Pinnacle Park Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Pinnacle Park Nursing & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 12, 2021

  The facility had a census of 41 residents. The sample included 14 residents with five reviewed for pressure ulcers. Based on observation, record review, and interview the facility failed to provide interventions to prevent the development of pressure ulcers for two of five sampled residents, Resident (R) 33, who developed a Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer, just under the skin), and R11, who developed one unstageable pressure ulcer (wound bed covered with slough,dead tissue that may be white, tan, or yellow or eschar,a dry dark scab). Findings included: - R33's Physician order [REDACTED]. […]

• No harm, potential for more than minimal, widespreadF730Jul 24, 2024

  The 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. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA 0, hired on 08/27/21, had no yearly performance evaluations upon request. CNA P, hired on 08/04/20, had no yearly performance evaluations upon request. […]

• No harm, potential for more than minimal, widespreadF880Jul 24, 2024

  The 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. Included Findings: - On 07/22/24 at 08:00 AM an electric razor with brown shavings was laid on an EBP cart outside of Resident (R)22's room. […]

• No harm, potential for more than minimal, widespreadF812Jul 6, 2022

  The 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. […]

• No harm, potential for more than minimal, widespreadF880Jan 12, 2021

  The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections, when staff cleaned a [MEDICAL CONDITION] ([MEDICAL CONDITION]-infection of the large intestine (colon) caused by bacteria) resident's room in the 100 Hall, and failed to change gloves appropriately when providing incontinent cares for Resident (R) 11 and R12. […]