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 Via Christi Village Pittsburg during CMS and state inspections, most recent first.
The facility failed to conduct required care plan meetings for four residents, including those with end-stage renal disease, hemiplegia, Alzheimer's, and colon cancer. Care plans were updated without resident or representative involvement, contrary to facility policy.
The facility failed to maintain resident equipment in a clean and safe condition, as observed with a toilet seat riser that had rusty legs and a cracked seat. Housekeeping/Maintenance staff acknowledged the need for replacement, but the facility lacked a policy for equipment maintenance.
The facility failed to maintain a clean environment in one of its neighborhoods, as surveyors observed dirty and stained privacy curtains in a shower room. Housekeeping staff confirmed responsibility for curtain cleanliness and acknowledged the need for washing or replacement. The facility also lacked a policy for maintaining and cleaning shower curtains.
A resident with severe cognitive impairment had a personal humidifier with a heavy build-up of a hardened, white substance, but the care plan lacked instructions for its maintenance. Staff interviews revealed confusion about responsibility for the humidifier's care, and the facility's policy requires care plans to include specific care needs, which was not followed.
The facility failed to update care plans for two residents with dementia, resulting in improper use of wheelchair footrests. Observations showed residents' feet skimming the floor or dangling between footrests during transport. Staff acknowledged the issue but did not revise care plans to include necessary instructions, violating facility policy.
Two residents with hemiplegia and cognitive impairments did not receive adequate grooming assistance, as observed in a LTC facility. One resident was not shaved on designated bath days, while another had food substances left on her face after meals. Staff interviews confirmed expectations for personal hygiene care, but these were not met, violating the facility's dignity policy.
Two residents with dementia in an LTC facility were improperly positioned in their wheelchairs due to the absence or misuse of footrests during staff-assisted transport. Despite facility policy requiring footrests, staff failed to ensure residents' feet were properly supported, leading to deficiencies in care.
A resident with severe cognitive impairment had a humidifier in their room that was not properly cleaned or maintained, leading to a build-up of a hardened, white substance. Facility staff were unclear about who was responsible for the humidifier's care, and the facility's water management policy was not adhered to.
A resident with end-stage renal disease receiving dialysis three times a week was not adequately assessed and monitored by the facility. Despite instructions in the care plan and facility policy, staff failed to consistently perform and document pre-dialysis and post-dialysis assessments, leading to a deficiency in care.
A resident with end-stage renal disease and moderate cognitive impairment received Midodrine outside the physician-ordered parameters, which specified administration only if systolic blood pressure was below 140 mmHg. The facility's staff administered the medication multiple times despite higher blood pressure readings, as confirmed by administrative nurses, violating the facility's policy on medication administration.
A facility failed to assess a resident for adverse effects of Olanzapine, an antipsychotic medication prescribed for violent behaviors. Despite the resident's severe cognitive impairment and the care plan's instructions to monitor for side effects, the necessary AIMS assessments were not conducted as required. Observations indicated potential adverse effects, such as tearfulness and nonsensical mumbling, which were not addressed, highlighting a lapse in following the facility's policy on behavioral assessments and monitoring.
A resident with severe cognitive impairment and at high risk for pressure ulcers developed a stage II ulcer. During wound care, a nurse failed to change gloves and perform hand hygiene after cleansing the wound, contrary to facility policy. This deficiency was confirmed by another staff member.
A cognitively impaired resident was found on the floor by a CMA, who administered medications and left without reporting the incident. The resident remained on the floor for four hours until discovered by a CNA, resulting in a left hip fracture requiring surgical repair.
A resident received two doses of oxycodone within two hours due to a nurse's failure to document the administration of a PRN dose in the EHR. The resident had a history of pneumonia and pain, with moderately impaired cognition. The facility's policy required proper documentation, which was not followed, leading to the medication error.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for four residents, as required by their policy. Resident 2, who has end-stage renal disease and receives dialysis, was not included in care plan meetings, as confirmed by Social Service Staff X. The resident's care plan was updated without the involvement of the resident or their representative, despite the facility's policy that encourages participation in care planning. Resident 13, diagnosed with hemiplegia after a stroke, also did not have care plan meetings conducted with their involvement. The resident, who requires extensive assistance with daily activities, had a care plan updated without their or their representative's participation. This was confirmed by Social Service Staff X, who acknowledged the omission of care plan meetings. Resident 7, with severe cognitive impairment due to Alzheimer's disease and dementia, and Resident 57, with colon cancer, were similarly affected. Resident 7's care plan was updated without a meeting, and Resident 57 had not had a care plan meeting since early in the year, missing scheduled meetings due to the absence of a social worker. The facility's policy mandates quarterly care plan meetings, which were not adhered to for these residents.
