The Springs of Pinnacle Mountain

In the surveyor’s words

From the most serious findings on record at The Springs of Pinnacle Mountain, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 11, 2023

  Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent potential accidents and/or elopement during Fire Watch periods as evidenced by fire doors propped open, the front entry door open, supply room storage room door propped open, magnetic lock to the secured unit not functioning, magnetic lock to the exit doors not functioning; and failure to ensure written policy and procedures were followed during Fire Watch periods due to sprinkler system/fire alarm systems not in working condition to prevent potential injuries to residents; and the facility failed to ensure that staff members performing fire watch were trained on fire watch procedures and what to do in the event of a fire to prevent potential injuries to residents, and the… […]

• Immediate jeopardy, patternF835Jan 11, 2023

  Based on observation, record review and interview the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by the failure to notify the Office of Long-Term Care (OLTC) of the non-functioning fire alarm and sprinkler system. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm and/or injury to affect all 80 residents who resided in the facility, as documented on the Midnight Census Report which was provided by the Administrator on 1/10/23 at 9:15 a.m. The facility Administrator was notified of the Immediate Jeopardy on 1/10/23 at 12:00 p.m. The findings are: 1. […]

• Immediate jeopardy, isolatedF686Oct 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure a pressure ulcer to the left heel, and a wound to the penis were identified, treated, and assessed weekly for 1 (Resident #1) of 2 (Residents #1 and #2) sampled residents who had pressure ulcers. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #1, who had pressure ulcers to his left heel, and penis that weren't treated. This failed practice had the potential to affect six residents with pressure ulcers according to a list provided by the Director of Nursing (DON) on 10/05/22 at 1:07 P.M. The facility was informed of the Immediate Jeopardy on 10/04/22 at approximately 3:03 PM. […]

• Actual harm, isolatedF697Apr 23, 2025

  Based on observation, record review, and interview, it was determined that the facility failed to consistently give prescription pain medication every four (4) hours, as scheduled, for one (1) (Resident #4) of five residents reviewed for medication review. The findings are: A review of an admission Record indicated Resident #4 was admitted to the facility with diagnoses that included: fracture to right ankle, chronic pain syndrome, anxiety disorder, bipolar disorder and borderline personality disorder. The quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/14/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact for their daily decision making. […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  Based on observation, interview, and record review, it was determined the facility failed to ensure food preparations were separate from soiled areas of the kitchen, to ensure kitchen equipment was cleaned before storage, and that hand sanitation was performed during meal service. The findings are: On 9/25/2024 at 11:14 AM, while observing the [NAME] puree the lunch meal that consisted of chicken, broccoli, noodles, and garlic herb biscuits, the right side of a sink that was 10 inches away from food blender had several inches of brown liquid with chunks of what appeared to be noodles and broccoli floating in it. On 9/25/2024 at 11:28 AM, the [NAME] was observed draining noodles in a colander on the clean, left side of the sink prior to pureeing them. […]