Pinnacle Specialty Care

Inspectors wroteBased on electronic health record (EHR), facility records, facility policies and staff interviews the facility failed to timely report an allegation of abuse for 1 of 2 residents (Resident #33) reviewed. The facility reported a census of 92 residents.

Inspectors wroteBased on electronic health record (EHR), facility records, personnel file and staff interview the facility failed to develop and implement a comprehensive Care Plan for 1 of 3 residents (Resident #22) reviewed. The facility reported a census of 92 residents.

Inspectors wroteBased on observation, electronic health record (EHR), facility policy review, resident and staff interviews, the facility failed to consistently respond to activated call lights within a reasonable amount of time. Residents reported having to wait up to 2 hours for a call light to be answered. Observations revealed a response time greater than 15 minutes for 2 of 2 residents observed (Residents #12 and #35). The facility reported a census of 92. Findings Include:1. Resident #35's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS listed Resident #35 as dependent (helper does all effort) for toileting hygiene. Resident #35 required partial/moderate assistance (helper does less than half effort) for toilet transfers. [...]

Inspectors wroteBased on observation, electronic health record (EHR), Medication Administration Record (MAR), facility records, facility policy review, resident and staff interviews, the facility failed ensure medication administration was performed in accordance with physician orders and failed to maintain accurate medical record documentation for 2 of 8 residents (Resident #16 and #19) reviewed. The facility reported a census of 92 residents. Findings Include:1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #19 had no hallucinations (seeing things that aren't there) or delusions (false beliefs). The MDS documented Resident #19 was dependent on a helper for all effort to roll left and right and for chair/bed-to-chair transfers. [...]

Inspectors wroteBased on document review, staff interviews, and facility policy review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues identified with repeat deficiencies during the current survey process in 1 area and corrections that remained incomplete in a reasonable time frame. The facility reported a census of 92 residents.

Inspectors wroteBased on record review, staff and physician interviews, and policy review the facility failed to ensure stock over-the-counter (OTC) medications were on hand for administration. This failure resulted in medications such as Miralax, Lidocaine patches, Sennaside, and Acetaminophen (APAP) being unavailable for multiple days. The facility reported a census of 93 residents.

Inspectors wroteBased on record review, resident, staff, and Advanced Registered Nurse Practitioner (ARNP) interview, the facility failed to revise the Care Plan to include new interventions to address skin integrity and non-compliance with bed rest for one of 16 residents reviewed (Resident #2). The facility reported a census of 93 residents.

Inspectors wroteBased on observation, record review, staff and resident interviews, and policy review the facility failed to provide Peripherally Inserted Central Catheter (PICC) line dressing changes for 1 of 3 residents reviewed for intravenous lines (Resident #9). The facility reported a census of 93 residents.

Inspectors wroteBased on record review, staff and resident interviews, and policy review, the facility failed to complete pre-dialysis assessments for 1 of 1 residents prior to their departure for dialysis services (Resident #5). The facility reported a census of 93 residents.

Inspectors wroteBased on record review, policy review, staff, and resident interviews, the facility failed to ensure 1 of 3 residents received adequate nursing supervision and follow up assessment after a staff member transferred a resident using less than the required staff needed to transfer him as directed in the Care Plan and resulted in him being lowered to the floor (Resident #4). The facility reported a census of 93 residents.

Inspectors wroteBased on observation, electronic health record (EHR), facility policy review, resident and staff interviews, the facility failed to consistently respond to activated call lights within a reasonable amount of time. Residents reported having to wait 1.5 to 2 hours for the call light to be answered. Observations revealed response time had been greater than 15 minutes for 1 of 4 residents observed (Resident #7). The facility reported a census of 93.

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility reported a census of 92 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 1 of 2 residents reviewed (Resident #27). The facility reported a census of 92 residents. Findings Include:Resident #27's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, and bipolar (mental health condition characterized by extreme mood swings, cycling between periods of mania and depression). The MDS lacked documentation of Post Traumatic Stress Disorder (PTSD) diagnosis. Review of the Psych Progress Notes for the initial visit dated 5/14/24 and current visit dated 4/15/25 included a diagnosis of PTSD. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for 2 of 2 reviewed (Residents #27 and #17). The facility reported a census of 92 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to revise the resident care plan for 1 of 22 residents reviewed (Resident #27). The facility identified a census of 92 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to notify the Long-Term Care (LTC) Ombudsman for 1 of 1 resident who transferred to the hospital (Resident #65). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to bathe a resident on a frequent and consistent basis for 1 of 1 resident reviewed (Resident #140). Resident #140 only received 1 bed bath in the 2 weeks since her admission. The facility reported a census of 81 residents.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to provide safety interventions for 1 of 4 residents reviewed (Resident #140). The facility was aware that Resident #140's wheelchair brakes didn't work. They continued to transfer her in and out of her wheelchair without repairing the wheelchair brakes or replacing the wheelchair with a different wheelchair which had working brakes. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, interview and policy review, the facility failed to serve the correct diet for 1 of 2 residents reviewed for nutrition (Resident #41). The facility reported a census of 81 residents.

Inspectors wroteBased on observation, clinical record review, and staff, resident, and visitor interviews, the facility failed to respect dignity for 1 of 5 residents reviewed (Resident #2). On 1/20/24-1/21/24 facility staff were aware that Resident #2's call light was not working. Resident #2 was incontinent and staff failed to provide a means for the Resident to contact staff for toileting, and assistance with other needs. The facility reported a census of 94 residents.

Inspectors wroteBased on observation, record review, staff and visitor interview, and policy review, the facility failed to ensure the resident call system functioned properly for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 94.

Inspectors wroteBased on clinical record review, staff, family, and provider interviews the facility failed to provide ongoing assessments, intervention, and physician updates to inform of an ongoing change in condition, for 1 of 6 residents reviewed (#1) who exhibited left leg swelling, intermittent pain, warmth, and a lump behind the left knee which resulted in the resident being transferred to a local emergency room with a blood clot on 6/6/23 after discharge from the facility to an Assisted Living home on 6/5/23. The facility reported a census of 89 residents.

Inspectors wroteBased on resident and family interview, facility record review, and staff interview, the facility failed to provide the opportunity for the resident and/or resident representative to participate in the development, review, and revision of his/her care plan on a quarterly basis for 3 of 3 residents reviewed (Resident #14, #35 and #75). The facility reported a census of 87 residents.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide services that met professional standards regarding medication administration for 1 of 2 residents observed (Resident #17) who did not have their insulin flex pen primed prior to administering insulin (to ensure the proper amount of insulin administered) and did not leave the needle injected in the skin for the recommended period of time to ensure the full dose of medication was given. The facility reported a census of 87 residents.

Inspectors wroteBased on clinical record review, observation, family interview, staff interview, and facility policy review the facility failed to provide appropriate intervention and catheter care to minimize or prevent complications from the occurrence of urinary tract infections for 1 of 3 residents reviewed (Residents #288). The facility reported a census of 87 residents.