Deficiency in Maintenance of Resident Equipment
Penalty
Summary
The facility failed to ensure that all resident equipment in the C Court neighborhood was maintained in a clean and safe condition. During an environmental tour, a toilet seat riser was observed to have multiple rusty areas on all four legs, and the plastic toilet seat was cracked at the area where it met residents' buttocks. Housekeeping/Maintenance Staff U acknowledged that the toilet seat riser needed to be discarded and mentioned that the facility had extra toilet seat risers available for replacement. However, the facility lacked a policy for the maintenance and upkeep of resident equipment, contributing to the deficiency.
Deficiency in Cleanliness of Shower Room Curtains
Penalty
Summary
The facility failed to maintain a clean environment in one of its four neighborhoods, specifically in a shower room on C Court. During an environmental tour, surveyors observed two privacy curtains that were dirty and stained. Housekeeping/Maintenance Staff U confirmed that housekeeping was responsible for ensuring the cleanliness of the privacy curtains in the shower rooms and acknowledged that the curtains needed to be washed or replaced. Additionally, the facility lacked a policy regarding the maintenance and cleaning of the shower curtains.
Failure to Include Humidifier Maintenance in Resident Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for a resident, identified as R27, regarding the care and maintenance of her personal humidifier. The resident, who has a diagnosis of dementia with severe cognitive impairment, was observed with a humidifier in her room that had a heavy build-up of a hardened, white substance in the spout and nebulizer chamber. Despite the presence of the humidifier and its condition, the care plan for the resident, revised on 10/14/24, did not include any staff instructions for the care and maintenance of the humidifier. Interviews with facility staff revealed a lack of clarity and responsibility regarding the maintenance of the resident's humidifier. A Certified Medication Aide (CMA) believed that the night shift staff was responsible for the humidifier's care, while another CMA was unsure of who was responsible. An Administrative Nurse confirmed that the care plan should have included staff instructions for the care and maintenance of personal humidifiers. The facility's policy on care plans, revised in 10/2021, mandates that comprehensive care plans should include resident-specific care needs with measurable goals and outcomes, which was not adhered to in this case.
Failure to Revise Care Plans for Wheelchair Footrest Use
Penalty
Summary
The facility failed to review and revise the care plans for two residents, R59 and R70, regarding the use of footrests for their wheelchairs. Resident 59, diagnosed with dementia and severe cognitive impairment, utilized a wheelchair for mobility and required varying levels of staff assistance. Despite this, her care plan lacked instructions for the use of footrests while being propelled by staff. Observations revealed that her feet skimmed the floor during transport, as her wheelchair lacked footrests. Staff members stated that footrests were not used because the resident sometimes self-propelled. Similarly, Resident 70, also diagnosed with dementia and severe cognitive impairment, required substantial to maximal assistance with mobility. Her care plan did not include instructions for the use of appropriate footrests. Observations showed that her feet dangled between the footrests or rested improperly, indicating a lack of support. Staff acknowledged the issue but had not addressed it in the care plan. The facility's policy required ongoing assessments and revisions of care plans as residents' conditions changed. However, the care plans for both residents were not updated to include necessary instructions for footrest use, leading to deficiencies in their care. The facility's failure to ensure proper footrest use while residents were being propelled by staff was confirmed by both staff and administrative personnel.
Failure to Provide Adequate Grooming Assistance
Penalty
Summary
The facility failed to provide adequate grooming assistance to two residents, R13 and R37, who were dependent on staff for personal hygiene. R13, who had hemiplegia following a stroke and moderate cognitive impairment, was observed with several days' worth of facial hair, indicating a lack of grooming. Despite being cooperative with bathing, the resident was not shaved on his designated bath days, as confirmed by interviews with staff members. The facility's policy on Quality of Life-Dignity emphasized the importance of maintaining residents' dignity through personal care, which was not adhered to in this case. R37, who also had hemiplegia and dementia, required extensive assistance with activities of daily living due to a recent diagnosis of Parkinson's disease. Observations revealed that the resident had food substances on her face after meals, which were not cleaned by staff members, including a Certified Medication Aide and a Licensed Nurse. The resident preferred to feed herself, but staff were expected to assist with personal hygiene afterward, which was not consistently done. This neglect in providing necessary personal hygiene care was contrary to the facility's policy aimed at enhancing residents' dignity and quality of life. Interviews with the Administrative Nurse confirmed that staff were expected to provide personal hygiene care to residents. However, the observations and interviews indicated a failure to meet these expectations, resulting in a deficiency in the care provided to these residents. The facility's inability to ensure proper grooming and hygiene assistance compromised the residents' comfort and dignity, as outlined in their care plans and the facility's policies.
