Inspection Reports for
The Springs at Pinnacle Mountain

The complaint investigation revealed that Resident #1 was given a regular diet tray with a cheeseburger and fries despite orders for a clear liquid diet and tube feedings. The resident experienced nausea, vomiting blood, and was found unresponsive and pronounced dead on 06/30/2025. The APRN was not notified of vomiting blood, and there were communication failures among staff regarding the resident's condition and diet.

The facility failed to ensure dietary orders were followed for Resident #1, who was mistakenly given a regular diet tray including a cheeseburger and fries instead of a clear liquid diet. This error contributed to the resident's discomfort, nausea, vomiting blood, and eventual death. Interviews revealed communication and documentation errors between nursing and dietary staff.

The complaint investigation was substantiated. Resident #1 was found to have been given a regular diet tray despite orders for a clear liquid diet and tube feedings. The resident experienced nausea, vomiting (including bloody vomitus), and was found unresponsive and pronounced dead on 06/30/2025. Family and staff interviews confirmed the dietary error and lack of timely notification of condition changes.

The facility failed to follow dietary orders for Resident #1, who was mistakenly given a regular diet tray including a cheeseburger and fries instead of the prescribed clear liquid diet. This error contributed to the resident's discomfort, nausea, vomiting, and eventual death. Interviews revealed communication and documentation discrepancies between nursing and dietary staff regarding the resident's diet orders.

The complaint investigation revealed that the facility did not file a police report after an abuse allegation involving Resident #1 and a Medical Assistant. The internal investigation was completed but follow-up with police was not conducted. For Resident #4, the facility failed to administer pain medication as ordered, with multiple scheduled doses missed due to lack of medication and delays in obtaining prior authorization.

The facility failed to report an abuse allegation to proper authorities for one resident and failed to consistently administer prescribed pain medication every four hours for another resident, resulting in actual harm.

The complaint involved an abuse allegation by Resident #1 against a Medical Assistant, where the facility failed to file a police report despite reporting the incident to law enforcement. The allegation was not substantiated due to lack of police records. Additionally, Resident #4's complaint involved failure to administer pain medication as prescribed, with multiple missed doses documented.

The facility failed to timely report an abuse allegation to proper authorities for one resident and failed to consistently administer prescribed pain medication every four hours for another resident, resulting in actual harm.

The facility was found deficient in reasonably accommodating resident needs, documenting advance directives, timely administration of scheduled pain medication, and maintaining proper food preparation and hygiene practices. Multiple minimal harm deficiencies were cited related to call light accessibility, advance directive documentation, pain medication timing, and food handling procedures.

The facility failed to keep residents' personal wheelchairs in good repair, with observed tears, holes, and peeling vinyl/leather on wheelchairs of three residents, posing potential hazards such as skin tears and difficulty in cleaning. Maintenance staff confirmed no reports had been made regarding needed repairs.

The facility was found deficient in ensuring reasonable accommodation of resident needs, documenting advance directives, administering scheduled pain medication on time, and maintaining proper food preparation and hygiene practices. Multiple residents were affected with minimal harm or potential for harm.

The facility failed to keep residents' personal wheelchairs in good repair, with observed tears, holes, and peeling vinyl/leather on wheelchairs of three residents, posing potential hazards such as skin tears and cleaning difficulties.

The facility was found deficient in multiple areas including failure to notify family members of care plan meetings, improper meal preparation and serving inconsistent with planned menus, inadequate food safety and sanitation practices, failure to maintain call devices within reach of residents, and unsecured access hatches in resident rooms. Deficiencies were generally assessed as minimal harm or potential for actual harm affecting a few to many residents.

The facility was found deficient in multiple areas including failure to notify family members of care plan meetings, improper meal preparation and serving practices affecting nutritional needs and food safety, failure to maintain call devices within reach of residents, and unsecured access hatches in resident rooms. These deficiencies posed minimal harm or potential for actual harm to residents.

The complaint investigation was substantiated with findings that Resident #1 and others experienced late medication administration, including 8:00 PM medications given after midnight. The Ombudsman reported concerns and communicated with facility staff, but grievances were not properly filed or documented.

The facility failed to ensure residents received medications within the prescribed two-hour window, particularly 8:00 PM medications, with documented late administration past midnight for multiple residents. Additionally, the facility failed to properly document grievances related to these medication delays, violating residents' rights to voice concerns without discrimination or reprisal.

The complaint investigation focused on Resident #1's report of receiving 8:00 PM medications late, sometimes after midnight, with the Ombudsman confirming the issue and reporting it to the Director of Nursing. The DON acknowledged the complaint but failed to file a grievance timely. Other residents also reported late medication administration.

The facility failed to ensure residents could voice grievances about late medication administration and failed to administer physician-prescribed medications within the ordered timeframe for 3 sampled residents. The issues primarily involved late administration of 8:00 PM medications, sometimes after midnight, affecting multiple residents.

The facility failed to promptly resolve resident grievances, ensure ordered skin treatments and oxygen therapy were properly administered, maintain a safe environment free of hazards, honor residents' dietary preferences, provide physician-ordered nutritional supplements, and maintain proper food safety and hygiene practices in the kitchen.

The complaint investigation was triggered by Resident #1's grievance filed on 11/21/2022 regarding dietary requests (e.g., wanting 2 eggs and 10 pieces of bacon every morning, peanut butter and jelly sandwich for late night snack) and missing personal items (sweatpants and sweatshirts) which had not been resolved by the facility as of the survey date.

The facility failed to promptly resolve grievances related to dietary requests and missing items for Resident #1, failed to ensure ordered skin treatments were consistently administered, failed to maintain a safe environment by not securing potentially hazardous items, failed to ensure oxygen was administered at the prescribed flow rate and humidifier bottles changed timely, failed to honor residents' food preferences and provide condiments and silverware, failed to provide physician-ordered nutritional supplements, and failed to maintain proper food safety practices including labeling, covering food, and staff hair containment in the kitchen.

The facility was found deficient in multiple areas including inadequate security of resident funds, untimely completion of admission Minimum Data Sets (MDS), incomplete care plans for tracheostomy and nebulizer treatments, improper respiratory care documentation and practices, delayed assistance with meals, inadequate personal hygiene care, improper feeding tube placement verification, improper storage of respiratory equipment, inappropriate use of psychotropic medications, unsecured medications in resident rooms, and failure to provide meals according to prescribed diets.

The facility was found deficient in multiple areas including inadequate surety bond coverage for resident funds, untimely completion of admission Minimum Data Sets (MDS), incomplete care plans for tracheostomy and nebulizer treatments, improper respiratory care documentation and practices, delayed assistance with meals, inadequate personal hygiene care, improper feeding tube placement verification, improper storage and maintenance of respiratory equipment, improper medication management including psychotropic PRN orders, unsecured medications in resident rooms, and failure to provide prescribed enhanced diets and pureed meals as per the written menu.