Peak Resources - Pinelake

In the surveyor’s words

From the most serious findings on record at Peak Resources - Pinelake, in the surveyor’s own words.

• Immediate jeopardy, isolatedF624Apr 8, 2021

  Based on record review and interviews with family, Adult Protective Services (APS) Social Worker, Medical Director, and staff, the facility failed to verify a resident ' s discharge location and also failed to assess the home environment to ensure it was safe and provided the level of care required to meet the resident ' s needs resulting in a cognitively impaired resident being discharged to his home where he resided without supervision. Resident #129 was discharged on [DATE] and on 3/12/21 a home visit was conducted by APS who assessed the resident to not have the capacity to live alone and he was subsequently sent to the hospital where he remained as of 4/8/21. This was for 1 of 2 discharged residents (Resident #129) reviewed. […]

• Immediate jeopardy, isolatedF689Apr 8, 2021

  Based on record review, observation, and interview with the Medical Director, Police Corporal, and staff, the facility failed to prevent a resident who had cognitive impairment and known wandering behaviors from exiting the facility unsupervised at night. On 3/9/21 Resident #129 exited the facility unsupervised and he self-propelled himself by wheelchair approximately 0.16 miles away from the facility on a roadway that had no sidewalks. This was for 1 of 3 residents reviewed who experienced wandering behaviors. Immediate Jeopardy began on 3/9/21 when Resident #129 exited the facility unsupervised at night. The Immediate Jeopardy was removed on 4/8/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. […]

• Actual harm, isolatedF689Nov 30, 2023

  Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner during incontinence care that resulted in a fall with a right hip fracture (Resident #17). This was for 1 of 6 residents reviewed for accidents. The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, seizure disorder and a history of a stroke resulting in left-sided weakness. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 had moderately impaired cognition and was dependent on one staff member for personal hygiene and toileting tasks. A quarterly MDS assessment dated [DATE] indicated Resident #17 was dependent on one staff member for toileting tasks. […]

• No harm, potential for more than minimal, patternF565Sep 22, 2022

  Based on record review, resident, and staff interviews, the facility failed to communicate the facility's efforts to address group concerns verbalized during Resident Council meetings and to resolve repeat concerns for 4 of 4 consecutive months (May 2022, June 2022, July 2022, and August 2022). Findings included: Resident Council minutes dated 05/25/22 indicated residents had voiced concerns related to items listed on the meal ticket was not served, and condiments not provided on the meal trays. […]

• No harm, potential for more than minimal, patternF686Sep 22, 2022

  Based on record review, observations and interviews, the facility failed to ensure alternating pressure reducing mattresses were set according to the residents' weights for 3 of 10 residents (Residents #236, #78 and #68) reviewed for pressure injuries. The findings included: 1. Resident #236 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) was not available. Resident #236's baseline care plan dated 9/12/2022 had a focus for pressure injury, stage 3, to the sacrum. The resident's medical record included a visit summary by the Wound Care Physician dated 9/14/2022. The summary indicated Resident #236 had a full thickness injury to the sacrum that measured .05 x .05 x 0.2 centimeters (cm). […]