Pittsburg Care and Rehab

In the surveyor’s words

From the most serious findings on record at Pittsburg Care and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF688Sep 15, 2022

  The 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. […]

• Actual harm, isolatedF692Sep 15, 2022

  The 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. […]

• Actual harm, isolatedF760Sep 15, 2022

  The 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 [CONDITION(S)], stroke, or other life-threatening health problems), which required hospitalization intervention/treatment. Findings included: - Review of Resident (R) 24's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF692Mar 4, 2021

  The facility reported a census of 58 residents. The sample included 17 residents, with four residents selected for nutritional review. Based upon observation, interview, and record review the facility, after identifying weight loss, failed to implement the registered dietitian's recommended interventions for one month, to prevent additional continued weight loss for one of the four sampled residents, Resident (R) 51. The failure to implement the recommendation resulted in further significant weight loss of 8.05% in 43 days- from 01/04/21, when R51 weighed 136.5 pounds to 02/16/21 when R51 weighed 125.5 pounds. Findings included: - A signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Mar 11, 2026

  The 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). Findings included:- On 03/11/26 at 10:04 AM, Maintenance Staff V reported the facility utilized a Legionella testing kit, which was conducted on 12/22/25 from the kitchen water. The final report, dated 12/30/25, did not detect Legionella. […]