Inspection Reports for
Heritage Gardens

The inspection found the facility generally maintained physical plant and food service standards, but noted a technical violation related to hot water temperature and deficiencies in medication administration practices. Five resident and five staff files were complete. Deficiencies and a technical violation were cited per California Code of Regulations.

The complaint involved a verbal altercation on April 4, 2025, where CNA 1 used multiple expletives towards Resident 1. The incident was witnessed by another staff member and the resident. The CNA was separated from employment on April 9, 2025. The facility policy prohibits such behavior, and the CNA's actions were deemed inappropriate.

The facility failed to ensure Resident 1 was treated with respect and dignity when CNA 1 engaged in a verbal altercation using profanity. The incident was confirmed by staff and resident statements, and the facility acknowledged the CNA's response was inappropriate and against policy.

The facility was generally well maintained with adequate physical plant conditions, food service, and health-related services; however, deficiencies were cited for medication administration practices and incomplete staff files.

The facility failed to ensure that a Licensed Vocational Nurse (LVN 2) maintained an active and current license, as the nurse worked with an expired license over a period of time. This posed a potential risk to 101 vulnerable residents.

The facility failed to complete timely Significant Change of Status Assessments, accurately code Minimum Data Set assessments for medications, implement therapy recommendations, obtain physician orders for oxygen therapy, maintain proper infection control practices, ensure staff licensure was current, and follow hand hygiene protocols. These deficiencies posed potential risks of delayed care, inaccurate resident assessments, infection, and compromised resident safety.

The facility failed to implement its blood glucose monitoring policy for one of four sampled residents, resulting in a delayed blood sugar check that may have contributed to the resident's transfer to an acute hospital. The facility acknowledged non-adherence to physician orders and its own policy.

The complaint investigation was based on allegations that facility staff did not meet resident's incontinence care needs and did not safeguard resident's belongings. The incontinence care allegation was unsubstantiated, while the safeguarding allegation was substantiated. The facility reimbursed the resident for missing furniture on 03/14/2024.

The allegation that staff did not meet residents' incontinence care needs was found to be unsubstantiated due to insufficient evidence. However, the allegation that staff did not safeguard resident's belongings was substantiated, as resident #1's dresser/mirror and night stand were documented missing and the facility reimbursed the resident for the missing furniture.

The complaint investigation was based on allegations that facility staff did not meet resident's incontinence care needs and did not safeguard resident's belongings. The incontinence care allegation was unsubstantiated, while the safeguarding allegation was substantiated with evidence including staff and resident interviews and record review.

Two allegations were investigated: one regarding unmet resident incontinence care needs, which was found unsubstantiated due to insufficient evidence; and another regarding failure to safeguard a resident's belongings, which was substantiated as the facility lost resident #1's dresser/mirror and night stand and reimbursed the resident for the missing furniture.

The facility failed to follow its ADL policy to ensure proper grooming and personal hygiene for one sampled resident, resulting in notably long and unclean fingernails, which posed a potential risk for infection.

The complaint was substantiated based on observation, interviews with CNA 1, LVN 2, and the Director of Nursing, and review of Resident 1's care plan and facility policies. CNA 1 admitted to placing the sheet to prevent Resident 1 from digging into her pants, which was not the correct measure. LVN 2 confirmed the incident and reported it to the Director of Nursing.

The facility failed to follow its policy and procedure for restraints, resulting in the inappropriate use of physical restraints on Resident 1. This failure posed potential risks including decreased mobility, circulation issues, psychological harm, and even death. Interviews and record reviews confirmed the incident and the facility's policy was not followed.

The facility was inspected overall including physical plant, food service, care and supervision, record review, and medical related services. One deficiency was cited for failure to maintain a health screening with tuberculosis results for staff #1 (S1).

The complaint investigation was substantiated by observations, interviews, and record reviews. CNA 1 admitted to using profanity around Resident 1, which compromised the resident's dignity and rights. The facility took disciplinary action against CNA 1, including potential termination if the behavior recurs.

The facility failed to ensure Resident 1 was treated with respect and dignity when CNA 1 used profanity around her. The CNA admitted to using profane language, and the facility took disciplinary action against the CNA, emphasizing the expectation that all staff treat residents with kindness, respect, and dignity.

No immediate health and safety concerns were observed; however, a deficiency was cited because the Administrator, Jaclyn Nava, did not have an Administrator Certification, though she provided verification of course completion and stated she would submit the certification application the same day.

No immediate health and safety concerns were observed; however, a deficiency was cited because the Administrator, Jaclyn Nava, did not have an Administrator Certification at the time of the visit.

