Pittsburg Skilled Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident, (Resident 1), was free from physical abuse when two Student Nurses (SN) witnessed Certified Nurse Assistant (CNA) 1 pushed Resident 1's face aggressively and forcefully back into Resident 1's wheelchair. This failure had the potential to result in physical and emotional harm on Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure presents a threat to residents reaching their highest practicable level of well-being and had the potential to endanger the health and safety of residents. (Cross reference F835)

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 15 sampled residents' (Residents 4, 8, and 10) Advanced Directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed with the residents and/or responsible parties when the Advanced Directive information was unmarked or marked unavailable on the Physician Orders for Life-Sustaining Treatment (POLST, a form designed that records patients' treatment wishes so emergency personnel know what treatments the patient wants in the event of a medical emergency) for Residents 4, 8, and 10. This had potential for the facility to provide treatment and services against the wishes of Residents 4, 8, and 10.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to provide homelike environment to three of 15 sampled residents (Resident 9, 36 and 19) when 1. The wall clock in shared room for Residents 9, 36 and 19 displayed an inaccurate time, with a potential to cause them confusion and disorientation of time, and 2. The overbed tables (a table with metal base with four wheels, a metallic leg on one side and a wooden tray on the top) for Residents 36 and 19 were chipped and unfurnished with rough edges, posing a potential risk for them getting scratched and hurting themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 35 and Resident 23) were administered melatonin (a sleep supplement that helps regulate the sleep-wake cycle) up to safety standards when melatonin was given at 4:00 p.m. to Resident 35 and Resident 23. This failure had the potential to place Resident 35 and Resident 23 at risk for physical harm or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate assessment/evaluation, did not attempt to use any alternatives prior to installing bed rails (adjustable metal or rigid plastic bars attached to the bed) for three of three sampled residents (Resident 36, 24 and 40). Facility did not obtain an informed consent for use of bed rails from Resident 36's Family Representative (FR). This failure placed Residents 36, 24 and 40 at risk of unnecessary use of bed rails and risk of entrapment, hitting against the rail, falling over the side rails, up to and including greater injury or death. Failure to obtain an informed consent placed Resident 36's FR to make an uninformed decision, be unaware of the medical necessity, and alternative options available instead of using bed rails. (Cross Reference F552).

Inspectors wroteBased an observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Resident 22 and Resident 38) received medications without an error. The facility's medication pass observation during the survey resulted in two errors out of 25 opportunities and indicated a medication error rate of 8 percent (%). This failure placed Resident 22 and Resident 38 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in undesired health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 38 when: 1. Medication refrigerator freezer had multiple ice packs and thick accumulation of ice with yellowish color, 2. Resident 25's glucagon (an injectable emergency medication used to treat very low blood sugar) was stored with eye medications, and 3. an unlabeled bottle of eyewash (a liquid solution used to clean eyes) was stored with liquid oral medications. These failed practices could contribute to unsafe storage of medications and potential for medication error.

Inspectors wroteBased on interview and record review, the facility administration did not follow their facility policy and procedure when a Registered Nurse's (RN) timecard adjustments for correction for 3 weekend days of April 2023 were done in August of 2024 (after 16 months had passed). This deficient practice had the potential for the residents to not receive the accurate amount of required time of care from an RN. (Cross Reference F727)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. two dryers' lint trap compartments were full of lint, and 2. a glucometer (a device used to check blood sugar level) device was not cleaned and disinfected properly according to the manufacturer's instructions and standards of practice. This failure had the potential to spread infectious diseases to all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat Resident 10 with dignity and respect when the resident was observed to be eating her pureed (cooked food that had been ground, pressed and blended to the consistency of creamy paste) breakfast in plastic cups. This failure had the potential to cause emotional distress to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure family representative (FR) of one of three sampled residents (Resident 36) made an informed decision for the use of bed rails for Resident 36. Facility did not share and maintain a record of accurate assessment of medical needs, alternative attempts that failed to meet resident's needs, alternatives considered but not attempted because they were inappropriate, prior to the use of bedrails, with Resident 36's FR. Facility designated a non-licensed professional (admission Coordinator-AC) to obtain informed consents for use of bed rails during admission process. This failure placed Resident 36's FR to be unaware of the medical necessity, and alternative options available instead of using bed rails. (Cross Reference F 700)

