Pinnacle Park Nursing & Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident (R) 3 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure Resident (R) 7 had an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent injury when a Certified Nurse Aide (CNA) provided footcare to Resident (R) 13, who had a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and received a cut to her left great toe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to hold blood pressure medication, per the physician-ordered parameters, for Resident (R) 13.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) were reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 56 residents. The facility identified two residents on contact-based precautions and six on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, hand hygiene, storage of oxygen tubing while not in use, and disinfecting of shared equipment. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility had a census of 56 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R)5's Care Plan to reflect her Hoyer lift (total body mechanical lift) transfer requirements. This deficient practice placed R5 at risk for impaired care due to uncommunicated care needs. Findings Including: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of heart failure, cerebrovascular disease, major depression (major mood disorder), cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. R5's Quarterly Minimum Data Set (MDS) completed 06/21/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. [...]

Inspectors wroteThe facility had a census of 56 residents. The sample included 14 residents with seven residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to ensure safe care practices were followed during staff-assisted care resulting in multiple preventable falls for Resident (R)5. This deficient practice placed R5 at risk for further falls and injuries. Findings Including: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of heart failure, cerebrovascular disease, major depression (major mood disorder), cognitive-communication disorder, abnormalities of gait, muscle weakness, and unsteadiness of her feet. R5's Quarterly Minimum Data Set (MDS) completed 06/21/24 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. [...]

Inspectors wroteThe facility reported a census of 56 residents. The sample included 14 residents with two reviewed for bowel and bladder incontinence. Based on record review, observations, and interviews, the facility failed to implement individualized toileting interventions to improve Resident (R)17's bowel and bladder incontinence or prevent worsening based on his incontinence evaluation. This deficient practice placed R17 at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of legal blindness, muscle weakness, stiffness to his right knee, unsteadiness on his feet, and lack of coordination. A review of R17's Quarterly Minimum Data Set (MDS) completed 05/20/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. [...]

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety for the 58 residents who resided in the facility and received their meals from the facility kitchen , when the facility kitchen failed to ensure clean and sanitary food prep areas, failed to dispose of expired food items, and had expired Parts Per Million (PPM-sanitizer strength test) strips. This placed the 58 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to ensure hazardous chemicals were securely stored. This deficient practice placed four cognitively impaired, independently mobile residents at risk for accidents.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the end of daily work shifts. This placed residents at risk for misappropriation of medications by staff.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendations for a 14 day stop date or physician's rationale for extended use with a stop date for as needed (PRN) psychotropic medications (medications used to treat mental illness, moods, behaviors) for one sampled resident, Resident (R) 43. This placed the resident at risk for unnecessary psychotropic medications and adverse side effects.

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use with a stop date for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for one sampled resident, Residents (R) 43. This placed the residents at risk for unnecessary psychotropic medications and adverse medication side effects.