Pinnacle Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pinnacle Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657Feb 24, 2022

  Based 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. Findings included: On 2/24/22 a review of resident records was completed regarding care planning. 1. Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5's medical record indicated IDT-Care Plan Reviews were held on 7/6/21 and 10/21/21. […]

• No harm, potential for more than minimal, isolatedF658Jan 29, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF676Jan 29, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF684Jan 29, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF690Jan 29, 2026

  Based 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. […]