The Springs Of Pinnacle Mountain

Based on record review, interview, and facility policy review, the facility failed to ensure dietary orders were followed for one (Resident #1) of three residents.The findings include: A review of Resident #1's admission Record indicated the facility admitted the resident on 06/25/2025, with diagnoses which included a partial intestinal obstruction, a non-cancerous growth or tumor of the pancreas, abnormal heart rhythm, and swelling of both lower limbs. A review of Resident #1’s 5-day Minimum Data Set (MDS) with an Assessment Reference Date of 06/27/2025, revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The remainder of the MDS, including functional abilities, health conditions, and medications, was not completed. A review of Resident #1’s Hospital Discharge records indicated the resident had the following procedures performed: on 06/03/2025 – Whipple Procedure (a complex abdominal surgery primarily used to treat tumors in the head of the pancreas) and a hernia repair. On 06/16/2025 – a medical procedure where a thin,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility document and policy review, it was determined that the facility failed to report an abuse allegation to proper authorities for 1 (Resident #1) of 5 residents, reviewed for abuse and neglect. The findings include: A review of the facility's undated policy titled Abuse, Neglect, and Misappropriation, indicated facility must notify local law enforcement agencies. A review of the admission Record Face Sheet, indicated Resident #1 was admitted to the facility on [DATE], with diagnoses that included type II diabetes mellitus, cognitive communication deficit, schizophrenia, and bipolar disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. On 04/21/2025 at 12:45PM, a review of the facility's internal investigation report, involving abuse allegations from Resident #1 against Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On 9/25/2024 at 11:59 AM, the [NAME] rinsed the colander out in the left side of the sink and hung it on a rack located directly above the sink, without washing and sanitizing it first. On 9/26/2024 at 8:17 AM, the surveyor asked the Dietary Manager (DM) if food preparation should be performed next to a dirty sink. The DM stated no, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, it was determined the facility failed to ensure reasonable accommodation of resident needs were provided for 2 (Residents #11,and #26) of 16 sampled residents. The findings are: Resident #11 had a score of 00 on the Brief Interview for Mental Status (BIMS) per a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/22/2024. Additionally, Resident #11 was identified as being non-ambulatory, dependent on staff for all activities of daily living, and non-verbal. During an observation on 9/23/2024 at 10:20 AM, Resident #11 did not have a call light in reach. Resident was sitting in chair in front of tv and call light was on the floor behind resident's chair. During an observation on 9/25/2024 at 1:10 PM, Resident #11 and Resident #26, who were roommates, were in their room sitting in chairs with no call lights within the resident's reach. Both call lights were laying in the floor behind their chairs. On 9/25/2024 at 1:13 PM, Certified Nursing Assistant (CNA) #6 said staff should make sure residents have the call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined the facility failed to formulate an advance directive, and document if formulation of an advanced directive was refused for 2 of 2 (Resident #13, and Resident #23) residents reviewed for advance directives. The findings are: A review of a facility policy titled, Advance Directives, revised December 2016, indicated the resident will be provided information concerning an advance directive upon admission. Information about whether the resident has executed an advance directive should be in medical records. The advance directives should be reviewed annually with the resident to ensure the directives are still the wishes of the resident. 1. A review of an Order Summary Report indicated Resident #13 had a diagnosis of Epilepsy. a. The quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 08/30/2024 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. b. On 09/24/24 at 10:00 AM, an advance directive was not available for review in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and facility policy review, the facility failed to keep resident's personal wheelchairs in good repair without holes, tears, and rips to prevent injuries for 3 (Residents #34, #43, and #45) reviewed for equipment safety. Findings include: A review of a facility policy titled, Maintenance Service, revised on 12/01/2009, indicated services would be provided to all areas of the building, grounds and equipment and maintenance personnel would follow safety regulations to ensure the safety and well-being of all concerned. During an observation on 09/23/2024 at 10:44 AM, the left arm rest on the wheelchair of Resident #43 was noted to be torn, the vinyl/leather turned up and the foam underneath showing. The right arm rest of the wheelchair had a tear/hole in the vinyl and was turned up around the edges. During an observation on 09/23/2024 10:45 AM, the back rest of the wheelchair along the edge, for Resident #45 was vinyl/leather was noted to be cracking and peeling, revealing the soft material underneath. During an observation on 09/25/24 at 9:42 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, it was determined the facility failed to administer scheduled pain medication for 1 of 1 (Resident #19) reviewed for pain. The findings are: Review of a facility policy titled, Administering Medications, indicated medications are administered according with the prescriber orders. Medications are administered in accordance with prescriber's orders, and within the required time frame. Medication administration times are determined by resident need and benefit, and not for staff convenience. Medications are administered within one hour of their prescribed time. A review of an Order Summary Report indicated that Resident #19 had a diagnoses of low back pain, unspecified, and polyarthritis. Resident #19 had an order for Hydrocodone- Acetaminophen (Pain) 10-325 mg scheduled four times a day with a start date of 08/28/2024. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator, freezer and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; leftover food items were used in a manner to maintain food quality; expired food items were promptly removed from stock to prevent potential food borne illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness; 1 of 1 ice machine was maintained in clean condition; hot food items were at temperature that was acceptable to the residents to improve palatability; and floor and kitchen appliances and were maintained in clean sanitary conditions to prevent the potential food borne illnesses for residents who received meals from 1 of 1 kitchen.; These failed practices had the potential to affect 73 residents who received meals from the kitchen (Total Census: 76), as documented on a list provided by the Dietary District Manager on 10/03/23. The findings are: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, 12 residents who received mechanical soft diets, and 57 residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary District Manager on 10/03/23 at 12:04 PM. findings are: 1. The menu for the lunch meal on 10/02/23 documented all diets were to receive strawberry shortcake and residents on regular diets were to receive 3 ounces of herb roasted chicken and residents on pureed diets were to receive pureed dinner roll. 2. On 10/02/23 at 1:10 PM, the residents on regular diets were served one small herb roasted chicken thigh each. At 1:44 PM, the Surveyor asked the Dietary District Manger to weigh the same amount of baked chicken served to the residents for lunch. She did so and stated, It weighed 1.9 ounces, instead of 3 ounces as per the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to ensure meals were served in a method that maintained the appearance, nutritive value, cold product, and hot food items at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 24 residents who received meal trays in their rooms on the 100 Hall, 5 residents who received meal trays in their rooms on the 200 Hall, 20 residents who received meal trays on the 300 Hall, 23 residents who received meal trays on the 400 Hall, as documented on a list provided by the Administrator on 10/03/23 at 11:40 AM. The findings are: 1. On 10/02/23 at 11:22 AM, the Surveyor asked Resident #6 if the food being served was satisfactory. Resident #6 reported that the food was good but was sometimes cold. The Surveyor asked if food being served cold was a frequent occurrence. Resident #6 stated, Sometimes. 2. On 10/02/23 at 12:14 PM, the Surveyor asked Resident #73 if the food being served was satisfactory. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 4 residents who received pureed diets as documented on a list provided by the Dietary District Manager on 10/03/23. The findings are: 1. On 10/02/23 at 12:07 PM, the following observations were made on the steam table: a. A pan of pureed brussels sprouts. The consistency of the pureed brussels sprouts was runny, not formed and was not smooth. There were pieces of brussels sprouts in the mixture. b. A pan pf pureed baked herb roasted chicken. The consistency was runny, not formed and not smooth. There were pieces of chicken visible in the mixture. At 1:35 PM, the Surveyor asked the Dietary Supervisor and the Dietary District Manger to describe the consistency of the pureed food items served to the residents on pureed diets. The Dietary Supervisor stated, Pureed brussels sprouts was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure call devices were in reach for 1 (Resident #65) of 6 (Residents #10, #21, #24, #49, #69 and #71) sampled residents who were bedbound as documented on a list provided by the Director of Nursing (DON) on 10/05/23 at 9:27 AM. The findings are: On 10/02/23 at 10:20 AM, Resident #65 was lying in bed with the call device lying on the floor by the head of the bed. The Surveyor asked if he was able to get out of bed unassisted. Resident #65 indicated that he could not. On 10/02/23 at 3:34 PM, Resident #65 was lying in bed. The call device was lying on the floor by the head of the bed. On 10/03/23 at 9:28 AM and 12:57 PM, Resident #65 was lying in bed. The call device was lying on the floor by the head of the bed. On 10/04/23 at 3:22 PM, Resident #65 was lying in bed. The call device was lying on the floor by the head of the bed. Resident #65 was unable to locate the call device. On 10/04/23 at 3:28 PM, CNA #3 picked the call device up from the floor and attached it to the bed near Resident #65, and confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure access hatches located in resident rooms were secured in 1 (Resident room [ROOM NUMBER]) of 12 (Resident Rooms #301, #302, #303, #304, #305, #306, #308, #309, #310, #311, #312 and #314) Resident Rooms on the 300 Hall. The findings are: On 10/02/23 at 3:13 PM, 10/3/23 at 9:20 AM, and 10/4/23 at 3:31 PM observed in room [ROOM NUMBER] a gray access hatch that was partly opened above a resident bed. There was a white pipe with a valve surrounded by a fibrous yellow material behind the hatch. Two residents were in the room. During interview on 10/04/23 at 3:35 PM, the Maintenance Director confirmed the pipe and valve in room [ROOM NUMBER] was the insulated water shut-off for the sprinkler system. On 10/05/23 at 10:51 AM Nurse Consultant #2 provided a document titled, Preventative Maintenance Program. It documented, .The Maintenance Director shall assess all aspects of the physical plant to determine if Preventive Maintenance (PM) is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify a family member of a Care Plan meeting for one (Resident #1) of 18 (Residents #1, #6, #12, #21, #29, #32, #33, #40, #41, #44, #47, #51, #64, #66, #67, #69, #73 and #276) sampled residents. The findings are: Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/23 documented the resident was severely cognitively impaired. Review of a Care Plan with a revision date of 04/24/21 noted Resident #1 was severely impaired in cognitive function related to diagnosis of Alzheimer's disease and needs assistance with all decision making. During an interview on 10/02/23 at 3:28 PM, Resident #1's family member stated, I have never come to a care plan meeting. I've never received any notification or been offered to come to a care plan meeting. During an interview on 10/04/23 at 9:15 AM, the Social Services Director said a letter is mailed out about a week and a half before the meeting and the family member is called to remind them. The Social Services Director said a template is used to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.