Heritage Pointe

Document required significant condition changes

Per CCR 87463(b), “the reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition”. This requirement is not met as evidenced by: Based on records reviewed, R1 was never assessed to be a fall risk in spite of multiple occurrences of falls between May 2023 and January 2024, at least one of which resulted in an injury. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Report specified resident events within seven days

Per CCR, “Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency (…) within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident (…)” This requirement was not met as evidenced by: Multiple fall incidents including instances that resulted in injury and/or hospitalization were not reported to the Department. This constitutes a potential

Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that Staff #1 (S1) did not have any annual training on file for the year of 2025.

Maintain facility in clean, safe, sanitary condition

Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that one delayed egress door in the memory care portion was non-operational at time of visit.

Address and clearance obligations before facility work

Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that Staff #11 (S11), Staff #12 (S12), Staff #13 (S13). Staff #14 (S14), Staff #15 (S15), and Staff #16 (S16), were not criminal background cleared or associated to the facility.

Update reappraisal at required intervals

Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the Reappraisals on file for Resident #2 (R2), Resident #6 (R6), and Resident #7 (R7) were outdated and need to be updated.

Assist residents with self-administered medication

Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the facility did not have Resident #11 (R11) Quetiapine Fumarate 25 MG medication present at the facility, despite R11 having an active order for the medication. LPA observed the facility did not have Resident #12 (R12) Fluticasone 50 MG medication, Milk of Magnesium, or Polyethylene, present at the facility, despite R12 having active orders.

Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During a tour of the kitchen, LPA observed one staff preparing food without a hairnet. The staff advised LPA that they did not have any hairnets and that they had to be ordered.

Regular observation and documentation of resident changes

Per CCR87477 Observation of the resident: "The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs." This requirement is not met as evidenced by the fact that R1's four broken teeth went unnoticed until they were diagnosed during a dentist visit organized by R1's responsible party. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Per CCR Section 87618(b)(1) on Oxygen Administration: "the licensee shall be responsible for the following: Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders". This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not monitor R1's ability to operate their oxygen equipment and failed to provide timely assistance. This constitutes a potential risk to the health, safety and personal rights of residents in care,

Care and supervision as defined by statute and rules

Per CCR 878464(f)(1) on Basic Services: "Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)". This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, instances of excessive response times were recorded for resident R1 over the reviewed period of January 2022.This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Per CCR 878464(f)(1) on Basic Services: "Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)". This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, multiple instances of excessive response times were recorded.This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Dignity in personal relationships

Per CCR (a) 87468.1(a)(1) defining Personal Rights: "Residents in all RCFE shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons". This requirement was not met as evidenced by: Based on staff and resident interviews conducted, staff member S1 was responsible of inappropriate behavior towards multiple residents. This constitutes a potential risk to the health, safety and personal rights of residents in care.

"Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety or welfare would be endangered.This requirement is not met as evidenced by: Based on staff interviews and records review, the licensee did not comply with the section cited above as residents' medications are not being dispensed as prescribed, which poses an immediate health, safety, and personal rights risk to persons in care.

Maintain separate complete record for each resident

(a) The licensee shall ensure that a separate, complete, and current record is maintained...This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the section cited above as four of nine resident MARs were observed to be incomplete, which poses a potential health, safety, and personal rights risk to persons in care.

Report specified resident events within seven days

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as an incident report was not submitted within seven days following a medication error which poses a potential health, safety, and personal rights risk to persons in care.

Based on a review of a sample of resident records, the licensee did not comply with the section cited above as two physician reports reviewed in a total of 10 had been conducted more than a year prior to the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.

The California Code of Regulations Section 87507(g)(3)(B)(2) states that: "A separate charge (...) may be assessed only if that charge is included in and authorized by the admission agreement." In the absence of the agreement and due to the COVID waivers in place at the time, the separate (...) charges for tray services should not have been assessed as observed on billing documents. This constitute a potential risk for the health, safety and personal rights of residents in care.

The California Code of Regulations Section 87464(f) on Basic Services states that: “Basic services shall at a minimum include care and supervision [meaning] (...) responsibility for (...) ongoing assistance with ADLs without which the resident’s physical health(...) would be endangered. Assistance includes (...) taking medication”This requirement is not met as evidenced by records reviewed at the facility and interviews conducted with staff confirmed that resident R1 was left out of Medication Management for after being assessed to require ongoing assistance with medication.

Fire approval and staff access to unlock systems

The California Code of Regulations Section 87705 states that: "(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, (...) and toxic substances (...)." This requirement is not met as evidenced by: Based on observations and interviews conducted during the initial inspection, substances falling under this regulation were found in two Memory Care bathrooms. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Telephone service and directory listing requirements

The California Code of Regulations 87311 Telephones states that: "All facilities shall have telephone service on the premises." This requirement was not met as evidenced by: Based on a majority of interviews conducted, telephone outages have been a common occurrence throughout the first semester of (...) the calendar year 2022 after a new phone system was installed by the facility. This posed a potential risk to the health, safety and personal rights of the residents in care.

Assist residents with self-administered medication

The California Code of Regulations Section 87465(a)(4) on Incidental Medical and Dental Care states that: “The licensee shall assist residents with self-administered medications as needed.” This requirement is not met as evidenced by the delay observed in the implementation of the resident’s transition into Medication Management.

The California Code of Regulations Section 87464(f) on Basic Services states that: “Basic services shall at a minimum include care and supervision [meaning] the facility assumes responsibility for (...) ongoing assistance with activities of daily living without which the resident’s physical health(...) would be endangered. Assistance includes (...) taking medication”This requirement is not met as evidenced by records reviewed at the facility and interviews conducted with staff confirmed that resident R1 was left out of Medication Management for 16 months after being assessed to require assistance with self-administration.

Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1,Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. CONTINUED BELOW This requirement was not met as evidenced by:Resident's call light alarm in Room 6A was not nswered in a timely manner. Based on LPAobservation and interviews which were conducted, resident call light alarms are not answered in a timelymanner. This poses a potential health, CONTINUED ...