Health inspection·June 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based 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. Findings: During a record review of Resident 1's admission Record (AR), printed on 5/8/25, the AR indicated Resident 1 was admitted to the facility in May 2023 with diagnoses of dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) and post-traumatic stress disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 5/25/24, the MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 0 out of 15 which indicated severely impaired mental status. During an observation and interview on 6/3/25 at 10:21 a.m. with Resident 1, Resident 1 was awake in his bed and noted to have tremors on his hands. Resident 1 did not respond when asked how he was doing. During an interview on 6/3/25 at 10:22 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated Resident 1 was totally dependent on staff with Activities of Daily Living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). CNA 1 further stated Resident 1 was cognitively impaired and unable to verbalize his needs. During a phone interview on 6/3/25 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was notified by two SNs and their clinical instructor that SN 1 and SN 2 witnessed a physical abuse on Resident 1 committed by CNA 1. LVN 1 stated Resident 1 had tremors and had behaviors of leaning forward when in the wheelchair. LVN 1 stated repositioning Resident 1 should have been done by two people using the proper technique such as placing the arms under Resident 1's armpits. LVN 1 stated CNA 1 should have never touched Resident 1's face to push him back into the wheelchair. LVN 1 stated Resident 1 could have had physical injury or mental harm. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055677 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 06/03/2025 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)