Pinnacle Specialty Care

In the surveyor’s words

From the most serious findings on record at Pinnacle Specialty Care, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 13, 2023

  Based on clinical record review, staff, family, and provider interviews the facility failed to provide ongoing assessments, intervention, and physician updates to inform of an ongoing change in condition, for 1 of 6 residents reviewed (#1) who exhibited left leg swelling, intermittent pain, warmth, and a lump behind the left knee which resulted in the resident being transferred to a local emergency room with a blood clot on 6/6/23 after discharge from the facility to an Assisted Living Home on 6/5/23. The facility reported a census of 89 residents. Findings include: According to the Quarterly Minimum Data Set (MDS) dated [DATE] Resident #1 had admitted to the facility on [DATE] with diagnoses including malnutrition, muscle weakness, and COPD. […]

• Actual harm, isolatedF760Oct 12, 2022

  Based on observation, clinical record review, resident, staff and a physician interview the facility failed to assure one resident remained free from a significant medication error, (Resident #1) The facility identified a census of 85 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 4/1/22 documented Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident required scheduled and as needed (PRN) pain medication related to frequent pain rated at a 5 on a scale of 0-10 with 10 having been the worst. A Care Plan with a goal initiated 3/29/22 documented the resident with pain related to the use of a [MEDICATION(S)] patch. […]

• No harm, potential for more than minimal, patternF755Apr 2, 2026

  Based on record review, staff and physician interviews, and policy review the facility failed to ensure stock over-the-counter (OTC) medications were on hand for administration. This failure resulted in medications such as Miralax, Lidocaine patches, Sennaside, and Acetaminophen (APAP) being unavailable for multiple days.The facility reported a census of 93 residents.Findings include: 1. Resident #7's March 2026 Medication Administration Record (MAR) revealed he did not receive Poly-Iron 150 Oral Capsule (medicine used to treat an iron deficiency) 150 milligrams (mg) on 3/12, 3/14, 3/15, 3/16, 3/17, 3/21, 3/22, 3/23, 3/24, and 3/25.Staff documented a code of 9 for these dates, which directed the reader to the Progress Notes for further explanation. […]

• No harm, potential for more than minimal, patternF584Oct 12, 2022

  Based on observation, staff interview and facility policy review the facility failed to assure one (1) resident resided in a clean, sanitary and homelike atmosphere (Resident #2 ) The facility identified a census of 85 residents. Findings include: During a facility tour on 9/22/22 at 2:15 p.m. observed a build-up of brown colored pieces, with the appearance of a bowel movement, along the drain of the shower room and a brown smear on the wall along the handrail located on the 400 hallway. An observation and interview on 9/22/22 at 2:49 p.m. revealed a staff member in room 402 with the resident who stated she had been ready for a shower. The staff member propelled the resident to the shower room located on the 400 hallway confirmed by Staff A, Assistant Director of Nursing (ADON). […]

• No harm, potential for more than minimal, patternF677Oct 12, 2022

  Based on observation, clinical record review, staff and resident interview and facility policy review, the facility failed to provide baths/showers for 5 of 5 residents reviewed, (Resident #3, # 7, #8, #9 and #10) and failed to properly perform perineal cares for 2 of 3 residents reviewed, (Resident #7 and #10) The facility identified a census of 85 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 9/9/22 , Resident #7 required extensive assistance of one (1) staff with showers/baths, toilet use and personal cares. A Documentation Survey Report forms dated August and September 2022 revealed the facility staff failed to bath/shower Resident #7 according to her bathing schedule documented as Wednesday and Saturday on the 2nd shift: a. […]