Inspection Reports for Gran Villas Pittsburg
1004 E. CENTENNIAL STREET, PITTSBURG, KS, 66762-6603
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 27, 2025, found no deficiencies and confirmed that all previous issues had been corrected. Earlier inspections showed some deficiencies related mainly to documentation of residents’ functional capacity and medication management responsibilities, with a significant complaint investigation in October 2023 identifying immediate jeopardy due to neglect of a cognitively impaired resident who eloped, along with multiple other issues including medication labeling and emergency preparedness. Complaint investigations prior to that were mostly unsubstantiated, except for a substantiated complaint in 2014 involving negotiated service agreements, health care service standards, and medication labeling. No fines, license suspensions, or enforcement actions were listed in the available reports. The facility appears to have addressed prior deficiencies over time, with recent inspections showing improvement and compliance with regulations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
24 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-03-11.
Findings
All deficiencies have been corrected as of the compliance date of 2025-03-26, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 24
Deficiencies: 2
Date: Mar 10, 2025
Visit Reason
The inspection was a licensure resurvey conducted on 03/10/25 and 03/11/25 to assess compliance with state regulations for the facility.
Findings
The facility failed to ensure that residents' functional capacity was accurately reflected on screening forms and that the negotiated service agreements identified who was responsible for administration and management of selected medications for residents who self-administer medications.
Deficiencies (2)
Failure to ensure that each resident's functional capacity at the time of screening was accurately reflected on the screening form for residents R1 and R3.
Failure to ensure that the negotiated service agreement reflected the administration and management responsibilities for selected medications for residents R1 and R3 who self-administer medications.
Report Facts
Census: 24
Residents in sample: 3
Residents self-administering medications: 13
Residents receiving insulin injections: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication management and interview confirming medication administration practices |
| Operator B | Named in interview confirming medication administration practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 10, 2025
Visit Reason
The document is a Plan of Correction submitted in response to findings from the licensure resurvey conducted on 03/10/25 and 03/11/25 at the facility.
Findings
The Plan of Correction addresses citations identified during the licensure resurvey conducted on the specified dates. Specific deficiencies or severity levels are not detailed in this document.
Inspection Report
Re-Inspection
Deficiencies: 9
Date: Oct 24, 2023
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.
Deficiencies (9)
Deficiency related to regulation 26-41-101 (f) (1)
Deficiency related to regulation 26-41-202 (h)
Deficiency related to regulation 26-41-205 (a) (1)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-205 (g) (2)
Deficiency related to regulation 26-41-102 (d)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 9
Date: Oct 2, 2023
Visit Reason
The inspection was a resurvey with a complaint #181341 at an assisted living facility conducted on 09/27/23, 09/28/23, and 10/02/23.
Complaint Details
The visit was complaint-related under complaint #181341. The complaint involved neglect of a cognitively impaired resident who eloped from the facility unsupervised, resulting in immediate jeopardy.
Findings
The facility was found to have multiple deficiencies including immediate jeopardy related to neglect of a cognitively impaired resident who eloped due to lack of supervision, failure to ensure proper signatures on negotiated service agreements, incomplete medication self-administration assessments, improper medication labeling, incomplete employee records, failure to conduct quarterly emergency preparedness reviews, and non-compliance with tuberculosis screening guidelines.
Deficiencies (9)
Failure to ensure resident R101 was not subjected to neglect by failing to implement interventions for resident safety, resulting in immediate jeopardy when R101 eloped.
Failure to ensure the Negotiated Service Agreement (NSA) for resident R103 was signed by all individuals involved.
Failure to ensure medication self-administration assessment was completed for resident R102's use of a Duopa pump.
Failure to ensure the NSA for resident R103 identified the responsible person for administration and management of selected medications.
Failure to ensure licensed pharmacist or nurse placed the full name of the resident on original packages of over-the-counter medications for four residents.
Failure to ensure each prescription medication container had a label provided by a dispensing pharmacist affixed to the container.
Failure to ensure timely verification of nurse aide registry for two of five newly hired employees.
Failure to ensure quarterly review of the facility's emergency management plan with employees and residents was completed.
Failure to ensure compliance with tuberculosis guidelines including timely TB symptom screening and two-step TB skin tests for newly hired staff.
Report Facts
Census: 27
Deficiencies cited: 9
Elopement duration: 45
Dates of inspection: 2023-09-27 to 2023-10-02
Employee registry verification delay: 15
TB skin test delay: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Documented resident R101's condition and elopement risk; provided statements regarding supervision and assessments. |
| Certified Medication Aide C | Certified Medication Aide | Provided witness statement regarding resident R101's elopement. |
| Certified Medication Aide D | Certified Medication Aide | Provided statements about medication administration and resident supervision. |
| Administrative Staff A | Administrative Staff | Informed of immediate jeopardy findings, submitted abatement plan, and confirmed expectations for nurse aide registry checks and emergency plan reviews. |
| Consultant Nurse E | Consultant Nurse | Informed of immediate jeopardy findings. |
| Licensed Nurse B | Licensed Nurse | Provided statements regarding medication administration and NSA details. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The document is a plan of correction responding to findings from a resurvey with a complaint #181341 conducted at the assisted living facility on 09/27/23, 09/28/23, and 10/02/23.
Complaint Details
The visit was triggered by complaint #181341; no substantiation status is provided in this document.
Findings
The plan of correction addresses citations identified during the resurvey related to the complaint investigation at the assisted living facility.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/14/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 9, 2019
Visit Reason
The visit was a resurvey of the assisted living facility conducted on 5/9/2019.
Findings
The resurvey resulted in no citations or deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 10, 2017
Visit Reason
Licensure resurvey with complaint investigations 109773 and 110010 at the assisted living facility.
Complaint Details
Complaint investigations 109773 and 110010 were conducted with no deficiencies found.
Findings
The inspection resulted in a finding of no deficiency citations on 5-10-17.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 25, 2015
Visit Reason
The licensure resurvey at the Assisted Living Facility in Pittsburg, Kansas, was conducted in conjunction with a complaints investigation #88412.
Complaint Details
Complaint investigation #88412 was conducted and resulted in no deficiencies.
Findings
The survey resulted in a finding of no deficiency citations on 06-24-15 and 06-25-15.
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Jun 2, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
The report confirms that the previously identified deficiencies under regulations 26-41-202 (a), 26-41-204 (i), and 26-41-205 (a) (3) were corrected as of June 2, 2014.
Deficiencies (3)
Deficiency under regulation 26-41-202 (a)
Deficiency under regulation 26-41-204 (i)
Deficiency under regulation 26-41-205 (a) (3)
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: May 7, 2014
Visit Reason
The inspection was a resurvey and investigation of complaint #74230 conducted on 5/5/14, 5/6/14, and 5/7/14 at an assisted living facility.
Complaint Details
The visit was triggered by complaint #74230. The investigation found substantiated deficiencies related to negotiated service agreements, health care services standards, and medication labeling.
Findings
The facility failed to develop written negotiated service agreements for residents at risk for falls, and health care services were not consistently provided by qualified staff according to acceptable standards of practice. Additionally, over-the-counter medications were not labeled with the full name of the resident by a licensed nurse or pharmacist.
Deficiencies (3)
Failure to ensure development of written negotiated service agreements for residents based on functional capacity screening including fall risk.
Failure to provide health care services by qualified staff in accordance with acceptable standards of practice, including lack of licensed nurse assessment and physician consultation after resident falls.
Failure to ensure licensed nurse or pharmacist placed the full name of the resident on over-the-counter medication packages.
Report Facts
Census: 27
Residents sampled: 3
Falls documented: 9
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