Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pittsburg Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and PTSD, who was totally dependent on staff and severely cognitively impaired, was physically abused when a CNA forcefully pushed the resident's face back into a wheelchair, as witnessed by two student nurses. The incident was later reported to facility leadership, and staff interviews confirmed the handling was inappropriate and abusive.
The facility did not ensure RN coverage for eight hours a day, seven days a week, as required. Staffing schedules from January to April 2023 showed missing RN coverage on several dates. The DON confirmed these gaps and acknowledged the risk of poor RN supervision, potentially endangering resident health and safety.
The facility failed to discuss and document Advanced Directives for three residents, as indicated by missing or unmarked information on their POLST forms. The Social Services Director confirmed the lack of documentation and follow-up during care conferences, contrary to the facility's policy.
The facility failed to maintain a homelike environment for three residents due to an inaccurate wall clock and damaged overbed tables. A CNA confirmed the clock's incorrect time, and the DON acknowledged potential confusion for residents. Two residents had chipped overbed tables, posing injury risks, with the Environmental Services Supervisor reporting the issue a month prior without action. The Administrator confirmed replacements were only made for non-functional tables, and an LVN noted the absence of a service request for replacement.
Two residents were given melatonin at 4:00 p.m., contrary to their prescribed orders to take it at bedtime. The facility's DON stated this was due to an early sleeping schedule, but the CP did not recommend this timing. The residents and their representatives were not informed, and the facility's policy on medication administration was not followed.
The facility failed to conduct proper assessments and obtain informed consent before installing bed rails for three residents. One resident's family was not informed of alternatives, and the facility did not document any alternative measures. Another resident's care plan lacked specific goals for safe bed rail use, and the facility backdated a physician's order. The third resident was not reassessed for safe bed rail use, and the facility used inappropriate bed rails provided by hospice.
Two residents with Type 2 diabetes were administered Metformin without meals, contrary to prescribed orders, resulting in an 8% medication error rate. An LVN gave the medication without food due to timing issues, despite the facility's policy requiring adherence to medication orders.
The facility failed to ensure safe medication storage and labeling, with issues including ice buildup in the medication refrigerator, improper storage of a resident's glucagon with eye medications, and an unlabeled eyewash bottle stored with oral medications. The Facility Maintenance Director had not maintained the refrigerator as required, and staff were unaware of proper storage protocols, leading to potential medication errors.
The facility failed to follow its policy on timecard adjustments, altering an RN's hours 16 months later without verification. The RN's hours were changed from four to eight on three weekends, despite her working only one hour to administer IV antibiotics. Discrepancies in documentation and mismatched signatures were found, and the facility's policy requiring timely salary adjustments was not followed.
The facility failed to maintain infection control practices in the laundry room and during glucometer use. Observations showed lint accumulation in dryer compartments, which were not cleaned as required, posing fire and infection risks. Additionally, an LVN improperly cleaned a glucometer with an alcohol pad instead of the approved disinfectant wipes, increasing infection spread risk. Facility policies and manufacturer's instructions for cleaning were not followed.
A resident with major depressive disorder was served pureed breakfast in plastic cups, which was deemed undignified by staff. An LVN transferred the food from plates to cups due to the need to return trays to the kitchen. Both the LVN and DON acknowledged this practice did not respect the resident's dignity, contrary to the facility's policy.
A facility failed to ensure a family representative made an informed decision about bed rails for a resident with severely impaired cognition. The Admission Coordinator, a non-licensed professional, obtained consent without proper training or documentation of alternatives. The Director of Nursing acknowledged the resident could not use the rails voluntarily, and the family representative was not informed of alternatives by the physician.
A resident with multiple health conditions died in the facility, but the Death in Facility Tracking Record was not completed or submitted to CMS as required. The MDSC admitted the oversight, which led to outdated payment information and quality measure data.
A facility failed to accurately assess and code a resident for Pneumonia in the MDS, leading to an incorrect active diagnosis. Observations and interviews confirmed the resident showed no symptoms of Pneumonia, and the MDS Coordinator found no supporting documentation. This resulted in an inaccurate reflection of the resident's medical condition.
