A list of the most recent deficiencies for The Springs of Pinnacle Mountain. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-05 | 2023-10-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-05 | 2023-10-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-05 | 2023-10-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-10-05 | 2023-10-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-10-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-05 | 2023-10-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-05 | 2023-10-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-02 | 2023-10-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-02 | 2023-10-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-23 | 2023-06-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-03 | 2023-03-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-03-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-03 | 2023-03-03 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-03 | 2023-03-03 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-03 | 2023-03-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-03 | 2023-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-01-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-11 | 2023-01-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-10 | 2022-10-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-10 | 2022-10-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-05 | 2022-10-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-05 | 2022-10-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-10-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-19 | 2022-09-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-19 | 2022-09-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-19 | 2022-09-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-19 | 2022-09-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-05 | 2022-09-04 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-08-05 | 2022-09-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-05 | 2022-09-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-08-05 | 2022-09-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-05 | 2022-09-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-08-05 | 2022-09-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-03 | 2022-09-04 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-08-03 | 2022-09-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-03 | 2022-09-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-03 | 2022-09-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-07 | 2022-03-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-07 | 2022-03-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-07 | 2022-03-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-16 | 2022-01-14 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-05-21 | 2021-06-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-21 | 2021-06-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-05-21 | 2021-06-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-21 | 2021-06-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-21 | 2021-06-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-21 | 2021-06-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-21 | 2021-06-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-21 | 2021-06-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-21 | 2021-06-18 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-21 | 2021-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-21 | 2021-06-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-18 | 2021-06-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-21 | 2021-05-21 | N |
