Pinnacle Peak Assisted Living Home LLC

Based on observation, record review, documentation review, and interview, for two of four employees reviewed, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation. The deficient practice posed a safety risk to residents if the Department was unable to verify new employees were provided orientation in accordance with the facility's policies and procedures. Findings include: 1. In observation, E3 and E4 were present, and working at the facility during the inspection. 2. In record review, the personnel records for E3 and E4 (hired on June 5, 2023) did not include documentation of orientation. 3. In documentation review, the facility's policy titled, "Orientation and In-Service Training," dated October 1, 2022, documented, "... New employee orientation is required to be completed by all new employees... is required to be completed by all new employees and volunteers before providing assisted living services to a resident and will contain the following:... Facility philosophy and goals... Resident rights and facility rules... Reporting abuse, neglect and exploitation, food storage... Infection control practices, etc... Suc training will be documented in the personnel record..." 4. During an interview, E1 and E2 reported E3 and E4 were assistant caregivers, hired on approximately June 5, 2023, and worked under the supervision of E1 and E2. E2 reported the assistant caregivers received orientation; however, acknowledged the orientation was not documented in the personnel records.

Based on observation, record review, and interview, for three of three residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not know if a medication was administered. Findings include: 1. The medical records for R1, R2, and R3 were reviewed by the compliance officer during the afternoon on June 15, 2023. The medications for R1, R2, and R3 were observed to be available on site during the inspection. 2. In record review, R1's medical record included medication orders for Tylenol 500 mg, take 2 tablets by mouth every 8 hours, Flomax, 0.4mg, take one tablet by mouth QD, Gabapentin 300 mg, take one tablet by mouth three times a day, Senna 8.6/50mg, take two tablets by mouth QD, Trazadone 50 mg, 1-2 tablets QHS, Ferrous Gluconate 324 mg, take one tablet by mouth QD, Celexa 20 mg, take one tablet by mouth QD, Tramadol 50 mg, Take one tablet by mouth twice daily and two tablets at 8pm. 3. R1's Medication administration record (MAR), dated June 2023, did not include documentation R1 received the medications on June 14, 15, and the morning medications on June 16, 2023. 4. In record review, R2's medical record included medication orders for Polyethylene Glycol 3350 Miralax powder, one capful in 8 oz water by mouth once daily, Sennoside 8.6 mg-50mg 2 tablets by mouth once daily, Arthritis pain ER 650 mg, one tablet by mouth twice daily, Mirtazapine 30 mg tablet, one tablet by mouth at bedtime, and Trazadone 100 mg tablet, take 2 tablets by mouth at bedtime. 5. R2's MAR, dated June, 2023, did not include documentation R2 received the Arthritis pain medication (second dose) on June 15, 2023, the Mirtazapine and Trazadone medications at 8:00pm on June 15, 2023, and the Polyethylene, Sennoside, Tamsulosin, Arthritis Pain at 8:00am on June 16, 2023. 6. In record review, R3's medical record included medication orders for Amiodarone 200 mg, 1 tablet by mouth QID, Eliquis, 2.5 mg, 1 tablet by mouth BID, Cymbalta 30mg, 1 tablet by mouth at 2pm, and 2 tablets po QHS, Pantoprazole 40mg, one tablet by mouth QD, Miralax 17g in water QD, Crestor 5 mg, one tablet by mouth QD, Swiss Kriss, take two tablets by mouth every morning and one tablet every evening 7. R3's MAR did not include documentation R3 received the medications on June 14, 15, and the morning medications on June 16, 2023. 8. During an interview, the findings were reviewed with E1 and E2, who reported the medications were administered to the residents as ordered; however, the medication administration was not documented on the MAR at the time of administration, as required.