Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pittsburg Care And Rehab during CMS and state inspections, most recent first.
The facility failed to fully implement its Legionella water management program as required by its infection prevention and control policy. Maintenance staff reported that only a single Legionella test of kitchen water had been conducted, which was negative, but there was no documentation of a facility water system map, no flow diagram of water distribution, and no identification of dead-end water areas where water could stagnate. This was inconsistent with the facility’s written policy that required waterborne microorganism control measures to follow CDC, HICPAC, FDA, and state and local health department recommendations.
A resident with dementia, severe cognitive impairment, and multiple psychiatric diagnoses had care-plan and physician orders requiring that staff sit and assist with every meal and snack due to weight loss. During observation, a CNA stood beside the resident’s Broda chair while attempting to assist with breakfast instead of sitting at eye level as specified. Staff interviews with a CMA and an LN confirmed that staff are expected to sit next to residents and engage them during meals, showing that the resident was not provided mealtime assistance in a manner consistent with her care plan or with dignified care practices.
Surveyors found that the facility did not include the required estimated daily rate for continued services on CMS-10055 SNF Advance Beneficiary Notices of Non-coverage for two residents whose Medicare Part A skilled stays ended and who remained for custodial care. The nurse responsible for issuing ABNs and administrative staff reported they had been instructed not to list the daily rate due to fluctuating prices, resulting in ABNs that lacked cost information despite facility policy outlining the need to inform Medicare beneficiaries about potential non-coverage and associated financial liability.
Surveyors found that PHI was not kept confidential when two unattended medication carts in separate hallways were left with unlocked laptop screens displaying a resident’s medications, DOB, allergy information, and code status, visible to anyone passing by and without nursing staff in view. Nursing staff and an administrative nurse acknowledged that carts should be locked and laptop screens closed or cleared when unattended, and facility policy required safeguarding all resident records to protect confidentiality.
Surveyors identified that two residents with dementia, depression, and anxiety were receiving daily antipsychotic medications without documented physician rationale or risk–benefit analysis for their continued use with non-approved indications. Each resident’s MDS showed severely impaired cognition and ongoing psychotropic use, while their care plans only directed staff to administer medications as ordered. Physician orders specified olanzapine for behaviors or a psychotic disorder, but the EMRs lacked documentation of multiple unsuccessful nonpharmacological interventions and risk–benefit considerations, and the available psychoactive medication consent forms did not contain the required physician justification, contrary to facility policy on psychotropic drug use.
A resident with dementia, major depressive disorder, anxiety, and bipolar disorder was admitted to hospice, but the facility failed to complete a required Significant Change MDS at the time of hospice admission. The resident had severely impaired cognition per prior MDS and CAA documentation and was receiving daily antipsychotic medication. The care plan only reflected hospice-provided extra bathing and did not include other hospice services, despite physician orders for hospice to evaluate and treat. Administrative nurses acknowledged that while a significant change MDS had been completed earlier for a different health status change, no new significant change MDS was done when hospice services began, contrary to the facility’s MDS transmission policy.
A resident with cardiomyopathy, COPD, depressive disorder, muscle weakness, and chronic joint and low back pain experienced frequent severe pain rated at 10/10 despite being on scheduled hydrocodone and topical diclofenac. The MDS and pain assessment documented frequent severe pain and scheduled opioid use, but there was no active PRN order for breakthrough pain, and the care plan lacked specific nonpharmacological pain interventions or an assessment of the resident’s acceptable pain level. Staff reported the resident continued to have significant pain in multiple joints, sometimes nonverbal but evident through facial expressions and decreased appetite, and an RN confirmed that orders and the care plan did not include PRN pain medication or nonpharmacological strategies, despite ongoing reports of severe pain.
Surveyors found that the facility did not fully integrate hospice services into the care plans for two residents receiving hospice care. Both residents had severe cognitive impairment and multiple psychiatric diagnoses, with documentation confirming hospice admission and physician orders for hospice evaluation and treatment. One resident’s care plan referenced hospice involvement and comfort measures but did not specify hospice services, while the other resident’s care plan only noted extra bathing by hospice. Staff reported that details of hospice services were kept in a separate hospice book and acknowledged that not all hospice services were reflected in the care plans, despite facility policy addressing hospice service provision and coordination.
The facility failed to maintain sanitary conditions in the therapy room, with unlabeled and expired food items found in the refrigerator and freezer, and a rusted, dirty microwave. Interviews confirmed the use of kitchen equipment for resident rehabilitation, but policies for food storage and equipment cleaning were not followed, risking foodborne illness.
A resident with chronic back pain and osteoarthritis requested positioning rails to aid in movement and alleviate pain. Despite communicating this need to multiple staff members, the request was not addressed promptly. The facility's policy required an assessment for such devices, which was delayed, impacting the resident's pain management and independence.
A facility failed to accurately document the administration of opioid medication for a resident with chronic pain in their MDS assessments. Despite receiving Fentanyl every 72 hours as per physician's orders, the MDS inaccurately indicated no opioid use. This discrepancy was confirmed by an administrative nurse, highlighting a failure in accurate assessment and documentation.
A resident with Huntington's disease and severe cognitive impairment experienced multiple falls due to the facility's failure to maintain nonskid strips in the bathroom. Observations showed worn and non-adhered strips, and staff interviews revealed frequent ambulation without assistance. The facility lacked a policy for inspecting nonskid strips, contributing to the deficiency.
A resident with a diagnosis of constipation did not receive necessary PRN medications for constipation over several periods, despite having physician's orders and a facility protocol in place. The staff failed to administer the medications or document any refusal by the resident, leading to the resident going without a bowel movement for several days on multiple occasions.
Failure to Implement Comprehensive Legionella Water Management Program
Penalty
Summary
The facility failed to implement a comprehensive water management program for Legionella disease as part of its infection prevention and control program for a census of 60 residents. During an observation and interview, the maintenance staff reported that the facility relied on a single Legionella testing kit performed on kitchen water in late December, which showed no Legionella detected. However, the maintenance staff verified there was no documentation of a map showing the facility’s incoming water source, no flow diagram of the facility’s water distribution system, and no identification of dead-end water areas where water could stagnate. The facility’s written Water Management, Legionella Testing policy, dated October 2022, stated that approaches to controlling waterborne microorganisms, including water systems decontamination, would be consistent with CDC, HICPAC, FDA, and state and local health department requirements, but the lack of these key documents demonstrated the policy was not fully implemented. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Provide Dignified, Care-Plan-Compliant Mealtime Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect, dignity, and appropriate care during mealtimes. The resident had diagnoses including dementia, major depressive disorder, anxiety, and bipolar disorder, with documentation of severely impaired cognition on the MDS and CAA, and daily antipsychotic use. The resident’s care plan and physician orders specified that staff were to provide set-up assistance to supervision with one staff, that someone must sit and assist her with every meal and snacks three times a day due to weight loss, and that she was to be assisted with meal intake at every meal. Despite these documented needs and interventions, observation showed that during breakfast the resident was seated in a Broda chair at the dining room table while a CNA stood next to her attempting to assist with the meal, rather than sitting next to her as required. Subsequent interviews with a CMA and a licensed nurse confirmed that nursing staff should be seated next to residents when assisting with meals, at eye level, and engaging them in conversation. These observations and staff statements demonstrate that the resident was not assisted in the manner specified in her care plan and orders, and that staff did not follow the expected practice for dignified, respectful mealtime assistance.
Failure to Include Estimated Daily Rate on SNF ABN Notices
Penalty
Summary
The facility failed to properly complete CMS-10055 Skilled Nursing Facility (SNF) Advance Beneficiary Notices of Non-coverage (ABNs) by omitting the estimated daily rate for continued services when Medicare Part A coverage ended. Record review showed that one resident’s Medicare Part A episode ran from 01/08/26 to 02/09/26, after which the resident remained in the facility for custodial care. The ABN issued on 02/09/26 did not include a daily rate for services. Another resident’s Medicare Part A episode ran from 08/25/25 to 11/07/25, and this resident also remained in the facility for custodial care. The ABN issued on 11/05/25 likewise lacked a daily rate for services. During interviews, the administrative nurse responsible for issuing ABNs at the time of discharge from skilled therapy stated that she had been instructed by the regional manager not to include the daily rate for services on the ABN due to fluctuations in the rate. Administrative staff also confirmed that the facility did not include the rate for services on ABN notices because the rate changed. The facility’s Beneficiary Notices policy, last approved in 07/2025, documented that Medicare beneficiaries have the right to have Medicare determine coverage for skilled services and described both expedited and standard appeals processes, including the need to inform beneficiaries of possible non-coverage and potential cost shifting from the SNF to the beneficiary, but the ABNs reviewed did not contain the required cost information.
Failure to Protect PHI on Unattended Medication Carts
Penalty
Summary
Surveyors identified a failure to maintain confidentiality of residents' protected health information (PHI) related to unsecured medication carts with visible electronic records. With a facility census of 60 residents and a sample of 15, observations showed a medication cart parked in the east hallway with a laptop on top, the screen unlocked and displaying a resident’s PHI, including medications, date of birth, allergy information, and code status. This screen was visible to anyone passing by, and no nursing staff were in view of the cart at the time of the observation. A similar observation was made in the west hallway, where another medication cart was parked with an unlocked laptop displaying a resident’s medications, date of birth, allergy information, and code status, again with no nursing staff present. Licensed nurses interviewed stated that the medication cart should be locked and the laptop screen cleared or closed when staff walk away, and an administrative nurse confirmed the expectation that laptop screens be closed or resident information cleared when staff are not working at the cart. The facility’s Confidentiality and Privacy of Information policy, last approved in 10/2025, documented that all resident information would be treated confidentially and that resident records of all types would be safeguarded to protect confidentiality.
Lack of Physician Rationale for Antipsychotic Use in Residents With Dementia
Penalty
Summary
Surveyors found that the facility failed to ensure appropriate indications and physician documentation for the continued use of antipsychotic medications in two residents with dementia. One resident had diagnoses of dementia, depression, and anxiety, with a Quarterly MDS showing severely impaired cognition and documentation of daily antipsychotic, antidepressant, anticonvulsant, and opioid use. The resident’s CAA noted daily antipsychotic use for dementia, and the care plan intervention was limited to administering medications as ordered. A physician order directed Zyprexa 5 mg twice daily via PEG tube or by mouth for combative behavior, hitting, and scratching. However, the clinical record lacked physician documentation of the risk versus benefit for this antipsychotic use with a non-approved indication in a resident with dementia, and the facility could not provide such documentation upon request. The only available consent form for psychoactive medication therapy did not include the required physician rationale or documentation of multiple unsuccessful nonpharmacological interventions. A second resident, also with diagnoses of dementia, depression, and anxiety and severely impaired cognition on the Quarterly MDS, was receiving hospice services and had received antipsychotic, antidepressant, antianxiety, and opioid medications. The CAA documented daily antipsychotic use for dementia, and the care plan intervention again only directed staff to administer medications as ordered. A physician order prescribed olanzapine 5 mg by mouth at bedtime for a psychotic disorder. Similar to the first resident, the clinical record for this resident lacked physician documentation of risk versus benefit for antipsychotic use with a non-approved indication in a resident with dementia, and the facility was unable to provide this documentation when requested. The consent form for psychoactive medication therapy for this resident also lacked the physician documentation supporting continued use with a non-approved indication, despite the facility’s policy stating that psychotropic drugs would only be used when necessary to treat specific indicated and effective conditions and not for staff discipline or convenience.
Failure to Complete Significant Change MDS Upon Hospice Admission
Penalty
Summary
The facility failed to identify a significant change in condition and complete a comprehensive Significant Change MDS when a resident was admitted to hospice services. The resident had documented diagnoses of dementia, major depressive disorder, anxiety, and bipolar disorder. A Significant MDS dated 12/28/25 showed a BIMS score of 99 with a staff interview indicating severely impaired cognition, and a Cognitive Loss/Dementia CAA dated 01/02/26 documented dementia and daily antipsychotic use. The care plan included an intervention for hospice to provide extra bathing on Mondays and Thursdays but lacked documentation of other hospice services. Physician orders dated 01/21/26 directed hospice of the family's choice to evaluate and treat, and the resident was observed seated in a Broda chair at the dining room table while a CNA attempted to assist with breakfast. Administrative staff interviews revealed that the required Significant Change MDS was not completed at the time of the resident's admission to hospice. One administrative nurse stated she had completed a significant change MDS prior to the resident's hospice admission and acknowledged she should have completed another significant MDS after hospice admission. Another administrative nurse confirmed that the significant change MDS was not completed when the resident was admitted to hospice, clarifying that the earlier significant change MDS had been done for a prior significant change in health status. The facility's policy on Electronic Transmission of the MDS, effective 10/2025, stated that MDS assessments, including significant change assessments, would be transmitted per state and federal guidelines, but this was not followed for the hospice admission event.
Inadequate Pain Management and Care Planning for Resident With Chronic Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident with chronic pain in the knees, lower back, and shoulders. The resident had diagnoses including cardiomyopathy, COPD, depressive disorder, need for assistance with personal care, and muscle weakness, and had intact cognition per a recent MDS. The MDS documented that the resident frequently experienced pain at a level of 10 on a 0–10 scale, which occasionally affected sleep, and that the resident was on a scheduled pain medication regimen and received nonpharmacological interventions, with no PRN pain medications. The Pain CAA indicated the resident took an opioid every six hours for low back pain and was to be monitored every shift and as needed for any pain. The care plan documented use of an opioid for chronic joint and lower back pain and directed staff to assess pain type, location, and characteristics before and after administration of PRN medication, and stated that long-acting opioid use was appropriate based on the resident’s history, but it lacked specific directions for nonpharmacological pain interventions. Physician orders included hydrocodone-acetaminophen 10-325 mg every six hours for low back pain, diclofenac gel to the right knee three times daily, and an order to monitor pain every shift related to PRN hydrocodone use, but there was no active PRN order for breakthrough pain. A physician progress note documented the resident reporting pain at level 10 in the right leg and knee, described as achy with pins and needles and worsened by movement, while taking hydrocodone 10 mg every six hours. During surveyor observation, the resident reported significant ongoing pain in joints, knees, shoulders, and lower back despite routine pain medication. A CNA reported the resident did not always verbalize pain but showed signs such as facial expressions and decreased appetite, which she reported to the nurse. A licensed nurse confirmed that physician orders lacked PRN pain medication despite reports of pain at level 10 and that the care plan and orders lacked direction for nonpharmacological pain interventions. An administrative nurse acknowledged the resident was on routine hydrocodone without breakthrough pain medication, had no nonpharmacological interventions in the care plan, and that there had been no assessment of the resident’s acceptable pain level or consultation for ongoing pain, in the context of a facility policy addressing unnecessary medications and appropriate duration based on assessment and therapeutic goals.
Failure to Integrate Hospice Services Into Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate collaboration with hospice providers and to incorporate hospice services into the residents’ care plans. One resident with dementia, depression, anxiety, and severely impaired cognition had documentation in the EMR and MDS indicating she was receiving hospice services, with a nursing note confirming hospice admission. Her care plan referenced consulting with the physician and social services to have hospice care in the facility and included comfort-focused interventions such as oxygen for comfort and pain management. However, the care plan did not clearly outline the specific hospice services being provided, despite her documented hospice status. Another resident with dementia, major depressive disorder, anxiety, bipolar disorder, and severely impaired cognition had an order for hospice of the family’s choice to evaluate and treat and was confirmed by nursing staff to have been admitted to hospice. The care plan for this resident only documented that hospice would provide extra bathing on two specified days and lacked other hospice services. Staff interviews revealed that information about hospice services was kept in a separate hospice-provided book and that not all hospice services were included in residents’ care plans. An administrative nurse acknowledged that the facility only included some, but not all, hospice services on the care plans, contrary to the facility’s hospice program policy that addressed services to be provided and coordination of care.
Unsanitary Food Storage and Equipment Maintenance in Therapy Room
Penalty
Summary
The facility failed to ensure sanitary food storage and maintenance of kitchen equipment in the therapy room, as observed during a survey. Unlabeled and undated hamburger patties were found in the therapy room refrigerator freezer, along with medical devices and cold packs. The refrigerator contained expired almond milk and yogurt, as well as a sack with various foods in undated, unmarked Styrofoam containers. Additionally, an opened container of chicken broth was found without an open date. The microwave in the therapy room was observed to have rusted surfaces and splatters of unidentified substances. Interviews with Maintenance Staff U and Therapy Consultant GG confirmed the unsanitary conditions and the use of kitchen equipment for resident rehabilitation purposes. The facility's policy on foods brought in by family or visitors required perishable foods to be stored in resealable containers with labels, but this was not adhered to. Furthermore, there was no policy for cleaning the microwave, contributing to the unsanitary conditions. The facility's failure to maintain the therapy room refrigerator, freezer, and microwave in a sanitary manner and to ensure food items did not exceed their use-by date posed a risk of foodborne illness among residents.
Failure to Timely Provide Positioning Devices for Resident
Penalty
Summary
The facility failed to timely assess and accommodate a resident's request for positioning devices to aid in movement and alleviate back pain. The resident, who had diagnoses including chronic back pain and osteoarthritis, was assessed with normal cognitive function and required supervision with activities of daily living. Despite the resident's ability to communicate his needs, he reported requesting positioning rails multiple times without them being provided. Observations and interviews revealed that the resident expressed his preference for positioning rails to several staff members, but the request was not acted upon until much later. A licensed nurse was unaware of the request until an interview, after which a work order was placed. The facility's policy required staff to assess the appropriateness of such devices, but this was not done in a timely manner, resulting in a delay in addressing the resident's needs for pain management and independence in bed mobility.
Inaccurate MDS Documentation for Opioid Medication
Penalty
Summary
The facility failed to complete accurate Minimum Data Sets (MDS) for a resident, identified as Resident 25, regarding the administration of opioid medications. The resident, who had a diagnosis of chronic pain, was documented in the Annual MDS and Quarterly MDS as not receiving opioid medication, despite evidence to the contrary. The resident's Electronic Medical Record (EMR) and Medication Administration Record (MAR) indicated that she was receiving Fentanyl, an opioid medication, every 72 hours as per physician's orders. This discrepancy was confirmed by Administrative Nurse D, who acknowledged that the MDSs were inaccurately coded during the lookback period of the assessments. The resident's care plan for pain management, revised in April 2024, instructed staff to administer a Fentanyl pain patch for chronic pain, which was consistent with the physician's orders documented in the EMR. However, the MDS assessments failed to reflect the administration of this opioid medication, leading to inaccurate documentation. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs, yet the oversight in coding resulted in the failure to accurately assess the resident's medication regimen.
Failure to Maintain Fall Interventions for Resident with Huntington's Disease
Penalty
Summary
The facility failed to maintain fall interventions for a resident diagnosed with Huntington's disease, major depressive disorder, and anxiety, who was assessed with severe cognitive impairment. The resident had a history of repeated falls, weakness, lack of coordination, and unsteadiness, and was independent for most activities of daily living, using a walker for mobility. Despite these needs, the resident experienced multiple falls, including two non-injury falls and one non-major injury fall since the last assessment. The care plan required nonskid strips in the bathroom and by the recliner, as well as fall mats, to prevent falls. Observations revealed that the nonskid strips in the resident's bathroom were worn and not adhered to the floor, increasing the risk of falls. Interviews with staff indicated that the resident often ambulated without a walker or calling for assistance, and the nonskid strips were frequently compromised due to wetness from the resident's habits. Maintenance staff confirmed the issue with the nonskid strips, and there was no facility policy for their inspection. This lack of maintenance and policy led to the deficiency in ensuring the resident's safety as care planned.
Failure to Administer PRN Medications for Constipation
Penalty
Summary
The facility failed to ensure that a resident remained free from unnecessary medications by not administering as-needed (PRN) medications for constipation. The resident, who had a diagnosis of constipation and was dependent on staff for toileting needs, did not have a bowel movement for several days on multiple occasions. Despite having physician's orders for various laxatives and stool softeners, the staff did not administer these medications or document any refusal by the resident to take them. The facility's bowel management protocol required staff to administer specific medications if a resident did not have a bowel movement for three, four, or five days, but this protocol was not followed. The resident's electronic medical record showed that there were three separate periods where the resident went without a bowel movement for four to six days. During these times, the staff failed to administer PRN medications or document any refusal by the resident to accept bowel management interventions. Interviews with facility staff revealed that the resident would sometimes refuse the ordered PRN medications, but there was no documentation to support this. The facility's protocol also required staff to make a brief nurse's note if a resident refused the protocol, which was not done in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pittsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Via Christi Village Pittsburg | 0 mi | ★★★★★ | 0 | 0 |
| Medicalodges Pittsburg | 1 mi | — | 0 | 0 |
| Medicalodges Frontenac | 4.8 mi | ★★★★★ | 0 | 0 |
| Arma Operator, Llc | 11.1 mi | ★★★★★ | 1 | 0 |
| Medicalodges Columbus | 17.5 mi | ★★★★★ | 1 | 1 |
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