Health inspection·October 10, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 1's Progress Notes from 7/24/23, the Progress Notes indicated Resident 1 was started on g-tube feeding initially running at 20 milliliters per hour (ml/hr), increased by 15 ml/hr until Resident 1 received 50 ml/hr of g-tube feeding formula. During a review of Resident 1's Nutritional Assessment by Registered Dietitian (RD) dated 7/27/23, the Nutritional Assessment indicated aside from the g-tube feeding formula, Resident 1 did not receive any food by mouth. The RD recommended to increase g-tube feeding to 60 ml/hr. During a review of Interdisciplinary Team (IDT, a group composed of individuals representing different departments of the facility) Notes dated 7/31/23, the IDT notes did not address Resident 1's aspiration risk while on g-tube feeding. During a review of Resident 1's incident report dated 8/19/23, the incident report indicated Resident 1 was noted with labored breathing, had crackles (rattling or bubbling lung sound that can be a sign of fluid in the air sacs) upon expiration (exhalation), and oxygen saturation was 84% at room air. The report indicated Resident 1 was sent to hospital where Resident 1 was diagnosed with sepsis. During a review of Hospitalist Discharge summary dated [DATE], the Hospitalist Discharge Summary indicated Resident 1 had diagnoses that included sepsis, acute respiratory failure, and aspiration into respiratory tract. During a review of Resident 1's Progress Notes dated 9/2/23, the Progress Notes indicated Resident 1 was noted with frothy sputum coming out from mouth and nose, had crackles upon expiration, and oxygen saturation was 86%. The notes indicated Resident 1 was taken to the hospital via 911. During a review of Hospitalist Discharge summary dated [DATE], the Hospitalist Discharge Summary indicated a diagnosis that included acute respiratory failure with hypoxia from recurrent aspiration, Resident 1 received antibiotics. During a review of Resident 1's IDT Notes dated 9/14/23, the IDT notes indicated current assessment of Resident 1's respiratory status but did not address how to prevent recurrence of aspiration. During an observation on 9/26/23 at 10:15 a.m., Resident 1 was lying on her back in low-Fowler's position (head is elevated 15 to 30º. During a joint interview on 9/26/23 at 10:23 a.m. with Licensed Vocational Nurse (LVN) 1 and Director of Nursing (DON), LVN 1 stated she had just turned off Resident 1's g-tube feeding. LVN 1 stated Resident 1's head was low to make it easier for Resident 1 to be turned and repositioned every two hours. LVN 1 stated aspiration precautions included making sure Resident 1's head is not flat and checking for oral secretions and suction every two hours as needed. DON stated Resident 1's head was not elevated at 45º. During an interview and review of the clinical record on 9/26/23 at 12:35 p.m. with DON, Resident 1's g-tube care plan, initiated 5/10/23, was reviewed. DON stated Resident 1 already had aspiration risk upon returning to the facility on 7/24/23. DON stated Resident 1's g-tube care plan should have included aspiration protocol to be observed. DON also stated Resident 1's care plan indicated interventions that included keeping the head of bed elevated at 45º when tube feeding is ongoing and thirty minutes after stopping the feeding. Resident 1's care plan interventions were all initiated on 5/10/23. DON stated Resident 1's g-tube feeding was not revised after 5/10/23, even after multiple (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsburg Skilled Nursing Center 535 School Street Pittsburg, CA 94565 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 re-hospitalizations related to aspiration. Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 9/26/23 at 4:40 p.m. with LVN 2, LVN 2 stated to check for signs of aspiration; one should check for facial grimacing, coughing, presence of drainage from g-tube site, formula not flowing freely, frothy sputum, and abnormal lung sounds. Residents Affected - Some During an interview on 10/10/23 at 9:45 a.m. with DON, DON stated, after thorough review of Resident 1's clinical records, DON stated she realized the mistake and made necessary changes. DON stated, for residents who are at risk for aspiration, staff were re-educated on aspiration protocol that included raising the head of bed to 45º and to hold the g-tube feeding when gastric residual volume (the amount of liquid remaining in the stomach following administration of g-tube feeding to assess g-tube feeding tolerance) is more than 100 ml. DON also stated gastric residual volume should have been documented in MAR. DON also stated the facility did not have a policy or protocol to address prevention of complications from g-tube (such as aspiration). During a review of Resident 1's Medication Administration Record (MAR) for August 2023, the MAR did not indicate gastric residual volume was monitored and head of bed was elevated 45º as indicated in the care plan. During a review of Resident 1's MAR for September 2023, the MAR indicated interventions making sure head of bed was elevated 45º and that gastric residual volume was monitored routinely was not done from 9/1/23 to 9/26/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055677 If continuation sheet Page 3 of 3