Inspection Reports for
The Pinnacles at Burton

The complaint was substantiated for allegations that staff did not present the resident’s advance directive form to emergency medical personnel and did not follow the resident’s hospice care plan. The allegations regarding medication mismanagement and failure to report the incident to the authorized representative were unsubstantiated.

The investigation substantiated that staff failed to provide Resident #1's advance directive/POLST form to emergency medical personnel and did not follow the resident's hospice care plan by not contacting hospice before calling 9-1-1, resulting in hospitalization. However, allegations of medication mismanagement and failure to report the incident to the authorized representative were unsubstantiated based on interviews and record reviews.

The complaint was received on 2025-09-16 and investigated on 2025-09-24. The allegations included residents sustaining unexplained injuries and staff failing to prevent resident-to-resident injury. The complaint was determined to be unfounded.

The investigation found that residents referenced in the allegations were not listed on the facility roster and are not residents of the facility. Based on the information gathered, the alleged violations were determined to be unfounded.

The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were identified during this inspection visit.

The complaint alleged that the kitchen area was not kept clean and free of pests, with reports of food contamination by pests. Interviews with staff and residents, review of pest control agreements, and inspection of the kitchen found no current pest issues or contamination. The allegation was unsubstantiated.

The investigation included interviews, record reviews, and a facility tour. The majority of staff and residents did not corroborate the allegation, and no evidence of pest activity was observed during the inspection. The facility has a weekly pest control service and trained kitchen staff following safety protocols. The allegation was found to be unsubstantiated due to insufficient evidence.

No deficiencies were cited during this inspection visit. The facility was found to have accurate and complete resident and staff records, current licensing fees, and proper certifications and insurance coverage.

The complaint alleged that staff did not seek timely emergency medical treatment for a resident after an unwitnessed fall with head impact on 2025-01-25 and subsequent incoherence on 2025-01-27, and did not notify the resident's responsible party of condition changes. Additional allegations included failure to provide adequate food and fluids. The investigation found neglect and lack of care and supervision substantiated for the medical treatment and notification allegations, but insufficient evidence to substantiate the food and fluid allegations.

The investigation substantiated neglect and lack of care and supervision related to a resident's fall with head impact where timely medical attention was not sought, and the resident's change in condition was not promptly noticed by staff. Allegations regarding failure to provide adequate food and fluids were unsubstantiated due to insufficient evidence. Deficiencies were cited for failure to immediately call 911 and failure to regularly observe residents for changes in condition.

The complaint alleged that the licensee did not provide copies of resident (R#1)'s records in a timely manner despite multiple requests from the resident's Power of Attorney (W#1). The investigation confirmed partial records were sent but the complete records were not provided, substantiating the complaint.

The investigation found that the facility staff failed to provide complete resident records to the designated representative despite multiple requests and follow-ups. The allegation was substantiated based on interviews, document reviews, and evidence gathered.

The complaint investigation was unannounced and conducted due to allegations including failure to administer medication as prescribed, failure to maintain resident hygiene, leaving residents soiled, failure to provide medical attention after falls, lack of running water, and failure to keep the facility free of pests. All allegations except the pest control issue were unsubstantiated.

All allegations except one were found unsubstantiated after interviews with residents and staff and record reviews. The allegation that the facility did not keep the premises free of pests was substantiated based on observations of live and dead vermin in the kitchen and pest control records indicating worsening cockroach activity.

The Licensing Program Analyst conducted a thorough inspection including a risk assessment for COVID-19, toured multiple floors and resident rooms, and found no deficiencies or citations at the time of the visit.

The complaint investigation was unsubstantiated for all allegations including inadequate food service, unclean facility, improper medication administration, and insufficient nighttime supervision.

The investigation found no sufficient evidence to substantiate any of the allegations. Observations, interviews with staff and residents, and record reviews indicated that food service, cleanliness, medication administration, and nighttime supervision met required standards.

The complaint alleged that a resident sustained multiple fractures while in care and that the facility did not seek timely medical attention. The allegation of multiple fractures was unsubstantiated, but the allegation regarding failure to seek timely medical attention was substantiated based on investigation findings and evidence.

The investigation found that the resident experienced two unwitnessed falls within two weeks, with medical assessments by staff determining no need for emergency services at the time. The resident was taken to the hospital two weeks after the initial fall and was found to have multiple fractures. The allegation of multiple fractures was unsubstantiated due to lack of evidence on when the injuries occurred, but the allegation that the facility did not seek timely medical attention was substantiated. A deficiency was cited related to failure to provide timely medical care.

The inspection found several deficiencies including an uneven porch floor and wasp nests accessible to residents, lack of a required complaint poster in the main entryway, and an outdated Emergency Disaster Plan. Other areas such as linens, bathrooms, kitchen, common rooms, safety equipment, resident and staff files, and medication storage were found to be in good condition.

No deficiencies were observed during the inspection; therefore, no citations were issued. Due to time constraints, a subsequent visit is required.

The facility was found to be in good condition with no observed deficiencies. Infection control practices were properly followed, all resident and staff files contained necessary documentation, medications were properly stored and matched to records, and safety equipment was up to date.

The complaint was unsubstantiated. Allegation #1 regarding unsafe environment was not supported by evidence as the resident's behavior was related to a known mental condition and managed by the facility. Allegation #2 regarding lack of night supervision was disproven by staff schedules and interviews confirming adequate night staffing.

The investigation included interviews, record reviews, and facility tours. It was found that one resident has a mental disorder causing yelling and screaming, but this was not due to distress and the facility has a care plan in place. The facility does have adequate night supervision with staff present 24/7. The allegations were not substantiated due to lack of preponderance of evidence.

No deficiencies were observed during the inspection. The facility was found to be in good repair with proper infection control measures, adequate supplies, and compliance with safety regulations.

The complaint investigation was substantiated. The allegation was that a resident was illegally evicted by being sent to the hospital and not allowed to return due to needing a higher level of care. Interviews and record reviews confirmed the facility did not reassess the resident or notify the family, and the resident's condition was prohibited for continued care at the facility.

The allegation of illegal eviction was substantiated. The investigation found that a resident with an unstageable pressure wound was sent to the hospital due to the facility's inability to provide the necessary higher level of care. The facility did not perform a reassessment or notify the resident's family about the worsening condition, which posed a potential health and safety risk.