Pittsburg Care and Rehab

Inspectors wroteThe facility had a census of 60 residents. Based on observation, interview, and record review, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by legionella).

Inspectors wroteThe facility identified a census of 60 residents. The sample included 15 residents with one resident reviewed for dignity. Based on interviews, observation, and record review the facility failed to ensure Resident (R) 9 was treated with respect, dignity, and care during mealtimes.

Inspectors wroteThe facility identified a census of 60 residents. The sample included 15 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interviews, the facility failed to provide form CMS-10055, Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN), which included the estimated cost for continued services for skilled services to the resident or their representative for Resident (R) 36 and R44.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to keep the residents protected health information (PHI) private on two medication carts parked in the west hallway and the east hallway.

Inspectors wroteThe facility identified a census of 60 residents. The sample included 15 residents with five residents reviewed for unnecessary medications. Based on interviews, observation, and record review the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)4 and R19, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion).

Inspectors wroteThe facility identified a census of 60 residents. The sample included 15 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 9 with the admission to hospice services.

Inspectors wroteThe facility had a census of 60 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to ensure adequate pain management was provided to Resident (R) 41 for ongoing pain in the knees, lower back, and shoulders.

Inspectors wroteThe facility identified a census of 60 residents. The sample included 15 residents with two residents reviewed for hospice services. Based on interviews, observation, and record review, the facility failed to ensure collaboration with the hospice provider for Resident (R) 19 and R9.

Inspectors wroteThe facility reported a census of 52 residents. Based on observation and interview the facility failed to ensure sanitary food storage in the therapy room refrigerator and failed to maintain the microwave in a sanitary manner.

Inspectors wroteThe facility reported a census of 52 residents with 16 residents selected for review, which included one resident reviewed for accommodation of needs. Based on observation, interview and record review, the facility failed to ensure staff assessed one Resident (R) 4, for positioning devices in a timely manner.

Inspectors wroteThe facility reported a census of 52 residents with 16 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R) 25, regarding opioid medications (a powerful pain-reducing medication).

Inspectors wroteThe facility reported a census of 52 residents with 16 sampled, including four residents reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure fall interventions were maintained for Resident (R)13. This placed the resident at increased risk for further falls, injury, and pain.

Inspectors wroteThe facility reported a census of 52 residents with 16 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure one Resident (R) 25 remained free from unnecessary medications related to the failure to administer as needed (PRN) medications for lack of bowel movements (BM) for longer than three days.

Inspectors wroteThe facility reported a census of 68 residents. The sample of 22 residents included seven residents reviewed for restorative nursing services. Based on observation, interview, and record review the facility failed to ensure five of the seven sampled residents received restorative nursing services to increase range of motion, prevent further decrease in range of motion, and/or prevent decrease in mobility. Resident (R)16 received therapy services and then no restorative nursing services and declined in range of motion and walking ability; R112 who received no restorative services after therapy; R34, R30, and R12 for no restorative nursing program when they had range of motion impairments. Findings Included: [...]

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review, including two residents reviewed for nutrition. Based on observation, interview, and record review, the facility failed to ensure adequate parameters of nutritional status for one of the two residents reviewed. The facility failed to ensure Resident (R)20 received her diet as ordered, failed to involve the Registered Dietician with R20's desire to lose weight, failed to appropriately monitor the resident's weight, and failed notify the physician of the significant weight loss. R20 experienced a 10.96 percent weight loss from 03/31/22 to 04/29/22, a 10.6 percent weight loss from 05/23/22 to 06/30/22, and a 23.55 percent weight loss from 03/31/22 to 09/03/22.

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review, which included six residents reviewed for medication use. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 24, remained free from a significant medication error when staff failed to administer antihypertensive medication (a drug used to lower blood pressure) as ordered by the physician on 117 instances between 07/05/22 through 08/21/22. This failure resulted in a hypertensive crisis (a severe increase in blood pressure that can lead to a heart attack, stroke, or other life-threatening health problems), which required hospitalization intervention/treatment.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, interview and record review, the facility failed to maintain an effective quality assurance committee that identified, developed and implemented appropriate intervention plans of action in a timely manner to ensure the residents received adequate needed quality care from the facility.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, interview and record review the facility failed to handle, store, process and transport linens to prevent the spread of infection for the residents of the facility.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas including rooms, bathrooms and in a shower room.

Inspectors wrote- The Medical Diagnosis tab located in the electronic medical record (EMR), for Resident (R)20, included diagnoses of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region, morbid obesity (a disorder involving excessive body fat, body mass index [BMI] greater than 40), and lymphedema (swelling caused by accumulation of lymph [a fluid that flows through the lymphatic system]). The admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required supervision and setup for eating and drinking. [...]

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review including nine residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, pressure in combination with shear and/or friction). [...]

Inspectors wroteThe facility reported a census of 66 residents with 22 selected for review, which included five residents reviewed for dialysis. Based on observation, interview, and record review, the facility failed to coordinate dialysis (a process that filters wastes and fluids from the body when the kidneys fail) care of pre and post weight assessments and details of the dialysis sessions with the dialysis provider as required for five of the five residents reviewed, 02 Resident (R)53, R41, R118, and R262.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to the facility kitchen areas, to maintain a sanitary, orderly, and comfortable interior for the residents of the facility.

Inspectors wroteThe facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, for the residents of the facility, with the presence of flies in various areas of the facility.

Inspectors wroteThe facility reported a census of 68 residents with 22 sampled which included one resident reviewed for choices. Based on observation, interview, and record review, the facility failed to provide individual choices for the one sampled dependent Resident (R)55 related to his preferences for clothing selection.

Inspectors wroteThe facility reported a census of 68 residents, with 22 sampled. Based on observation, interview, and record review, the facility failed to accurately complete a Comprehensive Assessment, and Quarterly Assessment, respectively related to the use of a Continuous Positive Air Pressure (CPAP) machine for one sampled Resident (R)55.

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to develop comprehensive person-centered care plans for one of the sampled residents, Resident (R)30 with range of motion impairments and the lack of a restorative program.

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review including four residents reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure three of the sampled residents, Resident (R)4, R39, and R46, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of their fingernails.

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review which included one resident selected for review of hospice services. Based on observation, interview and record review, the facility failed to coordinate care between hospice services and the facility to ensure the resident's advance directive for no resuscitative measures determined and carried out.

Inspectors wroteThe facility reported a census of 68 resident with 22 selected for review, which included four residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe transfer techniques for one resident (R) 34 of the four residents reviewed.

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to ensure one of the two residents, Resident (R)20's catheter drainage bag remained below bladder level and failed to drain the catheter bag in a sanitary manner to prevent urinary tract infection.

Inspectors wroteThe facility reported a census of 68 residents, with 22 sampled, which included one resident sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care to maintain respiratory equipment to prevent the spread of infection, for the one sampled Resident (R) 55.

Inspectors wroteThe facility reported a census of 68 residents with 22 selected for review. Based on record review and interview the facility failed to notify the physician for one of the residents, Resident (R)20, when she experienced a significant weight loss.

Inspectors wroteThe facility reported a census of 68 residents. The sample of 22 residents included six residents reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of multiple medications as ordered by the physician, for one resident of the six sampled residents; (R)60 related to pain medication and medications to treat gastrointestinal acid reflux (indigestion/heartburn).

Inspectors wroteThe facility reported a census of 68 residents which included five residents reviewed for influenza and pneumococcal vaccines. Based on interview and record review the facility failed to ensure two of the five residents (R24 and R 12) or their representatives received information/education for the benefits, risks, or medical contraindications regarding pneumococcal immunization.