A resident with schizophrenia was not given a required PASRR Level II evaluation due to unresponsiveness from facility staff, despite being identified as Level I positive for Serious Mental Illness. The Medical Record Director and Director of Nursing were unaware of the need for this evaluation, which should have been processed immediately according to facility policy.
A facility failed to monitor and document behaviors and side effects for a resident prescribed Sertraline for uncontrollable scratching. Despite the resident's inability to communicate, there was no documentation of behavior monitoring or side effects, contrary to the facility's policy on psychotropic medication use. This oversight risked the resident's individualized care.
A facility failed to provide storage for food brought by family members for a resident, leading to disappointment. Interviews revealed that there was no refrigerator available for storing such food, and residents were instructed to consume it immediately or have it discarded. The facility's policy indicated that outside food could be stored, but this was not implemented, affecting a resident with intact cognition who wished to save food brought by her son.
A facility failed to maintain accurate medical records when the DON backdated a physician order for bed rails for a resident admitted with post-hemorrhagic anemia. The order was created on one date but backdated to an earlier date without informing the MD, leading to inaccuracies in the resident's medical records. The Administrator was unaware of this action, which could result in document falsification.
The facility failed to meet the required minimum square footage per resident in 12 rooms, providing only 75.1 sq. ft. per resident instead of the mandated 80 sq. ft. Despite this, observations indicated sufficient space for care, no interference from equipment, and no resident complaints or safety concerns.
Physical Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) physically abused a resident by forcefully and aggressively pushing the resident's face back into a wheelchair. This incident was directly witnessed by two student nurses, who observed the CNA using his whole hand to push the resident's face, resulting in a whiplash motion. The CNA appeared frustrated while repositioning the resident, who repeatedly leaned forward in the wheelchair. The student nurses were disturbed by the event and later reported it to facility leadership. The resident involved had a history of dementia and post-traumatic stress disorder (PTSD), was totally dependent on staff for activities of daily living, and was severely cognitively impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of 0 out of 15. The resident was unable to verbalize needs and exhibited tremors. Staff interviews confirmed that the resident required two-person assistance for safe repositioning and that the CNA's method of handling was inappropriate and could have caused harm. Interviews with facility leadership, including the administrator and director of nursing, confirmed that the CNA's actions were considered abusive and demeaning. The administrator noted that the CNA had previously been investigated for suspected physical abuse, though it was unsubstantiated at that time. The facility's policy emphasized the right of residents to be free from abuse and the importance of maintaining a culture of compassion, particularly for those with cognitive or behavioral issues.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight hours a day, seven days a week, as required. A review of the facility's licensed staffing schedules from January 2023 through April 2023 revealed that there were no RNs scheduled to work the required hours on specific dates: January 7 and 30, February 5, and April 22, 29, and 30. This deficiency was confirmed through an interview with the Director of Nursing (DON), who acknowledged the lack of RN coverage on these dates. The DON also stated that the absence of RN coverage posed a risk of poor oversight of RN supervision, which could potentially endanger the health and safety of residents and hinder their ability to reach their highest practicable level of well-being.
Failure to Discuss and Document Advanced Directives
Penalty
Summary
The facility failed to ensure that the Advanced Directives for three residents were properly discussed and documented. For Resident 10, the Minimum Data Set indicated mild cognitive impairment, and the Physician Orders for Life-Sustaining Treatment (POLST) form lacked information on the presence of an Advanced Directive. During an interview, the Social Services Director (SSD) confirmed that there was no documentation of discussions regarding Advanced Directives with Resident 10's responsible party. Similarly, Resident 4's POLST indicated that Advanced Directive information was marked as not available, and Resident 8's POLST was unmarked. The SSD assumed the absence of an Advanced Directive when the POLST was unmarked and stated that follow-ups were supposed to occur during care conferences. However, the Multidisciplinary Care Conference forms for Residents 4 and 8 showed that their Advanced Directives were not followed up. The facility's policy required informing residents or their responsible parties about Advanced Directives during admission, but this was not documented for these residents.
