Pinnacle Health & Rehab Canton

Based on record review, interviews, and facility policy, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice by failing to follow their own Accident and Incident and Fall policies when a Certified Nursing Assistant (CNA) failed to notify the charge nurse before moving a resident after a witnessed fall for 1 of 3 residents reviewed for accidents (Resident [R] 26). As a result, the resident's arm got caught in his/her wheelchair, and he/she sustained a right humeral head fracture.Finding:Review of facility 's Accidents and Incidents Policy, revised 9/9/25, states Regardless of how minor an accident or incident may be .it must be reported to the charge nurse as soon as such accident/incident occurs is discovered . The Charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided .Do not move the victim until he/she has been examined for possible injuries .The Charge Nurse shall .Examine all accident/incident victims .Notify the victim's physician of the accident or…

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 and interview, the facility failed to ensure that the resident's environment was free of accident hazards by ensuring a base board heater cover was secure and in place covering sharp metal for 1 of 1 observation on 1 of 3 days of survey. (9/22/25)Finding:On 9/22/25 at 9:53 a.m., a surveyor observed a base board heating unit in the hallway across from resident room [ROOM NUMBER] that had the front cover partially off exposing sharp metal fins.On 9/22/25 at 9:58 a.m., in an interview with two surveyors present, the Director of Nursing confirmed the finding and stated that the facility has residents that ambulate around the facility and move around the facility in wheelchairs.

Based on record review and interview, the facility failed to ensure a residents call bell was within reach for 1 of 1 resident (Resident #1). Findings: Review of Resident #1 progress note dated 5/27/25 at 10:55 a.m. indicated that he/she sustained an unwitnessed fall, he/she was found in front of his/her wheelchair next to his/her bed. Review of the post fall assessment completed 5/27/25 showed the resident did not have his/her call bell within reach at the time of the fall. Review of Resident #1 care plan under the focus states he/she is at risk for falls. Further review shows that under Interventions/Tasks section of the care plan staff should Be sure (his/her) call light is within reach and encourage the resident to use it for assistance as needed On 6/10/25 at 11:00 a.m., the above information was discussed with the Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to promote care for a resident in a manner that maintains dignity and respect when staff failed to groom a resident on 3 of 3 survey days (Resident #31). In addition, the facility failed to identify a medication correctly to 1 of 1 resident observed for medication pass (Resident #242). Findings: 1. Resident #31 was admitted on [DATE] and has diagnosis of dementia and is dependent on staff for all of his/her activities of daily living needs. During observations on 7/29/24 at 11:01 a.m., 7/30/24 at 9:39 a.m., and 12:26 p.m., 7/31/24 at 8:21 a.m., Resident #31 was noted to have long facial/chin hair. Review of Resident #31's Task-Personal Hygiene-Support Provided - How resident maintains personal hygiene, including . shaving, revealed Resident #31 received 1-2 person hygiene assistance on 7/26/24 at 11:04 a.m., and 22:05 [10:05 p.m.], on 7/27/24 at 10:14 a.m., and 21:11 [10:11 p.m.], on 7/28/24 at 10:03 a.m., and 17:48 [5:48 p.m.] on 7/29/24 at 10:22 a.m.,…

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 observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for bathrooms, a ceiling tile, a patient lift, lights, floors and wheelchairs for 1 of 1 facility tour (7/31/24). Findings: A surveyor conducted a facility Environment tour on 7/31/24 from 12:05 p.m. to 12:30 p.m. with the Maintenance Director and the Administrator in which the following findings were observed: > The bathroom, located across from the nurse's station, had a dirty floor around base of the toilet and stained floor tiles. > The hallway ceiling tile, by resident room [ROOM NUMBER], had a large brown stain on it. > The sit-to-stand patient lift, in the hallway by resident room [ROOM NUMBER], had chipped/missing paint on the foot base creating an uncleanable surface. Additionally, there was dirt and food debris in the foot base area. > Resident room [ROOM NUMBER] - There was dust/debris in the bathroom…

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 observations, interviews, record reviews, and facility policy, the facility failed to update/implement a care plan in the area of falls for 2 of 2 sampled residents (#30 and #80, in the area of Post Traumatic Stress Disorder (PTSD) for 1 of 1 resident (Resident #9), and in the area of mood and behaviors for 1 of 1 residents reviewed for behaviors (Resident #31). Findings: 1. On 7/29/24 at 11:08 a.m., two surveyors observed Resident #30 in a wheelchair with his/her feet on the wheelchair pedals. The call bell was attached to the bed, outside of the resident's reach. The Surveyor asked the resident if he/she could reach the call bell, he/she attempted but could not reach. At this time, Certified Nurse Aide (CNA) #4 confirmed Resident #30 cannot propel independently in his/her wheelchair and would not be able to move the wheelchair to reach the call bell. Review of Resident #30's care plan for falls initiated on 1/5/23 instructs nursing to Be sure [his/her] call light is within reach and encourage 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, interview, record review and facility policy the facility failed to adequately date and ensure expired medications were removed from the supply available for use in 1 of 2 medication carts observed (nurse medication cart) and failed to ensure biologicals were stored at appropriate temperatures in 2 of 3 refrigerators observed (medication room top and bottom refrigerators). Findings: Facilities Storage of Medications policy and procedure, effective July 2020 states, All medications are maintained within the temperature ranges . refrigerated 36°F to 46°F with a thermometer to allow temperature monitoring .The facility should maintain a temperature log in the storage area to record temperatures at least once a day . The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC guidelines .When the original seal of the manufacturers container or vial is initially broken, that container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened . The nurse…

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 record reviews and interview, the facility failed to ensure that 2 of 2 residents reviewed with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination (Resident #10 and Resident #15). Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnosis of Schizophrenia. Resident #10's clinical record contained a PASRR Level I determination letter dated 6/12/24 that stated further PASRR evaluation was not required due to Resident #10 met the criteria for a short-term convalescence admission. Resident #10 was not discharged after a short stay and was assessed to be Nursing Facility level of care and continued to reside in the facility. The clinical record lacked evidence to indicate that the PASRR Level I was forwarded again to the State Mental Health Authority to determine if a PASRR Level II evaluation and…

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 interviews and record reviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents reviewed for baseline care plans. (#190). Findings: Resident #190 was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD). Review of Resident #190 active orders July 2024 revealed the following: -Order with start date of 7/23/24 for Advair HFA Inhalation Aerosol 115-21 MCG/ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. -Order with start date of 7/24/24 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for SOB or Wheezing via nebulizer and 3 ml inhale orally two times a day for copd. -Order with start date of 7/24/24 for Prednisone Oral Tablet 10 MG (Prednisone). Give 3…

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 record review and interviews, the facility failed to ensure that a care plan was updated to reflect the resident's current needs for range of motion for 1 of 1 residents reviewed for range of motion (ROM) (Resident #4). Finding: Resident #4 was most recently admitted [DATE] with diagnosis of Cerebral Palsy with muscle wasting and atrophy. Observations of Resident #4 on 7/29/24 at 11:56 a.m., and 7/30/24 at 1:15 p.m., revealed he/she has bilateral hand/arm contractures. At this time Resident #4 indicated that he/she did not have a hand brace and did not want one. Review of Resident #4's clinical record revealed order with start date of 12/22/17 states BRACE MAY WEAR PRN as needed for POSITIONING HAND/WRIST FOR NEUTRAL POSITION Further review of Resident #4's clinical record revealed order was discontinued on 9/5/23. Review of Resident #4's entire clinical record revealed that care plan meetings were held on 1/25/2024, 4/18/2024, 7/18/2024, and 10/26/2023. Review of Resident #4's Care Plan most recently…

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 observations and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a patient lift for 1 of 4 days of survey. (7/29/24) Finding: On 7/29/24 at 9:35 a.m., two surveyors observed a patient lift, available for use in the hallway by resident room [ROOM NUMBER], that was missing a sling bar safety clip that would prevent the sling strap from potentially coming off during a lift/transfer. On 7/29/24 at 10:15 a.m., the Director of Nursing confirmed a patient lift, available for use in the hallway by resident room [ROOM NUMBER], was missing a sling bar safety clip at the time of the surveyor's observations. The Director of Nursing stated that the lift has since been removed from the floor.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #9]. Findings: Review of policy Trauma Informed Care undated states .The resident, responsible party, and multidisciplinary team will develop a resident centered care plan the will include triggers that may [case] re-traumatization, as well as [anu] holistic interventions that may keep the resident safe and healthy . Resident #9 was admitted on [DATE] with diagnoses to include paranoid schizophrenia, anxiety disorder, Post traumatic stress disorder, bipolar, and major depressive disorder. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had a brief interview for mental status score of 15 of 15 indicating he/she is cognitively intact. Further review of MDS revealed resident had diagnoses to include…

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, interview, the facility's Refrigeration Policy, and the facility's Dish Machine Temperature Log, the facility failed to ensure facial hair protection was worn; failed to ensure the walk-in freezer temperatures were monitored; and failed to ensure refrigerator and freezer temperatures were monitored for 1 of 1 kitchen tour for 1 of 3 days of survey.(7/29/24). Findings: On 7/29/24 from 9:40 a.m. to 10:10 a.m., two surveyors conducted an initial kitchen tour with the Food Service Director in which the following findings were observed: Refrigeration Policy Procedure: 2. The morning cook is to read and record the inside thermometer of each refrigerator and freezer and record on the refrigerator/freezer temperature log sheet within 30 minutes of the shift. Procedure: 3. The evening cook is to read and record the inside thermometer of each refrigerator and freezer and record on the refrigerator/freezer temperature log sheet within 60 minutes of the end of the shift. Dish Machine Temperature Log 1. The Kitchen Supervisor will train dishwashing staff to monitor dish…

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 garbage was properly contained. On 7/29/24 the cart utilized to store garbage was observed to have no lid/cover, leaving the garbage inside the cart exposed, creating the potential for the harborage and feeding of pests for 1 of 3 days of survey. Finding: On 7/29/24 from 9:40 a.m. to 10:10 a.m., two surveyors conducted an initial kitchen tour with the Food Service Director in which the following findings were observed: > Two surveyors observed trash being stored in an open top cart outside the facility next to the kitchen area. On 7/29/24 at 10:10 a.m., in an interview, the Food Service Director confirmed the finding and stated that the trash is kept in the open bin and then wheeled to the large trash trailer later in the day.

Based on observation and interview, the facility failed to ensure that the kitchen walk-in freezer was maintained in good repair and in safe operating condition for 1 of 1 kitchen tours (7/29/24). Finding: On 7/29/24 from 9:40 a.m. to 10:10 a.m., two surveyors conducted an initial kitchen tour with the Food Service Director in which the following finding were observed: > The walk-in freezer had a large ice build-up keeping the freezing unit left fan from running and the freezing unit right fan made a loud noise while spinning and hitting an ice build-up near it. On 7/29/24 at 10:10 a.m., in an interview with two surveyors, the Food Service Director confirmed that there was a large ice build-up keeping the freezing unit left fan from running and the freezing unit right fan made a loud noise while spinning and hitting an ice build-up near it. The Food Service Director stated that the walk-in freezer had been worked on in February of 2024. The Food Service Director went on to state that it hasn't ran properly since, has been worked on many times and continues to ice up.

Based on record review, observations and interviews, and review of the rashes, data collection line listing, the facility failed to enhance the quality of care for residents when they failed to timely diagnose and treat Sarcoptes scabiei (scabies) and failed to follow CDC recommendations to prevent the spread and/or re-exposure in 7 of 7 residents who were infected with rashes. Findings: The facilities Infection Control Policy and Procedure for Transmission Based Precautions states, Appropriate precautions shall be used either at all times (Standard Precautions) or for individuals who are documented or suspected to have infections or communicable diseases that can be transmitted to others (transmission based precautions). Contact Precautions: and two standard precautions, implement contact precaution for residents known or expected to be infected or colonized with microorganisms that can be OK transmitted by direct contact with the resident or indirect contact with environmental services or resident care items in the resident's environment. Section A. Examples of infections…

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 record review, observations and interviews the facility failed to maintain and implement an infection control program to help prevent the development and transmission of infectious disease Sarcoptes scabiei (scabies) in 3 of 3 residents who were infected with rashes (#3, #5, #6) and failed to follow CDC recommendations to help prevent spread or reexposure. Findings: The facility's Infection Control Policy and Procedure for Transmission Based Precautions states, Appropriate precautions shall be used either at all times (Standard Precautions) or for individuals who are documented or suspected to have infections or communicable diseases that can be transmitted to others (transmission based precautions). Contact Precautions: and two standard precautions, implement contact precaution for residents known or expected to be infected or colonized with microorganisms that can be OK transmitted by direct contact with the resident or indirect contact with environmental services or resident care items in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 12 of 22 resident rooms, shower/whirlpool and bathrooms, hallways, a kitchenette and the laundry room for 2 of 3 days of survey. Findings: On 5/8/23 at approximately 10:25 a.m., during observations of room [ROOM NUMBER] and room [ROOM NUMBER], there was an unmarked urinal in the bathroom and in room [ROOM NUMBER] an unmarked graduated cylinder with dried dark yellow material on the bottom was observed. On 5/8/23 at 10:39 a.m., during an observation of room [ROOM NUMBER], two pink wash basins were sitting on the bathroom floor. On 5/9/23 at 8:15 a.m., during an additional observation of room [ROOM NUMBER], two pink wash basins were sitting on the bathroom floor. On 5/8/23 at 10:50 a.m., during an observation of room [ROOM NUMBER], a white specimen collector pan was on the floor in the bathroom. On 5/9/23 at 8:17 a.m., during an additional…

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 observations and interview, the facility failed to ensure that the resident's environment was free of accident hazards relating to a patient lift and a kitchen steamer a for 2 of 2 facility tours, for 1 of 3 days of survey. (5/8/23) In addition, the facility failed to ensure that the resident's environment was free of accident hazards relating to toilet safety frame and rails for 2 of 3 days of survey (5/8/23 and 5/9/23). Findings: 1. On 5/8/23 at 9:08 a.m., a surveyor observed an Invacare 450 patient lift, in the hallway, that was missing the six swing arm safety clips that secure the lift pads on the swing arm when in use. 2. On 5/8/23 at 9:50 a.m., the steamer in the kitchen was venting exhaust steam up towards the hood vent and directly over the outlet to the steamer. Condensation from the exhausted steam formed water which ran down the wall (ruining the wall) and dripped directly onto the steamer plug outlet creating a potential safety hazard . The cook confirmed, in an interview at this time, that…

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, the facility's Labeling and Dating Food policy and the Sanitation of Food Services Department policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a wall mounted fan, an exhaust fan, ceiling tiles, ceiling tile grids, ceiling air vents, a wall heater, the walls and the hood system. Additionally, the facility failed to ensure products on kitchen shelving, in a walk-in refrigerator, in a reach-in freezer and in a walk-in freezer were labeled/dated and/or secured closed for 1 of 1 tour. Findings: Review of the facility's Sanitation of Food Services Department noted: Policy: The food services staff shall maintain the sanitation of the Food Service Department through compliance with a written comprehensive cleaning schedule. Review of the facility's Labeling and Dating Food policy noted: Policy: The purpose of this policy is to provide a procedure for recording all food items that enter into a fridge. Procedure: 1. All items that are stored in the fridge must be covered. 2. All food items must be labeled…

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 observations, record reviews, interview, and the facility's Nursing Policy Manual, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection, for 1 of 1 sampled resident's reviewed for Respiratory Care (#7). Finding: Resident #7 was admitted to the facility on [DATE] with diagnoses to include Acute respiratory failure and Chronic Pulmonary Edema. On 5/8/23 at 10:35 a.m., during an interview with Resident #7, a surveyor observed the nebulizer tubing dated 1/30/23 and the nebulizer equipment to be sitting next to the nebulizer on a paper towel uncovered. The resident stated that he/she has used the nebulizer a few times since 1/30/23. The facility's Nursing Policy Manual noted under Cleaning of Durable Medical Equipment: Policy - To keep equipment clean and sanitized to reduce and prevent nosocomial infections. Procedures: 1. B. Oxygen concentrators: wiped down weekly along with changing oxygen tubing, nebulizer masks and cannulas. They…

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.