SMYRNA, DE - State inspectors documented multiple care planning failures and inadequate personal hygiene services at Pinnacle Rehabilitation & Health Center during an April 2025 complaint investigation, with surveyors finding residents with neglected nail care and incomplete interdisciplinary team involvement in treatment planning.
Neglected Personal Care for Cognitively Impaired Resident
During observations on April 8 and April 11, 2025, surveyors documented that a severely cognitively impaired resident requiring substantial to maximum assistance with personal hygiene had fingernails on both hands that were excessively long with dark, encrusted debris underneath each nail. The resident's cognitive impairment, documented in the admission Minimum Data Set assessment from March 13, meant they were unable to advocate for their own grooming needs.
When questioned by surveyors at 11:07 AM on April 11, a registered nurse unit manager acknowledged the resident needed nail care and revealed that a certified nursing assistant had attempted to provide this service the previous week. However, according to the nurse's statement, "the CNA was trying to do [the resident's] nail care and she became combative so it couldn't get done."
Proper nail hygiene serves multiple critical medical functions beyond cosmetic appearance. Long, debris-filled nails create environments where bacteria and fungi thrive, significantly increasing infection risk. For residents with compromised immune systems or diabetes, nail-related infections can lead to serious complications including cellulitis or systemic infections. Additionally, unkempt nails pose injury risks to both the resident and caregiving staff during routine care activities.
Failure to Update Care Plans
The facility's response to the resident's refusal of nail care revealed a systemic breakdown in care planning protocols. When asked whether the resident's Activities of Daily Living care plan had been revised to reflect the refusal of nail care, the unit manager confirmed: "No, she has not been care planned for refusing nail care."
Federal regulations require facilities to update care plans when residents refuse services or when initial approaches prove unsuccessful. The care plan should have been modified to include alternative strategies for providing nail care, such as attempting the service at different times of day, using different staff members, or employing behavioral interventions appropriate for cognitively impaired residents. The resident's existing care plan documented goals for the resident to be "clean, dressed and well-groomed daily to promote dignity and psychosocial wellbeing," with interventions including assistance with daily hygiene and grooming as needed. The failure to address the nail care refusal meant staff lacked documented guidance for handling this recurring situation.
Incomplete Interdisciplinary Team Participation
Inspectors identified a pattern of inadequate interdisciplinary team involvement in post-admission care planning meetings for multiple residents. Care conference attendance sheets for three residents admitted between February and May 2024 lacked evidence of attendance or input from essential team members, including physicians, registered nurses, certified nursing assistants, and dietary staff.
Comprehensive care planning requires input from all disciplines involved in a resident's care. Physicians provide medical oversight and treatment parameters. Registered nurses assess clinical needs and coordinate care delivery. Certified nursing assistants offer crucial insights into residents' daily functioning, preferences, and responses to care. Dietary staff address nutritional requirements and eating challenges. When any of these perspectives are missing, care plans may fail to address important aspects of residents' needs or miss opportunities to coordinate services effectively.
For one resident admitted on February 27, 2025, the social worker confirmed during an April 14 interview that physician, certified nursing assistant, and dietary input were not provided for the March 7 care planning meeting. This meant the initial care plan was developed without critical information about the resident's medical needs, daily care requirements, or nutritional considerations.
After surveyors notified the administrator and director of nursing via email on April 17 about the lack of interdisciplinary team participation, facility leadership acknowledged the deficiency and committed to ensuring participation from all required parties in all care plan meetings, including initial meetings.
Additional Issues Identified
The inspection narrative also referenced concerns related to providing treatment and care according to orders, residents' preferences, and professional standards of practice for two residents. However, the specific details of these treatment-related deficiencies were not fully detailed in the available documentation.
Regulatory Context
The documented violations represent failures to meet federal requirements for comprehensive care planning and maintenance of resident dignity through adequate grooming services. Federal nursing home regulations mandate that facilities provide services to help each resident attain or maintain their highest practicable physical, mental, and psychosocial well-being. This includes developing comprehensive care plans with input from qualified professionals and ensuring residents receive necessary personal care services.
The April 17, 2025 inspection was conducted in response to complaints, indicating that concerns about care quality prompted state oversight. All findings were reviewed with the facility administrator and director of nursing on the final day of the survey.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinnacle Rehabilitation & Health Center from 2025-04-17 including all violations, facility responses, and corrective action plans.
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