Deficiencies in Homelike Environment and Equipment Maintenance
Penalty
Summary
The facility failed to provide a homelike environment for three residents due to two main issues. Firstly, the wall clock in the shared room of three residents displayed an incorrect time, which was confirmed by a CNA who noted the clock needed a battery change. The Director of Nursing acknowledged that a non-functioning clock could cause confusion and disorientation among residents. The facility's policy on maintaining a homelike environment was reviewed, indicating the expectation for a safe and comfortable setting. Secondly, the overbed tables for two residents were found to be chipped and unfurnished with rough edges, posing a risk of injury. The Environmental Services Supervisor had reported the need for replacement to the Administrator a month prior, but no action had been taken. The Administrator confirmed that replacements were only made when tables were non-functional or damaged. A Licensed Vocational Nurse noted the risk of injury due to the residents' frail skin and the absence of a written service request for table replacement in the Maintenance Binder.
Improper Administration of Melatonin
Penalty
Summary
The facility failed to administer melatonin to two residents, Resident 35 and Resident 23, according to professional standards and prescribed orders. Resident 35 was ordered to take melatonin 30 minutes before bedtime as needed, while Resident 23 was to take it nightly at bedtime. However, both residents were routinely given melatonin at 4:00 p.m., which was not in accordance with their prescribed orders. This discrepancy was observed during medication pass observations and confirmed through record reviews of the residents' Medication Administration Records and hospital transfer documents. The Director of Nursing stated that the facility had implemented an early sleeping time for all residents, which led to the early administration of melatonin. However, the facility's Consultant Pharmacist clarified that the pharmacy did not recommend administering melatonin at 4:00 p.m. and emphasized that it should be given later in the evening to avoid safety issues. Interviews with Resident 23 and the Family Representative of Resident 35 revealed that they were not informed about the early administration of melatonin, and Resident 23 expressed a preference for taking it later. The facility's policy required medications to be administered according to orders and to consult with a physician if a dosage was believed to be inappropriate, which was not adhered to in this case.
Failure to Properly Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to conduct accurate assessments and evaluations before installing bed rails for three residents. For Resident 36, the facility did not attempt to use any alternatives prior to the installation of bed rails and failed to obtain informed consent from the family representative. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for bed mobility, yet the facility did not document any alternative measures or a proper informed consent process. The Director of Nursing (DON) acknowledged the lack of documentation regarding alternative attempts and informed consent. For Resident 40, the facility's Bed Rail Assessment (BRA) indicated the need for bed rails due to unsteady gait, but there was no evidence of alternative measures being considered. The care plan lacked specific goals and interventions for safe bed rail use. Observations showed that half side rails were used, contrary to the quarter size evaluated, and the facility did not reassess the resident for proper bed rail use upon admission. The DON admitted to backdating a physician's order for bed rails, indicating a lack of proper documentation and assessment. Resident 24 was admitted with a diagnosis of cerebral infarction and was totally dependent on staff for bed mobility. The BRA indicated the need for side rails, but like Resident 40, there was no documentation of alternative measures or a specific care plan for bed rail use. Observations confirmed the use of half side rails, and the facility failed to reassess the resident for safe bed rail use. The DON acknowledged the inaccurate assessment and lack of documentation regarding the use of bed rails, which were provided by the hospice agency.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that two residents, Resident 22 and Resident 38, received their medications without error, resulting in a medication error rate of 8%. Both residents had a diagnosis of Type 2 diabetes mellitus and were prescribed Metformin 1000 mg to be taken twice daily with meals to prevent gastrointestinal upset. During a medication pass observation, LVN 5 administered Metformin to both residents without offering food or a meal, contrary to the prescribed orders. LVN 5 acknowledged the error, stating that the medication was given without meals because of the timing of her rounds and the residents' readiness. The Consultant Pharmacist confirmed that Metformin should be taken with meals to prevent stomach discomfort. The Director of Nursing also stated that the medication should have been administered with meals to avoid affecting the residents' blood sugar levels. The facility's policy on administering medications requires adherence to prescribed orders, including timing, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage and labeling practices, as observed during a survey. The medication refrigerator freezer was found to have multiple ice packs and a thick accumulation of ice with a yellowish color. The Infection Preventionist (IP) was unaware of the reason for the ice buildup, and the Facility Maintenance Director (FMD) admitted that the refrigerator had not been cleaned or maintained since June 2024, despite the facility's policy requiring monthly cleaning. The FMD noted that the freezer door was not closing properly due to the ice buildup, which could lead to temperature changes affecting the medications stored inside. The Consultant Pharmacist (CP) confirmed that improper closure of the freezer door could cause defrosting and potentially alter medication labels. Additionally, Resident 25's glucagon, an injectable emergency medication, was improperly stored with eye medications, and an unlabeled bottle of eyewash was found with liquid oral medications. Licensed Vocational Nurse (LVN) 3 was unaware of the glucagon's presence due to its placement at the back of the drawer and did not know the owner of the unlabeled eyewash. LVN 3 also admitted to not knowing the facility's protocol for medication storage. The IP and CP both stated that medications should be stored separately by route to prevent infection spread and medication errors. The facility's policy indicated that drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling before storage.
