The Pinnacle Rehabilitation and Nursing Center

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 admission date of 02/16/24. 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 2/23/24 revealed Resident #31 was cognitively intact. Resident #31 required substantial or maximum assistance for showering or bathing, partial or moderate assistance for toileting and personal hygiene, and set up help for eating and oral hygiene.

2. Review of the medical record for Resident #32 revealed an admission date of 02/13/24. Diagnosis included acute respiratory failure, Parkinson's disease, shortness of breath, muscle atrophy, and prostate cancer.

Review of the comprehensive MDS assessment dated 02/20/24 revealed Resident #32 was cognitively intact. He was totally dependent on staff for toileting and required substantial or maximum assistance for showering or bathing and personal hygiene.

3. Review of the medical record for Resident #55 revealed an admission date of 01/12/24. Diagnosis included arthritis, diabetes, pancreatitis, pain and swelling of the left knee, and asthma.

Review of the comprehensive MDS assessment dated 01/19/24 revealed Resident #55 was totally dependent on staff for toileting and showering or bathing, required partial or moderate assistance for personal hygiene, and setup help for eating and oral hygiene.

Interview on 02/28/24 at 9:07 A.M. with Resident #55 revealed she felt like State Tested Nurse's Aide (STNA) #204 was constantly picking on her and demeaning her. STNA #204 told her they promoted independence in the facility and did not consider Resident #55's limitations due to her knee immobility and pain. STNA #204 referred to her as honey or baby which was inappropriate.

Interview on 02/28/24 at 9:15 A.M. with Resident's #31 and #32 as well as Resident #32's wife, revealed staff working on the night shift were especially rude. Staff came in at night and turned off the call light without addressing concerns. Resident #32's wife reported she had an issue with one employee who made a nasty comment to her husband. She reported the incident to the Director of Nursing (DON), and it was handled.

Interview on 02/28/24 at 9:42 A.M. with the Administrator and DON revealed they were aware of Resident #55's concerns regarding STNA #204. They revealed they had provided verbal counseling to STNA #204. They confirmed they were aware of the concerns with Resident #32 and his wife; they did not have knowledge of Resident #31's concerns.

Interview on 02/28/24 at 11:53 A.M., STNA #204 denied Resident #55 reported any concerns to her about disrespect or mistreatment.

Review of the personnel file for STNA #204 revealed a hire date of 11/09/15. The file contained an annual employee evaluation dated 10/27/23 with an action plan to work on her attitude and anger. The date of completion for the action plan was 11/30/23. The file contained verbal education dated 04/02/19 for a resident who felt his bath was not completed in an appropriate amount of time, a written warning dated 04/14/19 for arguing with another STNA in the hallway, and a written warning dated 07/31/15 for threatening a fellow employee with bodily harm. The progressive discipline policy was reviewed with STNA #204 on 10/09/23, highlighting behavior that was offensive to residents, visitors, or fellow employees, arguing or engaging in disruptive behavior with fellow employees in resident care areas, using foul or abusive language, threatening a fellow employee, resident, or visitor, or instigating a physical confrontation with a fellow employee, resident, or visitor.

Review of the facility policy titled Resident Rights

Based on observation, record review and interview, the facility failed to ensure the abdominal binder used to secure Resident #99's percutaneous endoscopic gastrostomy (PEG) tube was in place at all times. This finding affected one (Resident #99) of three residents reviewed for care.

Findings include:

Review of Resident #99's hospital documentation dated 06/15/23 revealed the resident was admitted for a urinary tract infection (UTI) and presented from the facility for a PEG tube (tube through the stomach for fluids and nutrition) removal which was replaced in the emergency room (pre admission to the skilled nursing facility).

Review of Resident #99's medical record revealed the resident was admitted to the facility on 06/15/23 with diagnoses including atherosclerotic heart disease, altered mental status and vascular dementia.

Review of Resident #99's hospital documentation dated 07/13/23 revealed the resident underwent replacement of a PEG tube on 07/12/23. An abdominal binder was ordered to prevent further PEG tube dislodgement in the future.

