Pinnacle Rehabilitation & Health Center
For profit - Corporation · 3034 South Dupont Blvd, Smyrna, DE 19977 · See home’s Medicare page
Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 18 months.
3.61
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 4.3
49.3%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 49.7%
151
Certified beds
Qualifying beds in the certified provider or supplier facility.
131
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Efraim Rooz (99%)
Indirect owners
No indirect owner information
Managerial control
No information available
Managing employee(s)
Juliet Fountain since Feb, 2020
Inspection Reports
44
total deficiencies
6
infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0756
Failure to:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0552
Failure to:
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0676
Failure to:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0679
Failure to:
Provide activities to meet all resident's needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0710
Failure to:
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0883
Failure to:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0622
Failure to:
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0623
Failure to:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0641
Failure to:
Ensure each resident receives an accurate assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0686
Failure to:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0583
Failure to:
Keep residents' personal and medical records private and confidential.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0636
Failure to:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0640
Failure to:
Encode each resident's assessment data and transmit these data to the State within 7 days of assessment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0756
Failure to:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0758
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0761
Failure to:
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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0791
Failure to:
Provide or obtain dental services for each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0881
Failure to:
Implement a program that monitors antibiotic use.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0883
Failure to:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Environmental Deficiency — F0908
Failure to:
Keep all essential equipment working safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Environmental Deficiency — F0469
Failure to:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Resident Rights Deficiency — F0174
Failure to:
Provide residents with private access to a telephone.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0241
Failure to:
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0244
Failure to:
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Environmental Deficiency — F0257
Failure to:
Maintain comfortable and safe temperature levels.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Environmental Deficiency — F0258
Failure to:
Maintain comfortable sound levels.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0279
Failure to:
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Pharmacy Service Deficiency — F0329
Failure to:
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Nutrition and Dietary Deficiency — F0362
Failure to:
Hire sufficient dietary support personnel.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0242
Failure to:
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0276
Failure to:
Assure that each resident's assessment is updated at least once every 3 months.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0280
Failure to:
Allow residents the right to participate in the planning or revision of care and treatment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0371
Failure to:
Store, cook, and serve food in a safe and clean way.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0406
Failure to:
Give or get specialized rehabilitative services per the patient's assessment or plan of care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Environmental Deficiency — F0441
Failure to:
Have a program that investigates, controls and keeps infection from spreading.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0356
Failure to:
Post nurse staffing information/data on a daily basis.
Severity
No actual harm, with potential for minimal harm
Scope
Many people affected
Seriousness
Penalties
$25.7K
total fines
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.