Pinnacle Multicare Nursing and Rehabilitation Cent

Inspectors wroteBased on observation, record review, and interview during the Recertification and Complaint Survey (Complaint #666294) conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure a resident received adequate supervision and assistance consistent with the resident's needs to prevent accidents. This was evident for one (1) (Resident #49) of seven (7) residents reviewed for accidents out of 35 total sampled residents. Specifically, Resident #49 fell and sustained major injury while being provided care in bed by Certified Nursing Assistant #2. This resulted in actual harm to Resident #49 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that residents who needed respiratory care were provided care that was consistent with professional standards of practice. This was evident for 3 (Residents #27, #451 and #412) of 5 residents reviewed for respiratory care out of 35 total sampled residents. Specifically, 1.) Nebulizer mask, oxygen cannula, and oxygen tubes were observed in residents' bedside that were not dated and were exposed or not kept in a bag. 2.) Resident #412 was observed receiving oxygen without a physician's order.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the New York State Department of Health. This was evident for 1 (Resident #318) of 7 residents reviewed for Accidents out of 35 total sampled residents. Specifically, the facility did not report to the New York State Department of Health an unwitnessed incident on 07/10/2025 when Resident #318 was observed on the floor with a laceration to the forehead that required 5 sutures. Resident #318 was unable to explain the occurrence.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that parenteral fluids were administered consistent with professional standards of practice. This was evident in 1 (Resident #451) of 2 residents reviewed for hydration, out of 35 total sampled residents. Specifically, Resident #451 was observed with undated peripheral intravenous catheter insertion site dressing and tubing. The intravenous solution was also not dated and was not labeled with the resident's name and flow rate.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure that food were served at a safe and appetizing temperature. This was evident for 1 (Unit 5) of 13 units observed. Specifically, on 07/30/2025, foods served during breakfast in Unit 5 were not maintained at palatable and appetizing temperature.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573 & NY00364335), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for two out of seven residents (Resident #1 and Resident #3) sampled for abuse. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573), the facility failed to thoroughly investigate an alleged violation of abuse. This was evident for one out of seven residents (Resident #1) sampled for abuse. Specifically, Resident #1's adult child reported to Registered Nurse Supervisor #1, on 12/18/2024, that they witnessed Certified Nursing Assistant #1 used the dining room table to shove Resident #1 to sit in their wheelchair on 12/18/2024 at 3:28 PM. The facility investigated the alleged allegation of abuse and concluded that abuse did not occur. The facility did not interview residents that were in the dining room and other staff that were on the unit to ascertain if there were any potential witness.

Inspectors wroteBased on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that garbage was properly disposed. Specifically, garbage was not covered while being removed from the kitchen to the disposal area. This was evident during the Kitchen task. The finding is: The facility policy and procedure titled Waste Disposal created 4/2018 and last revised 3/2023, documented garbage will be disposed of as needed throughout the day and at the end of each day. The policy further stated that prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers, trash bags shall be sealed prior to removing them from the facility, and trash will be deposited into a sealed container outside the premises. On 06/07/23 at 10:36 AM, Food Service Worker (FSW) #1 was observed disposing of kitchen garbage. [...]

Inspectors wroteBased on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, multiple items were observed in freezers and refrigerators without proper labeling and dating. This was evident during the Kitchen task.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Specifically, metal trays of raw fresh chicken were observed placed on top of cardboard boxes in the refrigerator and sandwiches were not maintained at an appropriate temperature. This was evident during the Kitchen Observation Task.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that residents received their personal needs account statements on a quarterly basis. Specifically, there was no documented evidence that 2 residents received their account statements on a consistent basis. This was evident for 2 out of 2 residents reviewed for Personal funds out of 38 sampled residents (Resident #180 and #388).

Inspectors wroteBased on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that a cognitively impaired resident's designated representative was informed of a change in medication. Specifically, a resident's medication to treat dementia was discontinued without documented evidence the family was made aware. This was evident for 1 of 2 residents reviewed for Notification of Change (Resident #55).

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey, the facility failed to ensure a resident's equipment was maintained in good condition. Specifically, a resident's wheelchair had faulty hand brakes preventing it from being in the locked position, and resident rooms and common areas were observed with dirty walls, short privacy curtains, dusty vents and AC units, unfinished plastered areas on the walls, rust and stains in the showers, and stained ceiling tiles. This was evident for 1 of 8 residents (Resident #388) and 2 of 12 Resident units (Unit #4 and #5) reviewed for the Environment.

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure a resident is free from physical restraint. Specifically, a resident was observed with a lap buddy that had not been identified as a restraint. This was evident for 1 of 3 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident # 439).

Inspectors wroteBased on staff interviews and record review conducted during a Recertification survey, the facility did not ensure that a portion of the Minimum Data Set (MDS) Assessment accurately reflected the resident's status. Specifically, 1). a lap buddy was not coded as a restraint and 2). discharge and admission MDS did not accurately document resident's admission and discharge status. This was evident for 1 of 3 residents reviewed for Position, Mobility and 1 of 1 residents reviewed for Hospitalization out of sample of 38 residents. (Resident # 439 & Resident #451)

Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was developed. Specifically, 1). care plans were not developed to address the use of a splint device and restraint and, 2). a care plan was not developed to address a resident's vision concerns. This was evident for 1 of 3 residents reviewed for Position, Mobility and 1 of 3 residents reviewed for Communication-Sensory out of sample of 38 residents (Resident # 439 & Resident # 334).

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that services and treatments were provided to prevent further decrease in ROM or mobility. Specifically, hand rolls, elbow splints, and cervical collar were not provided to residents as ordered. This was evident for 2 out of 3 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident # 439 and Resident #180).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility failed to ensure expired medications were identified timely and removed from current medication supply for disposition. Specifically, bags of intravenous fluids in the medication room on the 5th Floor and expired laxative medication was observed in the medication cart on the 14th Floor past the expiration date. This was evident on 2 of 12 units reviewed for Medication Storage (Unit 5 and Unit 14). The facility policy and procedure titled Medication Storage reviewed 08/2020 documented medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that a safe, functional, sanitary and comfortable environment was provided for residents, staff and the public. Specifically, the staff bathrooms were observed with brown stained floor tiles, cracked ceiling tiles, rusted ceilings, toilet paper holders in disrepair, a cracked trash can, and loose shelving. This was evident for 2 of 12 resident units observed for the Environment (Units 4 and 5).

Inspectors wroteBased on observation, record review and staff interview conducted during the recertification survey, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, a resident room was noted with numerous flies on several occasions. This was evident for 1 out of 12 units observed for Environmental Observations (Unit 4). The finding is: The surveyor requested the pest control policy and procedure, and none was provided. On 07/15/2021 at 10:29 AM, One small fly noted flying in dining room on the 4th floor. On 07/20/2021 at 11:03 AM during staff interview a fly was noted flying around at the nurse's station of the 4th Floor. On 07/19/2021 at 05:05 PM, room [ROOM NUMBER] P bathroom was observed with flies flying in the drain area, The bathroom trash can contained supplement and food waste. [...]