Pittsburg Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Pittsburg Skilled Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 24, 2021

  Based on observation, interview, and record review, the facility failed to provide a safe environment free of hazards for five of five sampled residents (Resident 1, 2, 3, 4, and 5) when the facility did not perform a structural assessment, repair and or maintenance of the roof that was soft, mushy, sunken and had multiple areas with water built up. The ceiling of Room A (occupied by Resident 1 and 2), collapsed on the morning of 1/31/21, in between the beds of Resident 1 and Resident 2, while they were in their beds. The ceiling of Room B (occupied by Resident 3 and 4) and Room C (occupied by Resident 5) had water that leaked from the ceiling on 1/31/21. […]

• No harm, potential for more than minimal, widespreadF727Aug 28, 2024

  Based 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) Findings: A review on 8/27/24 at 9:19 a.m., the facility's licensed staffing schedules for the month of January 2023 through April 2023 indicated there were no RNs scheduled to work eight hours a day during the following dates: 1. For the month of January: 1/7/23 and 1/30/23, 2. For the month of February: 2/5/23, and 3. […]

• No harm, potential for more than minimal, patternF578Aug 28, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF584Aug 28, 2024

  Based 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. Findings: 1. During an observation and interview on 8/26/24 at 8:00 a.m. […]

• No harm, potential for more than minimal, patternF658Aug 28, 2024

  Based 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. Findings: During a record review of Resident 35's hospital Transfer Summary orders, dated 7/25/24, the document indicated, Resident 35 had a medication order of Melatonin (Melanin) 3 milligrams (mg) Oral tablet - Take three tablets by mouth half hour before bedtime as needed for sleep. […]