The Pinnacle Rehabilitation and Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF921Oct 3, 2024

  Based on observation, interview, and review of manufacturer's safety data sheet , the facility failed to ensure that high touch surfaces were cleaned and disinfected to prevent the spread of infections in the facility. This affected all the residents in the facility. The facility census was 66. Findings include: An observation of the Housekeeper #75 on 10/02/24 at 10:00 A.M. revealed she was had a housekeeping cart with a bucket of water and cleaning solution on the top of the cart and a large bucket of cleaning solution on the bottom shelf of the housekeeping cart with a floor mop in the bucket. An interview with Housekeeping Manager (HM) #76 on 10/02/24 at 3:40 P.M. revealed she had two different types of cleaning products used to clean the facility. […]

• No harm, potential for more than minimal, isolatedF684Apr 23, 2026

  Based on record review and interview, the facility failed to ensure Resident #73's right hip/femur staples were removed timely. This finding affected one (Resident #73) of three residents reviewed for wounds. The facility census was 71.Findings include: Review of Resident #73's hospital Orthopedics Progress Note dated 03/11/26 at 6:49 A.M. revealed the resident was examined and the pain was controlled with medications. The resident was day two of status post right cephallomedullary nail.Review of Resident #73's hospital Discharge Summary form dated 03/13/26 at 2:46 P.M. […]

• No harm, potential for more than minimal, isolatedF755Mar 12, 2026

  Based on record review, observation, interview, manufactures guidelines and policy review, the facility failed to ensure Resident #13 rinsed her mouth after using a steroid inhaler. This affected one (Resident #13) of three residents observed for use of steroid inhalers. This also had the potential to affect seven (Residents #4, #9, #12, #33, #43, #59, and #87) identified by the facility as also receiving steroid inhaler treatments.Findings include:Review of the medical record for Resident #13 noted an admission date of 01/21/26. Diagnoses included obstructive pulmonary disease, unspecified asthma, and chronic respiratory failure with hypercapnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. […]

• No harm, potential for more than minimal, isolatedF580Apr 7, 2025

  Based on record review and interview, the facility failed to ensure Resident #53's legal guardian was notified of the resident's refusal of a planned procedure. This finding affected one (Resident #53) of three residents reviewed for changes in condition. Findings include: Review of Resident #53's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, depression and gastrostomy status. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of the Summit County Probate court form dated 10/11/24 revealed the resident's daughter was the guardian of person and estate. […]

• No harm, potential for more than minimal, isolatedF550Feb 28, 2024

  Based on record review, interview, and facility policy review the facility failed to ensure Residents #31, #32, and #55 were treated with dignity and respect. This affected three residents (#31, #32 and #55) of six residents reviewed for dignity and respect and had the potential to affect all residents. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), asthma, adult failure to thrive, sleep apnea, and high cholesterol. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. […]