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 investigation was triggered by observations of three residents experiencing unwitnessed falls on 09/11/2025, 09/12/2025, and 09/13/2025, which were not reported to the Department as required. The violation was substantiated and cited.

The facility was found noncompliant with Title 22 regulations, specifically Section 87211(a)(1)(D) regarding reporting requirements. Three residents experienced unwitnessed falls that were not reported, posing a potential health and safety risk. A deficiency was cited and a civil penalty issued.

The visit was triggered by complaint #11-AS-20250909091421. The investigation substantiated noncompliance with Title 22 regulations and identified deficiencies.

The facility was found not in compliance with Title 22 regulations, resulting in several deficiencies and a civil penalty. The administrator failed to meet qualifications and duties, posing a potential health and safety risk to residents.

The complaint alleged that the facility did not report incidents involving Resident #1 eloping from the premises and subsequent hospitalizations. The allegation was substantiated based on interviews, record reviews, and verification with the Community Care Licensing Regional Office.

The investigation substantiated that the facility failed to report incidents involving Resident #1, including elopements and hospitalizations, to Community Care Licensing as required. Interviews and record reviews confirmed the incidents and lack of reporting, posing an immediate health and safety risk.

The complaint alleged that staff did not seek timely emergency medical treatment for Resident #1 after a fall with head impact on January 25, 2025, and did not notify the resident's responsible party of the change in condition. Additional allegations included failure to provide food and fluids to the resident. The investigation found the neglect and lack of care and supervision substantiated for the medical treatment and notification allegations, but unsubstantiated for food and fluid provision.

The investigation substantiated that staff failed to seek timely emergency medical treatment and failed to notify the resident's responsible party of a change in condition following a fall with head impact. However, allegations regarding failure to provide food and fluids were unsubstantiated due to insufficient evidence. The facility was found to have violated regulations related to medical emergency response and resident observation.

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 records in a timely manner. The designated representative of resident (R#1) requested records multiple times starting February 24, 2025, but only partial records were provided by March 19, 2025. The allegation was substantiated based on interviews and record reviews.

The investigation found sufficient evidence to substantiate the allegation that the facility staff failed to provide complete resident records to the designated representative in a timely manner, posing a potential health and safety risk to residents.

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 addressed 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 pest infestation. All allegations except the pest infestation were unsubstantiated based on interviews and record reviews. The pest infestation allegation was substantiated.

All allegations except one were found unsubstantiated after interviews with residents and staff and record reviews. The allegation that staff did not keep the facility 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 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 inspection found that the facility conducts medication audits during shift changes but did not include surplus medications in regular audits. On 2024-05-07 and 2024-05-08, significant quantities of Oxycodone tablets were missing from Resident #1's surplus medication. Law enforcement was notified and visited the facility. The facility did not submit an Unusual Incident Report for the missing tablets. No citations were issued during this visit.

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.

The inspection found several deficiencies including an uneven porch floor and wasp nests accessible to residents, lack of a properly sized complaint poster at the front entryway, an outdated emergency disaster plan, and other minor issues. Safety equipment and resident files were found to be in order, but citations were issued due to the deficiencies.

The complaint 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. The investigation confirmed the facility did not perform required reassessments and failed to communicate with the resident's family.

The allegation of illegal eviction was substantiated. The investigation found that a resident was sent to the hospital due to needing a higher level of care and was not able to return to the facility. The facility failed to conduct a reassessment and did not contact the resident's family regarding the worsening condition, which posed a potential health and safety risk.

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.