Failure to Adhere to Timecard Adjustment Policy
Penalty
Summary
The facility administration failed to adhere to its policy and procedure regarding timecard adjustments for a Registered Nurse (RN). The issue arose when the RN's timecard was adjusted 16 months after the fact, changing her recorded hours from four to eight on three specific weekend days in April 2023. This adjustment was made in August 2024 without proper verification, as the Payroll Director (PD) altered the hours based on information from the Director of Staff Development (DSD), who claimed the RN worked eight hours but did not punch in correctly. However, the RN stated she only worked one hour on those weekends to administer IV antibiotics and was paid for four hours, as agreed with the facility. Further investigation revealed discrepancies in the documentation, including mismatched signatures on missed punch forms and inconsistencies between the RN's timecard and paycheck. The Director of Nursing (DON) and DSD acknowledged these discrepancies, with the DON denying recent involvement in signing the missed punch forms. The facility's policy requires salary adjustments to be reported within 30 days, but this was not followed, leading to the deficiency. The Administrator was unaware of who created the missed punch forms, and the RN confirmed she was paid correctly last year, further highlighting the administrative oversight.
Infection Control Lapses in Laundry and Glucometer Use
Penalty
Summary
The facility failed to maintain proper infection control practices in two key areas: the laundry room and the use of a glucometer. In the laundry room, an observation revealed that the lint trap compartments of two dryers were full of lint, which should have been cleaned every two hours according to the Environmental Services Supervisor (ESS). The ESS admitted that there was no documentation to confirm regular cleaning and maintenance of the dryers, which posed a potential fire hazard. The Infection Preventionist (IP) noted that excessive lint could also lead to respiratory diseases or infections among residents. The facility's policy on laundry and bedding, dated September 2022, emphasized the importance of maintaining laundry equipment according to the manufacturer's instructions to prevent microbial contamination. In another instance, a Licensed Vocational Nurse (LVN) failed to properly clean and disinfect a glucometer after use. The LVN used an alcohol pad for less than five seconds to wipe the glucometer after checking a resident's blood sugar, instead of using the facility's approved disinfectant wipes, Micro-Kill One Germicidal Alcohol Wipes. The IP stated that the proper procedure involved using one wipe to clean all areas and another to disinfect, ensuring the device remained wet for one minute to kill germs. The facility's policy on obtaining a fingerstick glucose level, dated October 2011, and the glucometer's owner's manual both outlined specific cleaning and disinfecting procedures that were not followed, increasing the risk of infection spread.
