Safety Report: Pinnacle Point Wellness & Rehabilitation
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
1Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
7Requirements cited on more than one inspection
J
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F684
Citations by topic
2Abuse, neglect & exploitation
2Infection control
5Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (5) than in the cycle before (12).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 3 | November 20, 2025; April 10, 2025; October 15, 2024 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 3 | April 10, 2025; October 15, 2024; November 20, 2023 |
| Ensure medication error rates are not 5 percent or greater. (F759) | 3 | April 10, 2025; October 15, 2024; April 19, 2024 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | June 29, 2026; April 10, 2025 |
| Provide and implement an infection prevention and control program. (F880) | 2 | November 20, 2025; April 10, 2025 |
| 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. (F584) | 2 | April 10, 2025; October 15, 2024 |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (F636) | 2 | April 10, 2025; October 15, 2024 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| April 19, 2024 | Payment Denial | Payment denial for 13 days, starting June 4, 2024 |
| November 20, 2023 | Payment Denial | Payment denial for 62 days, starting January 2, 2024 |
| November 20, 2023 | Fine | $52,878 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
June 29, 2026 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint
April 30, 2026 — 1 citation · complaint investigation
E
Honor the resident's right to choose his or her attending physician.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F555 · complaint · corrected May 19, 2026
November 20, 2025 — 3 citations
E
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F552 · corrected December 10, 2025
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · corrected December 10, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected December 10, 2025
April 10, 2025 — 12 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected May 25, 2025
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · corrected May 25, 2025
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected May 25, 2025
E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · corrected May 25, 2025
E
The resident has the right to receive notices in a format and a language he or she understands.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F574 · corrected May 25, 2025
E
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F569 · corrected May 25, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected May 25, 2025
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected May 25, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected May 25, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected May 25, 2025
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F636 · corrected May 25, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected May 25, 2025
October 15, 2024 — 17 citations
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F925 · corrected November 29, 2024
E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F921 · corrected November 29, 2024
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · corrected November 29, 2024
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected November 29, 2024
E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F700 · corrected November 29, 2024
E
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F692 · corrected November 29, 2024
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · corrected November 29, 2024
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected November 29, 2024
E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F636 · corrected November 29, 2024
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected November 29, 2024
E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · corrected November 29, 2024
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected November 29, 2024
E
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F582 · corrected November 29, 2024
E
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F558 · corrected November 29, 2024
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected November 29, 2024
D
Assist a resident in gaining access to vision and hearing services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F685 · corrected November 29, 2024
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected November 29, 2024
April 19, 2024 — 1 citation · complaint investigation
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · complaint · corrected June 9, 2024
February 29, 2024 — 1 citation · complaint investigation
F
Employ staff that are licensed, certified, or registered in accordance with state laws.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F839 · complaint · corrected March 4, 2024
November 20, 2023 — 3 citations (includes serious) · complaint investigation
J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected January 1, 2024
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · complaint · corrected February 27, 2024
D
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F919 · complaint · corrected February 27, 2024
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare