Pinnacle Health & Rehab At Sanford

Based on record review and interview, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Activities of Daily Living (ADL's) to meet the preferences and goals which included interventions for assistance needed for each resident to attaining or maintaining his or her highest practicable quality of life for 6 of 14 residents care plans reviewed. (Residents 6, 11, 21, 47, 55, 26, and 61) Findings: 1. Review of Resident #6's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting, bed mobility and ambulating. 2. Review of Resident #11's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, lower body dressing, bathing and oral hygiene. 3. Review of Resident #21's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for…

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 record reviews, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 2 of 2 units reviewed. Findings: A review of the facility's Shift Count policy and procedure dated: 2/3/2000, stated under Procedure, 1. All schedule II-V medications will be counted at the change of each shift by the off-going and the on-coming nurse. 3. If the count is correct, the keys change hands and the shift count sheet is signed by both nurses. On 2/11/25 at 11:00 a.m., during a medication storage observation of the Second Floor Medication Room, a surveyor reviewed the Controlled Substance Books and Shift Counts which indicated the facility counts at the change of each shift, approximately 3 times a day. The person authorized to administer medications…

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, interviews, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 3 medication storage refrigerators. Finding: A review of the United States (U.S.) Centers for Disease Control and Prevention: Vaccine Storage and Handling Toolkit dated 3/24/24 stated .Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. On 2/11/25 at 4:00 p.m., during an observation of the First Floor Unit's Medication Room, a surveyor observed a dormitory style refrigerator (small combination refrigerator/freezer unit that is outfitted with one exterior door). The refrigerator contained several vials of purified protein derivative (for tuberculosis testing), and unit dose syringes of pneumococcal and influenza vaccines. On 2/11/25 at 4:20 p.m., the finding was confirmed by the charge nurse and the Infection Preventionist. On 2/12/25 at 10:15 a.m., the finding was discussed with the Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 residents records reviewed during complaint investigations (Resident 2). Findings: On 9/13/2024 at 10:19 a.m., the Department of Licensing received a complaint indicating ADL care was not being provided to Resident 2 as stated in the care plan. Review of facility policy Activities of Daily Living dated 1/1/95 states .Activities of daily living include bathing, dressing, ambulation and transfer, eating, and use of speech, language or other functional communication systems.the care plan will identify any unique needs or special treatment and services necessary to maintain or improve functional ability. Resident 2 was admitted on [DATE] and has diagnoses to include Parkinson's disease and is dependent on facility staff for all ADL needs. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 2 had a Brief Interview for Mental…

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, interviews, and facility policy, the facility failed to implement interventions outlined in resident's care plan in the area of Activities of Daily Living (ADL) for 1 of 5 residents reviewed during complaint investigations. (Resident 2). Findings: On 9/13/2024 at 10:19 a.m., the Department of Licensing received a complaint indicating ADL care was not being provided to Resident 2 as stated in the care plan. Review of facility policy Comprehensive Care Plans dated 9/3/94 states It is the policy of Pinnacle Health & Rehab [NAME] to develop a comprehensive care plan for each resident, based on the needs identified in the comprehensive assessment .Each resident's plan of care describes the services being furnished to attain or maintain the resident's highest practical level of functioning . Resident 2 was admitted on [DATE] and has diagnoses to include Parkinsons disease and is dependent on facility staff for all ADL needs. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed…

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, and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection on 1 of 2 rooms observed (room [ROOM NUMBER]). Findings: Review of facility policy Infection Prevention and Control dated 5/2023 states it is the policy of [Facility] to maintain and active infection prevention and control program (IPCP). The program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Observation of shared sink in room [ROOM NUMBER] on 10/1/24 at 9:07 a.m., and 1:10 p.m., revealed the following items unlabeled and available for use: 2 deodorant bottles, 2- 8 ounce bottles of body wash, 1 bottle of mouthwash, 1 can of shaving cream. 1 opened can of ginger ale, 1 electric razor, approximately 8 razors held together with a rubber band, one small, soiled basin, and 1 white paper cup containing 1 toothbrush. During…

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, record reviews, and interviews, the facility failed to ensure proper medication and biological storage temperatures for 2 of 3 medication refrigerators in 1 of 2 medication storage rooms. Finding: On 11/14/2023 at 1:00 p.m., a surveyor observed the 2 medication refrigerators in the first-floor medication storage room. The upper refrigerator contained insulin, and 2 locked boxes for controlled liquid medications. The second refrigerator contained tuberculin purified protein derivative, influenza, and pneumococcal vaccines. Observation of the temperature logs for the medication refrigerators noted multiple shifts were lacking documentation. The Certified Nursing Assistant-Medications confirmed the finding. On 11/15/2023 at 9:50 a.m., a surveyor observed the first-floor medication room and refrigerator temperature logs with a Licensed Practical Nurse who stated the temperatures are to be checked and documented by a licensed nurse at every shift change. A review of the temperature logs lacked evidence of temperature monitoring of medication room refrigerators as…

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 maintain maintenance services necessary to maintain in good repair and sanitary condition of arm rests of resident's wheelchair, ceiling tiles in hallways and common areas, and thresh-hold of elevator entrance. Findings: 1. On 11/13/2023, at 10:37a.m. surveyor observed wheelchair arms cracked for Resident #5, in room [ROOM NUMBER], creating an uncleanable surface. 2. On 11/14/2023 at 2:00p.m. during an environmental tour with Director of Facilities Management, the following were observed: First floor: Three stained ceiling tiles above the microwave area in the Main Dining Room Three stained ceiling tiles, just outside of the elevator on the first floor Second floor: Three stained ceiling tiles just outside the elevator in the main hallway Three stained ceiling tiles in the 300-wing hallway just outside of room [ROOM NUMBER] 3. On 11/14/2023 at approximately 3:00p.m. surveyor observed thresh-hold floor plate exiting the elevator was buckled…

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 adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, on 2 of 2 floors (First and Second), and hallways, for 1 of 1 environmental tour. Findings: On 3/2/22 at 10:00 a.m., during the Environmental Tour with the Nurse Managers of the first and second floors, the following was observed: First-floor: The common hallways of the first-floor nursing unit were observed with a dark, dirty buildup along the edges and in the corners. The floors in rooms 131-138 have a dark, dirty buildup, in the corners, in the bathrooms around the toilet bases, and under the sinks. room [ROOM NUMBER] - The wall to the left of the light switch, is noted to have ripped sheetrock on the corner. The sink vanity has a large light-colored stain. room [ROOM NUMBER]- At the entrance to the room, the rubber strip under the door is coming loose. The wall next to the door frame has peeling paint with exposed…

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.