Resident Served Food in Plastic Cups, Violating Dignity
Penalty
Summary
The facility failed to treat a resident with dignity and respect by serving her pureed breakfast in plastic cups. The resident, who was diagnosed with major depressive disorder, was observed eating her meal in plastic cups while sitting in bed. When questioned, the resident expressed confusion about why her food was served in this manner. The Licensed Vocational Nurse (LVN) present during the observation identified the food as grits but was unable to identify another item, and explained that the resident ate from plastic cups because she was a slow eater. Further interviews revealed that another LVN transferred the food from plates to plastic cups because the breakfast trays and plates needed to be returned to the kitchen. This LVN acknowledged that serving food in plastic cups was not dignified. The Director of Nursing (DON) also confirmed that this practice did not treat the resident with dignity. The facility's policy on dignity, revised in August 2009, states that residents should be treated with dignity and respect at all times, which includes maintaining and enhancing their self-esteem and self-worth.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to ensure that the family representative (FR) of a resident made an informed decision regarding the use of bed rails. The facility did not provide or maintain a record of an accurate assessment of the resident's medical needs, nor did it document alternative attempts that failed to meet the resident's needs or alternatives considered but not attempted. Instead, a non-licensed professional, the Admission Coordinator (AC), was designated to obtain informed consents for the use of bed rails during the admission process. This led to the FR being unaware of the medical necessity and alternative options available instead of using bed rails. The resident in question had severely impaired cognition and was totally dependent on staff for activities of daily living. The care plan indicated the use of side rails as ordered, and a physician order specified the use of bilateral 1/4 siderails for bed mobility. However, the Director of Nursing (DON) acknowledged that the resident could not hold onto the side rails voluntarily and that they were used more for comfort rather than necessity. The DON also stated that the facility was not required to obtain informed consent if the bed rails were not used as restraints, and that the physician was responsible for obtaining such consent. Despite this, there was no documentation of any alternatives being used or a physician obtaining informed consent prior to the installation of the bed rails. The FR stated that she signed the consent upon the resident's admission after being informed by front desk staff about the use of bed rails to prevent falls. However, she did not recall any discussion with the resident's physician about alternatives or other medical reasons for using bed rails. The AC, who was responsible for obtaining informed consent, admitted to not having received official training on the process and was not a licensed medical professional. The facility's policy required staff to inform the resident or representative about the benefits and potential hazards associated with bed rails and to obtain informed consent, which was not adequately followed in this case.
Failure to Submit Death in Facility Tracking Record
Penalty
Summary
The facility failed to complete and submit the Death in Facility Tracking Record to the Centers for Medicare & Medicaid Services (CMS) for a resident who died in the facility. This oversight was identified during a review of the resident's records and an interview with the Minimum Data Set Coordinator (MDSC). The resident, who had been admitted with multiple diagnoses including Cervical Disc Disorder, Malignant Neoplasm of Prostate, Combined Systolic and Diastolic Heart Failure, and Chronic Obstructive Pulmonary Disease, passed away in the facility. The MDSC acknowledged that the Death in Facility Tracking Record was missed and not completed for submission. The facility's policy on MDS Submission Timeframes requires that resident assessments be conducted and submitted in accordance with federal and state guidelines. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the Death in Facility Tracking Record must be completed within 7 days of a resident's death and submitted within 14 days. The failure to adhere to these guidelines resulted in the resident's specific payment information and quality measure data being outdated.
Inaccurate MDS Coding for Pneumonia Diagnosis
Penalty
Summary
The facility failed to accurately assess and code a resident for a diagnosis of Pneumonia in the quarterly Minimum Data Set (MDS). The MDS was incorrectly coded to indicate an active diagnosis of Pneumonia, despite the resident not having this condition. This error was identified through observation, interviews, and record reviews, which revealed that the resident did not exhibit any symptoms of Pneumonia, such as respiratory distress or cough, during the assessment period. Interviews with the Certified Nursing Assistant and Licensed Vocational Nurse confirmed that the resident had not shown signs of Pneumonia recently. The MDS Coordinator also acknowledged that there was no documentation in the resident's nursing progress notes to support the diagnosis of Pneumonia during the look-back period. The facility's policy on maintaining accurate medical records was not adhered to, resulting in an outdated and inaccurate reflection of the resident's medical condition.
Failure to Complete PASRR Level II Evaluation for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 15, completed a Preadmission Screening and Resident Review (PASRR) Level II evaluation, which is a federal requirement for individuals with serious mental disorders or intellectual disabilities. Resident 15, who was diagnosed with schizophrenia, was readmitted to the facility and was identified as Level I positive for Serious Mental Illness (SMI) during a PASRR screening. Despite this, the necessary Level II evaluation was not scheduled because facility staff were unresponsive to multiple communication attempts within 48 hours of the Level I screening. Interviews with the Medical Record Director (MRD) and the Director of Nursing (DON) revealed a lack of awareness regarding the need for a Level II evaluation for Resident 15. The MRD, responsible for processing PASRR, was unaware of the attempted screening, while the DON acknowledged that the evaluation should have been processed immediately due to the Level I positive result. The facility's policy and procedure on PASRR screening indicated that residents on antipsychotic medications should be evaluated for appropriateness, but this was not adhered to in Resident 15's case.