The complaint involved an alleged abuse incident where a CNA slapped Resident 3's leg. The CNA was not suspended immediately after the allegation was reported, allowing potential for further abuse. The allegation was reported by a housekeeper and investigated by the facility, Ombudsman, Sheriff, and Department of Public Health. The CNA stated she was not assigned to Resident 3 but was asked to continue working. Facility staff acknowledged failure to follow policy requiring immediate suspension of accused employees.

The facility failed to ensure immediate protective measures by not suspending the CNA immediately after the alleged abuse to Resident 3 was reported. The CNA continued to have access to the alleged victim and other residents during the investigation, contrary to facility policy.

The facility failed to protect 92 clinically compromised residents when a treatment cart containing medications and biologicals was left unlocked and unattended by a licensed nurse, posing a risk of unauthorized access to harmful chemicals.

The complaint investigation found substantiated failure of staff to wear N95 masks in COVID-19 positive rooms, confirmed by observations and interviews with staff including CNA1, LVN1, Director of Staff Development, Infection Preventionist Nurse, and Administrator.

The facility failed to ensure staff adhered to infection prevention protocols by not wearing N95 masks in COVID-19 positive rooms, increasing the risk of virus transmission to a compromised resident. Multiple staff interviews and observations confirmed non-compliance with PPE requirements.

The facility failed to provide sufficient nursing staff on three of twelve sampled days in August 2023, with direct care service hours per patient day below the required 3.5 hours. This staffing deficiency had the potential to result in unmet psychosocial and physical needs and safety concerns for 101 residents. The facility's staffing policy was not followed as acknowledged by the Director of Nursing.

The complaint was substantiated regarding medication errors where a staff member mixed up a resident’s medication and delivered medication on a food tray to a resident that was not prescribed by a doctor. The complaint regarding failure to follow residents' modified food diets was unsubstantiated.

The allegation that staff dispensed medication not prescribed to residents was substantiated with one deficiency cited related to personnel training on medication administration. The allegation that the facility did not follow residents' modified food diets was unsubstantiated with no deficiencies cited.

The complaint was substantiated regarding medication errors where a staff member mixed up residents' medications. The complaint about failure to follow residents' modified food diets was unsubstantiated.

The allegation that staff dispensed medication not prescribed to residents was substantiated, with evidence that medication was delivered to the wrong resident. One deficiency was cited related to personnel training on medication administration. The allegation that the facility did not follow residents' modified food diets was unsubstantiated, with evidence showing residents' diet preferences were being served.

The facility was found deficient in multiple areas including call light accessibility for residents, privacy breaches in medication communication, inaccurate resident assessments, failure to provide ordered physical therapy, improper enteral nutrition administration, medication labeling and storage issues, medication errors, dietary service deficiencies including food texture and sanitation, incomplete medical records, infection control lapses, and kitchen equipment maintenance problems.

The complaint was substantiated based on interviews and record review. The allegation that staff were not providing a resident with diapers was found valid.

The investigation found that the facility knowingly provided a resident (R1) with the wrong sized pull-up diapers from May 16, 2022 to June 7, 2022, causing pain and failing to manage incontinent care properly. The allegation was substantiated and one deficiency was cited.

The complaint was substantiated based on interviews and record review. The allegation that staff were not providing the resident with diapers was found valid.

The investigation found that the facility supplied the resident with the wrong sized pull-up diapers from May 16, 2022 to June 7, 2022, causing pain to the resident. The allegation was substantiated and one deficiency was cited related to failure to provide appropriate incontinent care products.

The complaint investigation included two allegations: 1) Staff are not providing residents with diapers and liners, which was unsubstantiated. 2) Staff are not following doctors' orders, which was substantiated with evidence of missed treatment on 5/10/2020.

The allegation that staff did not provide residents with diapers and liners was unsubstantiated due to lack of preponderance of evidence. The allegation that staff did not follow doctors' orders was substantiated, with evidence that treatment was missed on one day due to lack of skilled staff.

The complaint investigation was initiated based on allegations received on 2020-05-08. One allegation regarding failure to provide diapers and liners was unsubstantiated. Another allegation regarding failure to follow doctors' orders was substantiated.

The allegation that staff were not providing residents with diapers and liners was unsubstantiated due to lack of preponderance of evidence. However, the allegation that staff were not following doctors' orders was substantiated, as staff failed to apply a prescribed topical treatment on one occasion due to lack of skilled professional staff.

The facility was found deficient in multiple areas including failure to notify physicians of lab results, medication administration errors leading to neglect, inaccurate resident assessments, failure to follow medication orders, inadequate pain management documentation, improper handling of home medications, food safety and sanitation issues, improper waste disposal, and infection control lapses.