Improper Wheelchair Positioning for Residents with Dementia
Penalty
Summary
The facility failed to properly position two residents, R59 and R70, in their wheelchairs, which led to deficiencies in their care. Resident R59, diagnosed with dementia and severe cognitive impairment, required assistance with mobility and used a wheelchair. Despite the care plan indicating independence with the wheelchair, observations showed that R59's feet skimmed the floor during transport due to the absence of footrests. Staff members, including CNAs and a CMA, acknowledged that footrests were not used because the resident sometimes self-propelled. However, the facility's policy required footrests during staff-assisted transport, which was not adhered to. Resident R70, also diagnosed with dementia and severe cognitive impairment, required substantial to maximal assistance with mobility. Observations revealed that R70's feet were not properly supported on the wheelchair footrests, with instances of feet dangling or resting improperly. Staff, including a CNA, failed to notice the improper positioning of the resident's feet. The facility's policy mandated that residents' feet should rest comfortably on footrests during transport, which was not followed in R70's case. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed the expectation that footrests should be used during transport to ensure residents' feet are properly positioned. The facility's policy for safe patient transport in wheelchairs, approved earlier in the year, was not implemented effectively, resulting in the improper positioning of both residents during transport.
Failure to Maintain Resident's Humidifier
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, identified as R27, by not maintaining and cleaning a humidifier in the resident's room. The resident, who has a diagnosis of dementia with severe cognitive impairment, was observed with a humidifier that had a heavy build-up of a hardened, white substance in the spout and nebulizer chamber. This condition persisted over several days, indicating a lack of maintenance and cleaning of the device. Interviews with facility staff revealed confusion and uncertainty regarding the responsibility for the care and cleaning of the resident's humidifier. Certified Medication Aides were unsure of who was responsible, and the Administrative Nurse did not know how often the humidifiers should be cleaned. The facility's policy on water management to reduce Legionella exposure was not followed, as it included guidelines for maintaining devices like humidifiers to prevent the growth and spread of Legionella.
Failure to Monitor Dialysis Patient
Penalty
Summary
The facility failed to provide adequate assessment and monitoring for a resident with end-stage renal disease who required dialysis three times a week. The resident, who had moderate cognitive impairment, was at risk for nutritional and fluid volume imbalance. The care plan instructed staff to assess the dialysis access site for bleeding and ensure stable blood pressure before the resident resumed activity. However, the facility did not consistently perform or document pre-dialysis and post-dialysis assessments as required. Specifically, the Dialysis Communication forms from late September to mid-October lacked pre-dialysis and post-dialysis assessments on multiple occasions. The Nurse's Progress Notes also lacked documentation of these evaluations. Interviews with staff confirmed that assessments should have been conducted and documented, but this was not done consistently. The facility's policy required staff to assess the access site and document the resident's condition before and after dialysis, but these procedures were not followed, leading to a deficiency in care.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically regarding the administration of Midodrine, a medication used to increase blood pressure. The resident, who had end-stage renal disease and was receiving dialysis, had a physician's order to administer Midodrine only if the systolic blood pressure (SBP) was less than 140 mmHg. However, the Medication Administration Record (MAR) showed multiple instances where staff administered Midodrine despite the resident's SBP being above the ordered threshold, ranging from 142 mmHg to 175 mmHg. The resident's medical records indicated moderate cognitive impairment and a risk for nutritional and fluid volume imbalance due to dialysis treatments. Despite these considerations, the facility's staff did not adhere to the physician's parameters for administering Midodrine, as confirmed by interviews with administrative nurses. The facility's policy required staff to record medication and any specified parameters, but this was not followed, leading to the administration of Midodrine outside the prescribed limits.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to adequately assess a resident, identified as R44, for adverse effects of an antipsychotic medication, specifically Olanzapine, which was prescribed for violent behaviors. The resident, who has a history of dementia with behavioral disturbances, anxiety, and pseudobulbar affect, was noted to have severe cognitive impairment with a BIMS score of one. Despite the care plan's instructions to monitor for adverse effects due to the medication's Black Box warning, the facility did not perform the necessary assessments using the AIMS tool to check for extrapyramidal side effects. The last documented AIMS assessment was completed several months prior, and the facility's policy required such assessments every three months. Observations of the resident showed signs of potential adverse effects, such as tearfulness, flat affect, and nonsensical mumbling, which were not adequately addressed by the facility. An interview with Administrative Nurse E confirmed the expectation for regular assessments using the AIMS tool, which had not been met. The facility's policy on Behavioral Assessments, Intervention, and Monitoring emphasized the need for minimal complications through both nonpharmacological and pharmacological interventions, yet the interdisciplinary team failed to review and discuss the necessary interventions and findings for this resident.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during wound care for a resident identified as R27. The resident, who has a diagnosis of dementia and severe cognitive impairment, was at high risk for developing pressure ulcers. Despite having no unhealed pressure ulcers at the time of the initial assessment, the resident developed a stage II pressure ulcer on the coccyx, which was being treated according to a physician's order. During a dressing change, Administrative Nurse F did not change gloves or perform hand hygiene after cleansing the wound and before measuring it, which was against the facility's wound care policy. The facility's policy, revised in May 2023, clearly stated that staff should remove gloves, perform hand hygiene, and don clean gloves after cleansing a wound. However, during an observation on October 16, 2024, Administrative Nurse F admitted to not following this protocol. This lapse in procedure was confirmed by another staff member, Administrative Nurse D, who stated that the expectation was for staff to change gloves and perform hand hygiene after cleansing a wound and before measuring it. This failure to perform proper hand hygiene during wound care was a deficiency identified by the surveyors.
Failure to Prevent Neglect of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent the neglect of a cognitively impaired resident. On the morning of 11/27/23, a Certified Medication Aide (CMA) found the resident on the floor with her legs extended in the doorway of her closet. Despite observing the resident in this condition, the CMA administered medications and left the room without reporting the incident to any other staff members. The resident remained on the floor for four hours until a Certified Nurse Aide (CNA) heard noises coming from the room and discovered the resident still on the floor. The resident was then assessed by a Licensed Nurse (LN) and found to have a left hip fracture, which required surgical repair. The resident had a history of vascular dementia, diabetes mellitus, hypertension, seizures, anxiety, depressive disorder, narcolepsy, bilateral hearing loss, and mixed receptive-expressive language disorder. She was severely cognitively impaired, requiring extensive assistance with bed mobility, transfers, and toileting, and had a history of falls. The resident's care plans included specific instructions for fall prevention and assistance with activities of daily living (ADLs). The facility's investigation revealed that the CMA did not think anything of the resident being on the floor because she had known the resident to do her own thing while still needing help. However, the facility's abuse prevention policy clearly stated that residents have the right to be free from neglect. The failure to report the resident's fall and provide immediate assistance resulted in the resident remaining on the floor for an extended period, leading to a serious injury that required emergency medical intervention.
Removal Plan
- The facility educated all staff on the topics of Falls, Abuse, Neglect and Exploitation, and Timely Reporting.
- R1 was assessed by Administrative Nurse D and no adverse effects noted.
- R1's care plan related for falls reviewed by the Interdisciplinary Team and fall interventions were appropriate.
- Staff education provided for all clinical staff and completed prior to the onsite survey.
Medication Error Due to Documentation Failure
Penalty
Summary
The facility failed to prevent a medication error when a Licensed Nurse (LN) did not document the administration of a pain medication in a resident's Electronic Health Records (EHR). On the specified date, LN I administered a five-milligram tablet of oxycodone as an as-needed (PRN) pain medication at 06:00 AM. However, this administration was not recorded in the Medication Administration Record (MAR). Two hours later, at 08:00 AM, another nurse, LN H, administered the resident's scheduled dose of oxycodone, which was supposed to be given one hour before the resident left for dialysis. This resulted in the resident receiving two doses of oxycodone within a two-hour period, contrary to the physician's order that required a six-hour interval between doses. The resident involved had a history of pneumonia and pain, with moderately impaired cognition as indicated by a Brief Interview of Mental Status score of eight. The resident's Pain Care Plan documented a pain rating of four out of ten. The facility's Medication Administration Policy required verification of the right resident, medication, dosage, time, and method of administration, and documentation in the MAR after each medication was given. Despite these guidelines, the failure to document the PRN dose led to the medication error. The incident was confirmed through interviews with the involved nurses and a review of the controlled substance log and progress notes.
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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 | 0 mi | ★★★★★ | 8 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.