Pinnacle Point Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pinnacle Point Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 20, 2023

  Based on observation, record review, and interview, the facility failed to evaluate and respond to a change in condition for two residents (Resident #152, and #72) when the facility failed to recognize one resident (Resident #152) was lethargic, difficult to arouse, and had minimal to no oral intake for over 24 hours which resulted in an emergency discharge to the hospital for severe dehydration, urinary tract infection and possible sepsis (a life threatening result of infection that could lead to tissue damage, organ failure and death). […]

• Actual harm, isolatedF697May 23, 2023

  Based on observation, interview, and record review, the facility failed to manage pain for one resident, (Resident #10), when staff failed to assess and document resident's pain, administer pain medication timely and provide non-pharmacological (non medication ways to prevent pain such as ice, positioning, meditation, etc) pain relief measures, in a review of 20 sampled residents. The facility census was 96. The facility did not provide a policy on pain control. Review of Resident #10's quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 4/13/23, showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive deficits. […]

• Actual harm, isolatedF605Nov 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #84) out of 18 sampled residents, was not ordered and administered medications which were not required to treat medical symptoms and resulted in altering the resident's behavior, such that the resident required a lesser amount of effort or care. Observations showed the resident sleeping for prolonged periods of time, had difficulty keeping eyes open when talking, speech was slow and soft with words slow and elongated during enunciation and incontinent. […]

• Actual harm, isolatedF600May 13, 2022

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #55) out of 45 sampled residents was free from mental abuse when a staff member used his/her cell phone to record the resident as he/she was out in the hallway, on the floor with his/her legs extended in front of him/her and his/her night gown was above the top of his/her legs exposing his/her thighs and hip area. The staff member, who was present in the video, posted the video to social media to share it with others and included a demeaning comment about the resident who he/she described to have fallen multiple times and had just fallen again. The resident, who had dementia, was unaware the he/she was being recorded. […]

• Actual harm, isolatedF684Mar 26, 2021

  Based on observations, interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when: the facility failed to notify the physician when Residents #377 and #1 sustained a change in condition; failed to obtain physician ordered labs and notify the physician and the responsible party when Resident #377 refused to have labs drawn and failed to ensure an indwelling catheter was maintained and free from infection for Resident #377; and failed to obtain and complete physician ordered treatments to bilateral lower extremities for Residents #24 and #93. […]