Pinnacle Peak Senior Living.

“Based on observation and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed E4 rotating R6 to R6’s side in bed to check if R6 needed assistance with incontinence care. The COs observed no caregiver supervision during this interaction. 2. In an interview, E1 reported E4 was an assisted caregiver. 3. A review of E4’s personnel record revealed a caregiver certificate was not available. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1’s medical record revealed a service plan dated for June 26, 2025 did not include a signature from the resident or R1's representative. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed the following unlocked medication in the facility: antifungal powder on the counter in a common area; A & D ointment and Calmoseptine ointment in the bathroom cabinet of R2; Triamcinolone ointment, Fleet Laxatives glycerin suppositories, and Aleve pain reliever tablets in the bathroom of R5. 2. A review of R2 and R5's medical record revealed R2 and R5 did not self-administer the listed medication. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.  4. This is a repeat deficiency from the inspection conducted on January 30, 2024.”

“Based on observation, record review, and interview, the manager failed to ensure the premise was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to the resident.   Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed R1 had a half-bed rail on the right side of R1's bed in the upright position. 2. A review of R1’s medical record revealed a service plan that revealed R1 received directed care services. R1's service plan indicated R1 required half-bed rails for repositioning. 3. In an interview with R1, when asked if R1 knew how to let down the bed rail, R1 replied no. When asked if the bed rail prevented R1 from exiting the bed, R1 replied yes. 4. In an interview, E3 reported R1 needed to have the bed rail due to behavioral issues that would cause R1 to injure themselves without the bed rail and R1 was a fall risk. 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were stored in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed the following toxic materials unlocked throughout the facility: Shout Advanced stain scrubber laundry stain remover gel (stored by the facility) in the bedroom of R4; A container of cleaning products (such as Windex and toilet bowl cleaner); a bottle of nail polish remover in a caregiver room that was left unlocked; Febreeze air freshener left in common areas; and Colorox disinfecting wipes left in common areas. 2. The COs observed residents present at the facility who were receiving directed care services and were ambulatory. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;”

“Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed in the facility's kitchen two unlocked cabinets above the counter that could easily be opened. In the cabinets were bottles of medications for all ten residents. Additionally, the medication cart located in the dinning room area, was found to be unlocked and had a key in the key lock. The medication cart also contained medications for the residents. 2. In an interview, E2 acknowledged the medications were not stored in a locked cabinet which posted a health and safety risk.”