Review of Resident #99's physician orders revealed an order dated 08/08/23 for an abdominal binder to be in place to protect the PEG tube every shift.

Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated 09/29/23 revealed the resident exhibited severe cognitive impairment.

Review of Resident #99's nursing progress note dated 12/21/23 at 2:00 A.M. authored by Licensed Practical Nurse (LPN) #804 indicated the resident's PEG tube fell out and was lying next to her. An order was obtained to send the resident to the hospital for a PEG tube replacement.

Review of Resident #99's hospital discharge paperwork dated 12/21/23 revealed the PEG tube was reinserted.

Observation on 12/22/23 of Resident #99's PEG tube binder revealed the binder was secured and in place.

Telephone interview on 12/22/23 at 10:24 A.M. with LPN #804 with the Administrator and Director of Nursing (DON) present revealed she found Resident #99's PEG tube out and lying on the bed. LPN #804 stated the resident did not have a PEG tube binder in place the time of the observation and she was unaware of where the binder went.

Review of the Enteral Nutrition policy revised 01/14 indicated if the resident had a feeding tube placed prior to admission or returning to the facility, the Physician and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident.

This deficiency represents non-compliance investigated under Complaint Number OH00148986.

Based on interview and record review the facility failed to ensure residents were treated with respect and dignity. This affected four residents (#24, #55, #62, and #68) reviewed for respect and dignity and had the potential to affect all residents residing in the facility. The facility census was 68.

Findings include:

Review of Resident #24's medical records revealed an admission date of 09/02/22. Diagnoses included blood clots and chronic obstructive pulmonary disease and respiratory failure.

Review of Resident #24's Minimum Data Set (MDS) assessment dated 09/09/22 revealed Resident #24 had intact cognition and required limited assistance with toileting and personal hygiene.

Review of Resident #55's medical records revealed an admission date of 02/24/22. Diagnoses included chronic heart failure, respiratory failure and overactive bladder.

Review of Resident #55's MDS assessment dated 09/08/22 revealed Resident #55 had intact cognition and required extensive assistance with toileting and personal hygiene.

Review of Resident #62's medical records revealed an admission date of 03/28/22. Diagnoses included paralysis, muscle wasting and need for personal care.

Review of Resident #62's MDS assessment dated 08/30/22 revealed Resident #62 had intact cognition and required extensive assistance with toileting and personal hygiene.

Review of Resident #68's medical records revealed an admission date of 08/19/22. Diagnoses included femur fracture and respiratory failure.

Review of Resident #68's MDS assessment dated 09/04/22 revealed Resident #68 had impaired cognition and required extensive assistance with toileting and personal hygiene.

Interview on 09/15/22 at 10:38 A.M. with Resident #55 revealed she had concerns related to multiple staff members treating her in disrespectful manner. Resident #55 stated she had requested incontinence care (unable to recall the exact date) from State Tested Nursing Assistant (STNA) #209 and STNA #209 had refused to thoroughly dry her stating why you are just gonna wet yourself again anyway. Resident #55 stated STNA #301 had refused to provide her with incontinence care at approximately 4:30 A.M. (date unknown) and told her you are not wet enough to be changed yet and STNA #301 did not return to provide her with incontinence care until approximately 6:30 A.M. Resident #55 stated STNA #300 had offered her water recently (date unknown) and Resident #55 asked for a cup of ice instead of the water. Resident #55 stated STNA #300 told her if you don't take the water now don't ask me for any later. Resident #55 stated she had made her concerns known to the Administrator as well as the Former Director of Nursing (FDON). Resident #55 further stated when Former Specified Resident (FSR) #80 was in the facility Registered Nurse (RN) #210 yelled at FSR #80 for attempting to get out of bed unassisted. Resident #55 stated she informed a floor nurse (LPN #203) about the incident and the nurse informed her she would notify the Administrator.

Interview on 09/15/22 at 11:03 A.M. with Resident #62 revealed he had concerns with STNA #215. Resident #62 stated he had some personal papers on his bedside table and STNA #215 entered his room (unknown date) with his breakfast tray. Resident #62 asked STNA #215 not to place his breakfast tray on top of his papers and STNA #215 proceeded to place the tray on top of his papers anyway. When Resident #62 asked STNA #215 to move the tray so he could move his papers, STNA #215 became upset and pushed the bedside table up against the wall and left the room. Resident #62 stated STNA #215 told the Administrator he was the one that had gotten aggressive and pushed the bedside table against the wall.

Interview on 09/15/22 at 11:20 A.M. with Licensed Practical Nurse (LPN) #201 revealed she was the unit manager and had been made aware of concerns with Resident #55's care and stated Resident #55 had informed her of STNA #209. LPN #201 stated STNA #209 had received verbal counseling regarding the incident. LPN #201 stated she had not been aware of Resident #55's other concerns.

Interview on 09/15/22 at 4:55 P.M. with Registered Nurse (RN) #210 revealed the Administrator had asked that he no longer provide care to Resident #55 or her former roommate (Resident #80) in May 2022 after Resident #55 reported he had yelled at her roommate. Further interview with RN #210 revealed he had also been asked not to provide care for Resident #68 due to the resident had stated he had yelled at her. RN #210 denied he had yelled at Resident #68 and stated the resident's husband had spoken with Resident #68 and he was now allowed to care for her.

Interview on 09/15/22 at 5:11 P.M. with the Administrator and Director of Nursing (DON) revealed they had been been made aware Resident #55 had concerns with RN #210 and stated he was not able to care for either her of her roommate.

Review of STNA #209's personnel file revealed a written warning dated 09/12/22 that stated she had behaviors that she knew or should know that were offensive to residents. No further explanation was provided in the disciplinary action.

Review of STNA #300's personnel file revealed a discussion was had on 06/22/22 regarding Resident #55's care. Documentation stated Resident #55 had stated STNA #300 had offered the resident water and the resident stated she did not want water at this time and employee was accused of saying then dont ask for any water later.

Review of RN #210's personnel file revealed a written warning dated 05/17/22 that he was discourteous, and rude to residents. RN #210 had been inserviced on customer service. The personnel file further contained a written warning dated 06/10/21 regarding RN #210 had a verbal confrontation with a resident's family member.

Interview on 09/19/22 at 2:40 P.M. with the Administrator revealed she was unable to provide a clear explanation regarding STNA #209's disciplinary action, however confirmed the write up included offensive behaviors.

Review of facility policy titled Resident Rights dated December 2016 revealed residents had the right to be treated with respect, kindness and dignity.

This deficiency substantiates Complaint number OH00135488.

Based on observation and interview the facility failed to provide a clean and sanitary environment for Resident #24 when Resident #24's bedside commode was not emptied in a timely manner. This affected one resident (#24) of three residents reviewed for environment (#24,#30 and #55). The facility census was 50.

Findings include:

Interview on 09/15/22 at 1:48 P.M. with Resident #24 revealed staff sometimes refused to empty her bedside commode. Observation at time of interview revealed Resident #24's bedside commode contained urine and feces. Resident #24 stated it had not been emptied since the previous night. Resident #24 stated she had asked the staff to empty it this afternoon and no staff had returned to empty the bedside commode.

Interview on 09/15/22 at 2:04 P.M. with State Tested Nursing Assistant (STNA) #215 revealed she was not aware Resident #24's bedside commode needed to be emptied. STNA #215 entered Resident #24's room at time of interview and confirmed the bedside commode bucket contained urine and feces.

Interview on 09/19/22 at 12:23 P.M. with Resident #24 revealed her bedside commode had not been emptied since the previous evening and stated she had asked staff to empty it last night as well as this morning. Observation confirmed there was urine and feces in the bedside commode and a strong odor was detected.

Interview on 09/19/22 at 12:35 P.M. with STNA #206 revealed she was not aware Resident #24's bedside commode needed to be emptied. STNA #206 entered Resident #24's room and confirmed the presence of urine and feces in the bedside commode bucket.

This deficiency substantiates Complaint Number OH00135488.