Pinnacle Health & Rehab Canton

In the surveyor’s words

From the most serious findings on record at Pinnacle Health & Rehab Canton, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF583Nov 19, 2025

  Based on observations and interviews, the facility failed to ensure the confidentiality of protected health information for 1 of 41 residents during 1 of 3 days of survey (Resident #3).Findings:On 9/24/25 at 3:15 p.m., two surveyors observed an unattended medication cart outside room [ROOM NUMBER] with a fully open computer monitor with Resident #3's electronic Medication Administration Record (eMAR) displayed, visible and easily accessible to residents, visitors or other unauthorized persons. There were no staff observed in the area, and 1 resident was observed in the hall. […]

• No harm, potential for more than minimal, patternF584Nov 19, 2025

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment for 3 of 3 days of survey (9/22/25, 9/23/25 and 9/24/25) for resident rooms, hallways and the laundry room for 3 of 3 facility tours.Findings:1. On 9/22/25 at 8:00 a.m., a surveyor toured and observed the facility to smell of stale urine and feces throughout the facility.2. On 9/23/25 at 7:55 a.m., a picture was handing on the wall by room [ROOM NUMBER]. The frame was observed to be broken in the bottom left corner and was held together with scotch tape. There was also picture hanging directly across the hall on the wall with the bottom right edge of the frame coming apart. […]

• No harm, potential for more than minimal, patternF656Nov 19, 2025

  Based on record review and interview, the facility failed to develop/implement goals and interventions for psychotropic use for 3 of 16 care plans reviewed (Resident's #2, #6 and #7).Findings: 1.Resident #3 was admitted on 5/25 and has diagnoses to include major depressive disorder. Review of Resident 's active orders revealed he/she is taking antidepressant medications Remeron and Lexapro, and antianxiety medication Lorazepam. Review of Resident #3's care plan updated 5/13/25 states [Resident #3] uses antidepressant medication r/t Depression. Monitor/document side effects and effectiveness Q-SHIFT. […]

• No harm, potential for more than minimal, patternF657Nov 19, 2025

  Based on record review and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 16 residents (R) reviewed for care planning (R2, R6, R12, R36, R35).Findings: 1. A review of R35's clinical record revealed an MDS admission Assessment was completed on 8/12/25. Further review of R35's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. On 9/23/25 at 11:32 a.m. during an interview with 2 surveyors, the Social Services Director stated that an IDT meeting was not held following R35's admission Assessment. […]

• No harm, potential for more than minimal, patternF757Nov 19, 2025

  Based on record review and interviews, the facility failed to monitor and document targeted side effects to support the use of an antipsychotic and antianxiety medication for of 3 residents reviewed for unnecessary medications (Resident's #2, #6 ). Findings: 1.Resident #3 was admitted on [DATE] and has diagnoses to include major depressive disorder. Review of Resident #3's active orders revealed: -Order with start date of 5/14/25 for antidepressant Lexapro Oral tablet 10 mg (Escitalopram) Give 1 tablet by mouth one time a day. -Order with start date of 5/13/25 for antidepressant Remeron Oral Tablet 15 mg (Mirtazapine). […]