Failure to Monitor Sertraline Use and Side Effects
Penalty
Summary
The facility failed to monitor and document specific behaviors and side effects related to the use of Sertraline for a resident who was being treated for uncontrollable scratching. The resident, who was unable to communicate her needs or understand others, was observed to have a habit of scratching herself. Despite being prescribed Sertraline for generalized anxiety disorder manifested by uncontrollable scratching, there was no documentation of behavior monitoring or side effects from the medication. Interviews with facility staff, including a CNA and an LVN, revealed that there was a lack of awareness and documentation regarding the resident's behavior and any changes since the initiation of Sertraline. The facility's policy on psychotropic medication use emphasized the need for adequate monitoring for efficacy and adverse consequences, which was not adhered to in this case. This oversight placed the resident at risk of not receiving individualized care to address her medical, mental, and psychosocial needs.
Failure to Provide Storage for Resident's Outside Food
Penalty
Summary
The facility failed to provide storage for food brought by family members for residents, specifically affecting one resident, Resident 14. During interviews, it was revealed that the facility did not have a refrigerator available for storing such food, and residents were instructed to consume the food immediately or have it discarded. Certified Nursing Assistant (CNA) 1 confirmed that there was no place to keep leftover food, and the Administrator stated that the facility did not reheat food brought by family and any remaining food was thrown away. This lack of storage led to Resident 14 feeling disappointed as she could not save food brought by her son for later consumption. Resident 14, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, expressed her disappointment during an interview, stating that she would like to save food brought by her son. The facility's policy, dated 2018, indicated that food brought from outside could be stored in the facility kitchen, nursing station's refrigerator, or in residents' personal refrigerators. However, the Registered Dietitian (RD) confirmed that there was no refrigerator available for this purpose, contradicting the facility's policy.
Inaccurate Medical Record Due to Backdated Physician Order
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident when a physician order for bed rails was backdated without verification. The order was created on August 27, 2024, but was backdated to April 13, 2024, by the Director of Nursing (DON) without informing the Medical Doctor (MD). This action resulted in an inaccurate reflection of the physician's orders for the use of bed rails for the resident. The resident was admitted with a diagnosis of post-hemorrhagic anemia and was observed with half-sized bed rails provided by a hospice agency. During a review of the resident's electronic health record, it was found that the DON created and backdated the order due to the absence of an order in the system. The DON acknowledged the mistake, stating that the order should have been dated on the day it was received. The facility's Administrator was unaware of this action and stated that backdating could lead to document falsification.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide residents with the required minimum square footage per resident in multiple occupancy rooms. Specifically, 12 out of 20 rooms were identified as having less than the mandated 80 square feet per resident. Each of these rooms, numbered 3, 4, 5, 7, 9, 10, 12, 15, 17, 18, 19, and 20, measured a total of 225.36 square feet and housed three residents, resulting in only 75.1 square feet per resident. This deficiency was observed during a survey conducted on August 26, 2024, with the Facility's Maintenance Director. Despite the deficiency in room size, observations from August 25 to August 28, 2024, indicated that there was sufficient space for the provision of care, and no heavy equipment was stored in the rooms that could interfere with residents' care. Each resident had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns reported as a result of the decreased space in the affected rooms. A recommendation for a room size waiver was made.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pittsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diamond Ridge Healthcare Center | 1.1 mi | — | 3 | 0 |
| Delta View Post Acute | 3.9 mi | — | 6 | 0 |
| Lone Tree Post Acute | 6.1 mi | — | 2 | 0 |
| Stonebrook Post Acute | 6.3 mi | — | 4 | 0 |
| Diablo Valley Post Acute | 7.9 mi | — | 11 | 0 |
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