The Pinnacles at Burton

87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: (1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. This requirement is not met as evidenced by:Based on interviews and record reviews, the licensee failed to provide (R1's) Advanced Directives/POLST to EMT on 10/06/25 which lead to hospitalization. This violation poses a potential health, safety, or personal rights risk to residents in care.

87633 Hospice Care of Terminally Ill Residents (d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement is not met as evidenced by:Based on interviews and record reviews, the licensee failed to follow the hospice care plan, as required, by not contacting hospce first during an emergency on 10/06/25 and instead calling 9-1-1, resulting in R1's hospitalization. This violation poses a potential health, safety, or personal rights risk to residents in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental..., that appropriate assistance is provided when such observation reveals unmet needs...This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head impact and a change of conditon was not observed for decline in health condition. This violaiton poses a potential health and safety risk to residents in care.

Call 9-1-1 for imminent health threats

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat... an apparent life-threatening medical crisis...This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head impact due to a fall and no medical attention was provided with a 911. This violaiton poses a potential health and safety risk to residents in care.

Licensee responsibility for records confidentiality

87506 Resident Records(c) All information and records obtained from or regarding residents shall be confidential.(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.This requirement was not met as evidence by: Based on a review of records and interviews, the facility staff failed to ensure (R#1)'s designated representative did not get their records upon request.This poses a potential health and safety risk to all residents in care.

Kitchen sanitation against contamination sources

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in having evidence of vermin in the kitchen area, which poses a potential health risk to persons in care.

Regular observation and documentation of resident changes

The licensee shall ensure that residents are regularly observed for changes in physical,...This was not met as evident by:Facility sent R#1 to hospital 2 weeks after initial fall. Which poses a potential health and safety risk for persons in care.

Knowledge of the requirements for providing care and supervision appropriate to the residents. This was not met as evidence by: Facility sent R#1 to hospital 2 weeks after initial fall. Which poses a potential health and safety risk for persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España and Administrator, Bernice Pulanco observed outdated Emergency Disaster Plan for Residential Care (LIC 610E), which poses/posed a potential health, safety or personal rights risk to persons in care.

RCFE complaint poster posting requirements

Based on observation and interview, the licensee did not comply with the section cited above.Licensing Program Analyst (LPA) David España and Administrator, Bernice Pulanco observed front entryway of the facility to not have a PUB 475 poster meeting size requirements 20”X26,” which poses/posed a potential health, safety or personal rights risk to persons in care.

Hazardous areas restricted from residents

Based on observation and interview, the licensee did not comply with the section cited above.Licensing Program Analyst (LPA) David España and Administrator, Bernice Pulanco observed room 316/317 resident porch with uneven porch floor. Additionally, LPA and Administrator observed both outdoor patios (total of two) with wasps and wasps/hornet nest accessible to residents in care (i.e., exterminator may be required), which poses/posed a potential health, safety or personal rights risk to persons in care.

87463-(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This was not mey as evidenved by Based on observations and interviews due to higher level of carewhich poses a potetial health, safety to persons in care.

87405-h)The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463.This was not met as evidenced byBased observations and interviews no pre appraisal done which poses a potential health, safety to prsons in care