Inspection Reports for
The Pointe at Summit Hills

The complaint investigation was substantiated for the allegation that staff did not assist residents with medication consumption. The allegation that medication was not administered timely was unsubstantiated.

The allegation that staff did not assist residents with consuming medication was substantiated based on interviews and record reviews. The allegation that staff did not administer medication in a timely manner was unsubstantiated due to lack of sufficient evidence.

The complaint alleging staff mishandled a resident's medication was substantiated based on records and interviews. The preponderance of evidence standard was met.

The investigation found that a resident (R1) missed a medication for October 2025 without a doctor's order to discontinue or hold it, and staff did not contact the doctor regarding the missed medication. The allegation was substantiated and deficiencies were cited.

The analysts observed bleach and other sanitizing cleaning products stored on a separate shelf from food products in the facility pantry. A Technical Violation was reviewed with the Administrator during the exit interview.

The complaint investigation was substantiated for improper food storage but unsubstantiated for serving expired foods and unsafe food handling practices.

The investigation substantiated the allegation that staff were not properly storing foods, with evidence of expired and improperly dated food items found in the refrigerator. The allegations that staff served expired foods and did not practice safe food handling procedures were unsubstantiated based on interviews and observations.

The visit was triggered by a complaint and was an unannounced subsequent complaint investigation. Deficiencies were substantiated as cited.

The facility was found noncompliant with medication administration and storage requirements, posing immediate health and safety risks to residents. Deficiencies were cited related to failure to administer medications as prescribed and unsecured medication storage.

The facility was generally clean and well-maintained with proper food storage and fire safety measures. However, medication management deficiencies were found involving inaccurate pill counts and improper storage of medications in non-original containers.

The facility was generally clean and well-maintained with proper food storage and medication security. However, a deficiency was found regarding the lack of a written Home Health Care plan agreement for one resident.

The complaint alleged that staff did not allow the resident to receive private phone calls. The allegation was substantiated based on interviews and record reviews.

The investigation substantiated that the facility did not ensure the resident had reasonable privacy during a phone call, violating personal rights. A plan of correction was reviewed and discussed with the facility.

The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

The investigation found insufficient evidence to substantiate the allegations of neglect. However, a deficiency was identified during the investigation.

This was a complaint-related investigation where deficiencies were substantiated regarding failure to call emergency services after a resident fall resulting in fracture.

The facility failed to immediately call emergency services after resident R1 fell and sustained a fracture, which poses an immediate health and safety risk to residents.

The complaint investigation was substantiated based on interviews, records review, and photographic evidence. The allegations of staff locking a resident inside their room and over medicating were confirmed.

The investigation substantiated the allegations that staff locked a resident inside their room as evidenced by a sign on the resident's door stating to keep it locked at all times. Additionally, the facility failed to document the times morphine was administered to the resident, violating medication administration requirements.

The complaint investigation was substantiated for allegations of improper room maintenance, inadequate bedding and laundry services, medication mishandling on specified dates in May, and failure to provide timely access to resident records. Other allegations were unsubstantiated due to lack of evidence.

The investigation substantiated deficiencies related to improper maintenance of a resident's room, failure to provide appropriate bedding, inadequate laundry services, missed medication administration on multiple dates, and delayed authorized representative access to resident records. Other allegations such as pressure injury prevention, heart monitor handling, and room locking were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for neglect and lack of care resulting in multiple resident falls and injuries, inadequate laundry services, delayed staff response, medication administration failures, incomplete medical records, and failure to provide documents timely. Some allegations regarding pressure injury, unsafe bedding, medication storage, and resident wandering were unsubstantiated or unfounded.

The investigation substantiated multiple allegations including neglect resulting in resident falls and injuries, failure to maintain a clean and clutter-free environment, inadequate laundry services, delayed staff response to resident calls, missed medication administration and refills, incomplete medical records, and failure to provide requested documents timely. Some allegations related to medication storage and resident wandering were unsubstantiated or unfounded.

The complaint investigation was substantiated for failure to timely answer call bells, leaving residents in soiled diapers causing rashes, and failure to return calls to authorized representatives. Other allegations about timely showers and residents left on the floor were unsubstantiated due to lack of evidence.

The investigation substantiated that staff failed to respond timely to call bells, with one resident's call bell unanswered for over 6 hours and another call never acknowledged. The resident was also left in soiled diapers causing a rash. Additionally, the facility failed to maintain accurate emergency contact information and did not return calls to the resident's responsible party. Other allegations regarding timely showers and residents left on the floor were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated based on interviews and photographic evidence. The allegation that staff did not properly clean and sanitize a resident's restroom was confirmed.

The investigation substantiated that staff did not ensure the resident's restroom was properly cleaned and sanitized, with evidence including feces smeared on the toilet seat, trash can, and a soiled depend left on the bathroom counter, posing health and safety risks.

The complaint investigation found the facility lacked a qualified Administrator. Staff Griselda "Gracie" Ramirez was reviewed for designation as Administrator but did not meet experience requirements. The deficiency was substantiated and a plan of correction was required.

The facility was found to not have a current Administrator who meets the required qualifications. A deficiency was issued related to Administrator qualifications.

The complaint was substantiated based on the preponderance of evidence standard after interviews and record reviews. The facility was cited and issued a plan of correction.

The Licensing Program Analyst conducted interviews and record reviews and found the allegations to be substantiated. The facility was cited and issued a plan of correction.

The complaint investigation was substantiated. Allegations included a resident eloping without supervision, improper disposal of soiled depends, and missed medications. Some allegations about daily clothing changes and medication swallowing were unsubstantiated due to lack of evidence.

The investigation substantiated that a resident with dementia eloped unsupervised, soiled depends were improperly disposed of in an uncovered trash can, and multiple medication errors were documented. Some allegations regarding daily clothing changes and medication swallowing were unsubstantiated due to insufficient evidence.

The facility failed to provide adequate care and supervision for resident R1, who left the facility unsupervised from 6:40 AM to 5:25 PM. Civil penalties were issued for this violation.

The inspection found deficiencies related to medication administration errors and staff training requirements. The facility had a medication error involving a resident and several staff were not up to date with required annual training.

The complaint investigation was unannounced and based on allegations including passageway obstructions, pests, resident showering, medication errors, insufficient PPE supply, and cleanliness. Most allegations were unsubstantiated except for the cleanliness issue which was substantiated.

The investigation found most allegations unsubstantiated, including passageway obstructions, pests, resident showering, medication errors, and PPE supply. However, the complaint that the facility was not maintained clean and sanitary was substantiated due to stained carpets and urine odor in specific resident rooms.

The complaint was substantiated as the family member reported Resident R1 ran out of medication 2 days ago and the facility had not refilled it, which was confirmed by medication records and staff interview.

The inspection found that Resident R1 had missed a minimum of 15 doses of prescribed medication due to the facility not refilling the medication on time. A deficiency was cited for failure to arrange timely medical care and medication refills.

The Licensing Program Analyst found that resident R1 missed a dose of Med1 due to medication being out of stock and a pharmacy refill issue. Staff did not administer the liquid form of Med1 received, and the medication administration record was inaccurately initialed. The facility did not confirm medication administration and did not inquire about tablet refills after the family provided over-the-counter medication.

The complaint was substantiated based on interviews and records review. Specific findings included failure to administer Resident 1's medication for three days, delayed administration of Resident 6's medication, and incorrect medication given to Resident 7. The preponderance of evidence standard was met.

The investigation substantiated the complaint that the facility failed to administer prescribed medications to residents on multiple occasions, including missed doses and administration of incorrect medication, posing an immediate health and safety risk.

This visit was a follow-up to two complaint investigations (24-AS-20220808110307 and 24-AS-20221110085240) regarding delayed staff response and medication errors. The medication error incident report was not submitted as required.

The facility was found to have delayed response times to resident call buttons, with staff responding between 30 minutes to an hour instead of the expected 10-15 minutes. Additionally, the facility failed to submit an incident report to Community Care Licensing after a medication error involving a resident.

The complaint investigation was substantiated based on interviews and record reviews. The allegation of medication mismanagement was confirmed.

The investigation substantiated the allegation that the facility mismanaged resident R1's medication, causing a delay in refill and the resident not receiving medication on time, posing an immediate risk to health and safety.