with Fall History
Penalty
Summary
The facility failed to complete an accurate Significant Change Minimum Data Set (MDS) for a resident with a history of falls. The resident, diagnosed with dementia and severe cognitive impairment, experienced multiple falls, including one injury fall, since the prior assessment. Despite these incidents, the Fall Care Area Assessment (CAA) lacked necessary information regarding the resident's falls, which is a critical component for assessing and planning care for residents at high risk of falls. The resident's care plan, revised earlier in the year, indicated that the resident could be impulsive and required specific interventions to prevent falls, such as ensuring the room was free from clutter and not leaving the resident alone in a wheelchair. However, the facility's documentation, including the Significant Change MDS and the Fall CAA, did not accurately reflect the resident's fall history and risk, as confirmed by an administrative nurse. This oversight indicates a failure in the facility's use of the Resident Assessment Instrument (RAI) for accurate MDS completion.
Failure to Complete Daily Staff Posting
Penalty
Summary
The facility failed to complete the Daily Staff Posting to include the total and actual hours worked by direct care staff as required. The deficiency was identified during a review of the Daily Staffing Sheet dated from September 12, 2024, through September 18, 2024, which revealed a lack of actual hours worked for licensed and certified nursing staff. An interview with Business Office Staff EE on September 19, 2024, disclosed that she was responsible for logging the actual hours worked from the time clock and posting it on a Daily Staff Posting, but this had not been done since June 11, 2024. Additionally, an interview with Administrative Nurse D on the same day revealed that she filled in the Daily Staffing sheet to ensure adequate staff, while the business office was supposed to fill in the actual hours worked based on the time clock. The facility's Benefits Improvement Protection Act (BIPA) Nurse Staff Posting policy, revised in December 2019, instructed the charge nurse for the shift to fill in the total hours worked at the end of the shift, and the business office personnel were to verify and record the actual hours worked using payroll data. The facility's failure to calculate the total and actual hours worked by direct care staff on the Daily Staffing Sheet and/or on the Daily Staff Posting led to the deficiency.
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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) |
|---|---|---|---|---|
| Pittsburg Care And Rehab | 1 mi | ★★★★★ | 8 | 0 |
| Via Christi Village Pittsburg | 1 mi | ★★★★★ | 0 | 0 |
| Medicalodges Frontenac | 5.7 mi | ★★★★★ | 0 | 0 |
| Arma Operator, Llc | 12 mi | ★★★★★ | 1 | 0 |
| Medicalodges Columbus | 16.6 mi | ★★★★★ | 1 | 1 |
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