Pinnacle Specialty Care

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, policy review, staff, and resident interviews, the facility failed to ensure 1 of 3 residents received adequate nursing supervision and follow up assessment after a staff member transferred a resident using less than the required staff needed to transfer him as directed in the Care Plan and resulted

in him being lowered to the floor (Resident #4). The facility reported a census of 93 residents. Findings include:The Minimum Data Set (MDS) dated [DATE REDACTED] for Resident #4 documented a Brief Interview for Mental Status of 9, suggesting moderate cognitive impairment. The MDS documented he is dependent on staff (staff does all the effort) for transferring from chair or bed to chair transfers. The MDS revealed he had diagnoses of cancer, malnutrition, and septicemia (a life-threatening condition where an infection spreads throughout the bloodstream).Review of Witnessed Fall report for Resident #4 dated 8/4/25 at 10:00 AM informed Resident #4 wife called and reported a CNA lowered Resident #4 to the floor on 8/1/25. The facility implemented an intervention to educate staff on how he is transferred. Record review of the Corrective Action Form dated 8/4/25 for Staff D documented the following verbal warning: Staff D transferred the resident with one assist, despite the resident's mention that they would require a second person for the transfer. As a result, the CNA dropped the resident to the floor without reporting the incident to any nursing staff. During an interview on 10/13/25 at 12:15 PM Resident #4 informed he had a fall at the facility in August 2025 after returning from the hospital. He revealed he told Staff D, Certified Nurse Aide (CNA), she could not do it herself and needed someone else to help her, but Staff D did not listen. He explained Staff D had to lower him to the floor. During an interview on 10/14/25 at 1:18 PM with the Administrator informed Staff D did not notify a nurse when she lowered Resident #4 to the floor on 8/1/25 and he was not assessed by a nurse at the time of the fall. She then informed on 8/4/25 Resident #4 wife informed the facility of the incident on 8/1/25 and the Director of Nursing (DON) provided education for Staff D, and a fall report was completed. During an interview on 10/14/25 at 1:24 PM with the Director of Nursing (DON) informed she provided education on 8/4/25 to Staff D regarding Resident #4 fall on 8/1/25 and no injuries resulted from being lowered to the floor. She informed Staff D informed her she thought he only needed one (1) staff to assist him. She informed staff D was educated all falls even if lowered to the floor need to have assessments completed by a nurse. Review of Resident #4 current Care Plan on 10/14/25 instructed staff starting on 4/30/25 he needs assistance of two (2) staff for transfers. The Care Plan also documented a fall intervention implemented on 8/1/25 informing fall education was provided to staff.Review of the facility policy, Falls - Clinical Protocol, Assessment and Recognition, revised March 2018 instructed

the following: Staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Specialty Care

1223 Prairieview Road Cedar Falls, IA 50613

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Nursing Assistant on 1/4/24 verifying all had been reviewed. Review of the employee file for Staff C documented a hire date of 4/10/25. The Job Description with a position title of Charge Nurse - LPN directed to supervise response to resident's call for assistance.The Job Description lacked defining response to resident's call for assistance. Staff C signed the Job Description on 4/10/25. The Orientation Checklist: Licensed Nurses included the call light system. Staff C signed the Orientation Checklist: Licensed Nurses verifying all had been reviewed. The document lacked a date of completion. Review of Call Light Audit Reports revealed 33 rooms with activated call lights had been audited. Audits dated back to 9/9/25 and revealed the facility identified 2 call lights exceeded 15 minutes. The Call Light Audit Report lacked the identified room of 308.Review of the Answering Call Light facility policy reviewed March 2021, indicated the purpose of the procedure is to ensure timely response to the resident's request and needs. The policy directs staff:1. Identify yourself and politely respond to the resident by his/her name (e.g., this is Mrs. [NAME], Mr. [NAME], how may I help you?)a. If the resident needs assistance, indicate the approximate time it will take for you to respond.b. If the resident's request requires another staff member, notify the individual.c. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. 2. If assistance is needed when you enter the room, summon help by using the call signal. The policy lacked defining timely response to the resident's needs.

Event ID:

Facility ID:

If continuation sheet