Inspectors wroteBased on interview and record review, the facility failed to complete and submit the Death in Facility Tracking Record to Centers for Medicare & Medicaid Services (CMS) for one of one sampled resident (Resident 5) when Resident 5 died in the facility on [DATE]. This failure resulted in Resident 5's specific payment information and quality measure data to be out of date.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess and code one of 15 sampled residents (Resident 36) for diagnosis of Pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) in the quarterly Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) when the MDS was coded Yes for an active diagnosis of Pneumonia and Resident 36 did not have Pneumonia. This failure resulted in an outdated and inaccurate reflection of Resident 36's medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 15) of one sampled resident completed a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that 1. all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2. be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document specific behavior and side effects related to the use of Sertraline (a medication used to treat depression) for one of five sampled residents (Resident 36) being used for a behavior of uncontrollable scratching. This failure placed Resident 36 at risk for not receiving individualized care to address her medical, mental and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to allow one of five sampled residents (Resident 14) to store food brought by family member in the facility's refrigerator. This failure resulted in Resident 14 feeling disappointed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of medical record for one of one sampled resident (Resident 40), when a physician order to implement bed rails (a barrier attached to the side of a bed) was created on 8/27/24 for a four-month older date, 4/13/24 without any verification. This failure resulted in inaccurate reflection of physician orders to implement bed rails for Resident 40.

Inspectors wroteBased on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents for 12 of 20 rooms (Rooms 3, 4, 5, 7, 9, 10, 12, 15, 17, 18, 19, and 20). The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings.

Inspectors wroteBased on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who received nutrition through g-tube feeding, received appropriate treatment and services to prevent complications of enteral feeding when: a. Resident 1's head was not elevated during and after feeding, b. Aspiration precautions were not observed even after multiple hospitalizations related to aspiration. These failures had contributed in multiple admissions to the hospital for aspiration pneumonia (lung infection caused by something other than air being inhaled into the respiratory tract, can be food, liquid, stomach contents).

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to three of three sampled residents (Resident 26, 31, 34) after they were discharged from Medicare Part A services and continued to live in the facility. This deficient practice resulted in Resident 26, Resident 31, Resident 34, and their responsible parties being uninformed about their potential liability for payment and related standard claim appeal rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS- an assessment tool used to guide care) for two of 14 sampled residents (Resident 27 and 29) when: 1. Resident 27's MDS assessment inaccurately reflected significant weight loss; and 2. Resident 29's MDS assessment inaccurately reflected Resident 29 walking with one-staff total assistance and not receiving any physical restraints. This deficient practice resulted in an inaccurate reflection of Resident 27 and Resident 29's comprehensive assessment and had the potential for inadequate weight management for Resident 27 and inadequate care to meet Resident 29's needs.

Inspectors wroteBased on observation, interview, and record review, for three of 34 sampled residents (Resident 31, 9, 21), the facility failed to provide the necessary care to maintain good grooming and personal hygiene when Resident 31, 9, and 21 had long, dirty, and/or jagged fingernails. This failure resulted to Resident 31, 9, and 21 not receiving adequate nail care and had the potential for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were dated and labeled, emergency medications were replaced, and emergency medications and controlled substances (medications with high abuse or misuse potential) were correctly logged when: 1. One 2.5 mL (milliliter, unit of measurement) bottle of bimatoprost (medication to treat glaucoma) ophthalmic solution was opened but not dated and one Multi-Dose Inhaler (MDI) of budesonide 80 mcg (microgram, unit of measuring weight)/formoterol fumarate dihydrate 4.5 mcg (medication used to help with breathing) was opened but not dated or labeled with resident identifier; 2. The opened Oral Emergency Kit (E-Kit, a box with emergency medications) was not replaced by the pharmacy within 24 hours; 3. Emergency Drug Kit Use Log had inaccurate medication usage records; 4. [...]

