Pinnacle Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 30 sampled residents, a resident's nasogastric (NG) tube feed did not have the formula bag labeled with the complete date and time of the administration. Resident identifier: 54. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia. Resident 54's medical record was reviewed 1/26/26 through 1/29/26. On 1/25/26, resident 54's physician ordered an Enteral Feed every shift continuous tube feeding Jevity 1.2 with a rate of 30 mL (milliliter) an hour continuously for 24 hours. On 1/26/26 at 12:10 PM, an observation was made of resident 54's tube feed. [...]

Inspectors wroteBased on the comprehensive assessment of a resident, the facility must ensure that a resident's abilities in ADLs do not diminish unless the resident's clinical condition demonstrates that diminution was unavoidable. This includes ensuring the resident is provided the necessary care and services to maintain personal hygiene. Specifically 1 of 30 residents sampled, the facility failed to provide timely incontinence care after staff were notified of a soiled condition, resulting in the resident remaining in soiled clothing for one hour and 44 minutes. Resident identifier: 13 Resident 13 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, muscle weakness, and dementia. On 1/26/26 at 11:55 AM, an observation was made of resident 13 with soiled pants being assisted into room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 30 sampled residents, staff were not monitoring changes in skin conditions with a resident or documenting bandage changes. Resident identifier: 50. Resident 50 was admitted to the facility on [DATE] with diagnoses which included, Type 2 Diabetes and restless leg syndrome. Resident 50's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 2:31 PM, a concurrent interview and observation was conducted with resident 50. Resident 50 stated that he had open sores on his lower leg and that he had them for at least a week. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents who were continent of bladder received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. Specifically, for 1 out of 30 sampled residents, the resident was given a PureWick external catheter without an order or directions for use. Resident identifier: 53. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, unsteadiness on feet, difficulty in walking, and muscle weakness. Resident 53's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 1:44 PM, a concurrent interview and observation was made of resident 53 and her room. There was a suction canister on the bedside table with a suction tube that contained a dark amber fluid. [...]

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments during visits. Specifically, for 1 out of 30 sampled residents, the physician did not include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. Resident identifier: 53. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, unsteadiness on feet, difficulty in walking, and muscle weakness. Resident 53's medical record was reviewed 1/26/26 through 1/29/26. A review of resident 53's progress notes revealed: a. On 12/4/25 at 3:23 PM, a nursing note documented, Resident was seen by [Name redacted]. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 30 sampled residents, Enhanced Barrier Precautions (EBP) were not worn for a resident with a Nasogastric (NG) feeding tube and the end of the NG tube was uncapped and touching an intravenous pole. Resident identifier: 54. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia. Resident 54's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 11:39 AM, an observation was made of resident 54. Resident 54 had an EBP sign on the door. [...]

Inspectors wroteBased on observation and interview, it was determined for 22 of 33 that the facility did not treat each resident with respect and dignity. Specifically, the facility did not serve residents sitting at the same table in the dining room at the same time. Resident identifiers: 3, 4, 6, 10, 11, 13, 16, 22, 26, 27, 29, 31, 32, 34, 37, 38, 41, 42, 154, 156, 205 and 206.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, a resident was observed to have medications on the bedside table and was not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 156.

Inspectors wroteBased on interview, observation, and record review it was determined, for 1 of 33 sampled residents, the facility did not allow resident the right to request, refuse and/or discontinue treatment and to formulate an advanced directive. Specifically, a resident's Provider Order for Life-Sustaining Treatment (POLST) form did not match in their electronic medical record. Resident identifiers:156.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 of 33 sampled residents, orders were being checked off as completed for catheter care when a catheter had been discontinued. Resident identifier: 31.

Inspectors wroteBased on interview and record review, it was determined, for 2 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not identify a change in condition for a resident prior to her death and TED (Thrombo-Embolic Deterrent) hose were administered without a physician's order. Resident Identifiers: 31 and 51.

Inspectors wroteBased on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's blood pressure medication was administered outside of the physician ordered parameters. Resident identifier: 35.

Inspectors wroteBased on interview and record review it was determine, for 1 of 33 sampled residents, that the facility did not obtain radiology services only when ordered by a physician. Specifically, an x-ray was obtained without a physician order. Resident identifier: 28.

Inspectors wroteBased on interview and record review, it was determined that the facility did not conduct quarterly review assessments of the comprehensive care plans by the interdisciplinary team (IDT). Specifically, for 4 out of 30 sampled residents, the facility did not have quarterly review assessments of the comprehensive care plans by the IDT. Resident identifiers: 4, 5, 42, and 250.

Inspectors wroteBased on observation and interview it was determined, for 1 of 30 sample residents, that the resident was not able to make choices about aspects of her life in the facility that were significant to the resident. Specifically, the facility did not allow the resident the right to smoke cigarettes at times deemed desirable to the resident, instead only allowing the resident to smoke during the facility designated smoking times. Resident identifier: 27.