Inspectors wrote3. During a review of Resident 27's admission Record dated 6/23/22, the record indicated Resident 27 was admitted to the facility on [DATE] with unspecified dementia with behavioral disturbance and major depressive disorder. During a review of Resident 27's Physician's order summary report dated 6/22/22 indicated Resident 27 received one tablet of 50 milligrams (mg) of Quetiapine Fumarate [a psychotropic medication used to treat mental disorders] by mouth at bedtime for unspecified dementia with behavioral disturbance manifested by seeing, feeling or hearing things that are not there since 11/30/2019. During a record review and interview with RN, on 6/24/22, at 8:30 a.m., facility's document titled, Consultant Pharmacist Medication Regimen Review . dated 4/1/22 through 4/26/22 for Resident 27 was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error was not five percent or greater for two of six sampled residents (Resident 19 and 8) when: 1. Resident 19 was administered lactobacillus acidophilus (medication helps with digestive issues) 75 million cells (unit of measure) instead of 500 million cells, as prescribed; and 2. Resident 8 was administered sennosides (medication to treat constipation) 8.6 milligram (mg, unit of measure) tablet as a whole tablet and not crushed. This failure resulted in two medication errors out of 28 opportunities, resulted in a medication error rate of 7.14%, and put the residents at risk of receiving a subtherapeutic dose of medication or increased risk of aspiration (accidentally inhaling food or liquid into airway) and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. the medication room (MR) temperature was out of range; 2. the refrigerator containing controlled medications was unlocked; 3. loose pills were found in two medication carts (Medication Cart 1 and 2); 4. medications not administered were stored unlabeled in a drawer in the med carts; 5. controlled medications to be disposed were store in a single locked, not permanently affixed drawer; and 6. disposed controlled substances were kept in an openly accessible container. These failures had the potential for administration of medication to the wrong resident, temperature sensitive medications to degrade, diversion of medications, and miscount of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. four packages of bread in the freezer were unlabeled and undated; 2. four pieces of pie crust were undated; 3. the dietary aide did not wear a face mask; 4. two white electric fans were brownish and dusty; and 5. the condiment rack was brownish and sticky. These failures had the potential to cause food contamination and food borne illness to 34 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when one of three sampled residents (Resident 8) did not have a date on the tubing of the nebulizer (a small machine that turns liquid medicine into a mist, and the tip of the tubing with the mouthpiece was on the floor. This failure placed Resident 8 at risk for healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use the least restrictive alternatives and to reevaluate the use of a Posey bed (a hospital bed, canopy, and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) for one of 14 sampled residents (Resident 29) when Resident 29 used a Posey bed and was not reevaluated. This failure placed Resident 29 at risk of impaired psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Pre-admission Screening and Resident Review (PASRR) assessment for one of two sampled residents (Resident 3) when Resident 3's PASRR did not reflect the diagnosis of Parkinson's Disease (a gradual and progressive movement disorder that initially causes tremor [vibration] in one hand, stiffness or slowing of movement). This failure placed Resident 3 at risk to not receive an in-depth mental illness evaluation and care appropriate to his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan for one of 14 sampled residents (Resident 29) when Resident 29's care plan for a Posey bed restraint (a hospital bed, canopy and mattress system where all walls are zipped up from outside and the resident cannot exit out of it without assistance) was not reviewed and revised for two years and ten months. This failure placed Resident 29 at risk for impaired psychosocial well-being and had the potential to not meet Resident 29's care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 28) received dental care services when Resident 28 did not receive treatment for tooth extraction for over three consecutive months. This failure resulted in Resident 28 to experience teeth pain and placed Resident 28 at potential risk for inability to eat or chew well.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was posted and readily available, when the daily staffing ratio information was not posted for two consecutive days on 6/22/22 and 6/23/22, and the staffing ratio data was not maintained for 26 days for the month of 5/2022 and five days for the month of 6/2022 for at least 18 months. This failure resulted in staffing information not being readily available to residents and visitors at any given time.

Inspectors wroteBased on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents for 12 of 20 rooms (Rooms 3, 4, 5, 7, 9, 10, 12, 15, 17, 18, 19, and 20). The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings.

Inspectors wroteBased on interview and record review, for one of 13 sampled residents (Resident 37), the facility failed to implement their written policies and procedures when a staff member witnessed Resident 37 being called disparaging and derogatory names by her roommate, Resident 38. The facility did not prevent further incidents, did not identify the incident as abuse, did not conduct an investigation, did not protect Resident 37 from abuse, and did not report the abuse. This failure resulted in continuing verbal abuse of Resident 37 by Resident 38 and caused Resident 37 to feel stressed, angry, heavy in the chest, cold, and clammy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 13 sampled residents (Residents 20 and 46) were provided with respiratory care per physicians' orders when: 1. Resident 20 was given 4 Liters per minute (L/min) of oxygen instead of 2 L/min per doctor's orders. 2. Resident 46 was given 4.5 L/min of oxygen instead of 2 L/min per doctor's orders. These deficient practices had the potential for life-threatening complications related to oxygen toxicity.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure one of 13 sampled residents (Resident 6) was able to carry out activities of daily living (ADLs) when staff repeatedly failed to assist the resident with inserting his dentures. This failure resulted in Resident 6 feeling humiliated and neglected and had the potential to effect the resident's nutrition and oral hygiene.

Inspectors wroteBased on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents for 12 of 20 rooms (Rooms 3, 4, 5, 7, 9, 10, 12, 15, 17, 18, 19, 20). This failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings.