Avir at Heritage Oaks

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 8 confidential residents (R#1, R#4, and R#6) in that: The facility failed to ensure staff were informed there was a working shower in the facility for residents reviewed for showers in 4 of 4 hallways (Halls AA, BB, CC, and DD). This could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident with food and drink that was palatable, attractive and at a safe and appetizing temperature for 5 of 8 confidential residents (Residents #1, #2, #3, #4, and #5) reviewed for food palatability in that: Residents #1, #2, #3, #4, and #5 voiced concerned about cold food and bread that was wet, soggy, and not toasted. This failure could result in a decline in residents' consumption of food, cause residents unwanted weight loss, and/or food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 5 of 8 confidential residents (R#1, R#2, R#3, R#4, and R #5) reviewed for meals. Residents #1, #2, #3, #4, and #5 voiced concerned about not having plates, cups, and eating utensils. These failures could result in a decline in residents' consumption of food and cause residents unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 meal (lunch meal on 6/10/2026) reviewed for meal accuracy, in that: 1. The facility failed to ensure the correct meal was served on 6/10/2026 according to the prepared menu for lunch for 108 residents. 2. The facility failed to ensure staff followed the correct weekly prepared menu. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 2 (4/24/2026 and 4/25/2026) of 30 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours on 4/24/2026 and 4/25/2026. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 9 confidential residents in that:The facility failed to ensure staff were not on their personal cell phones while providing care, which included assisting residents with their showers. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 5 of 33 residents ( Residents #30, #32, #93, #127, and #130) reviewed for resident rights . The facility failed to obtain signed informed consent based on information of the benefits, risks, and options available for Resident #30, #32, #93, #127, and #130 prior to administering psychotropic medication. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 3 of 6 residents (Residents #1, 5, and 6) reviewed for advanced directives. The facility failed to ensure Residents #1, #5, and #6 who was listed as DNR (Do Not Resuscitate), had an Do Not Resuscitate form that did not have missed required information. These failures could place residents at risk of not having their end-of-life wishes honored and incomplete records.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public, for 2 of 3 showers (Wildflower and Magnolia) and 2 of 12 rooms (rooms [ROOM NUMBERS]). The facility failed to ensure the Magnolia Shower had been repaired for approximately 4 months. The facility failed to ensure the showers in Magnolia and Wildflower units were held between water temperatures of 100-110 F degrees. The facility failed to ensure the bathroom sinks hot water in rooms [ROOM NUMBERS] were held between water temperatures of 100-110 F degrees. These failures could place residents at risk for lack of home-like environment and comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make information on how to file a grievance or complaint available to the residents for 9 of 9 confidential residents reviewed for grievances. The facility failed to ensure 9 of 9 residents were provided, through postings in prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food and drink that was palatable, attractive and at a safe and appetizing temperature for 5 residents (Residents #8, #60, #99, #101, and 1 confidential resident) reviewed for food palatability. one of one kitchen. A. Resident #8, #60, #99, #101 voiced concerned of cold food, flavor and/or texture. B. Nine of the 9 foods sampled on the meal tray were cold. C. One of the 9 foods sampled on the meal tray was mushy. D. Three of the 9 foods sampled on the meal tray had no flavor. E. Three of the 9 foods sampled on the meal tray were chunky. F. One of the 9 foods sampled on the meal tray was tough. These failures could result in a decline in residents' consumption of food and residents to have unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the garbage can used for food waste was covered unless in use. 3) The facility failed to ensure the hair restraint was properly worn. 4) The facility failed to ensure the dish and pot washing area were clean. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (#1 and #2), in that: The door for dumpster #2 was left open. Garbage and debris in the vicinity of the 2 dumpsters. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #58 and Resident #29) reviewed for infection control. CNA D failed to utilize EBP and hand hygiene during foley catheter (a flexible, sterile tube inserted into the bladder to drain urine, held in place by an inflated balloon) care on Resident #58. CNA E failed to utilize glove change and hand hygiene during incontinence care on Resident #29. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for respect and dignity. CNA C failed to provide privacy to Resident #1 when CNA C left Resident #1 naked in bed with the door open on 3/15/2026. This failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from abuse and/or neglect for 1 of 6 residents (Resident #1) reviewed for abuse and/or neglect. MM A told Resident #1 to get the fuck out of my face on 3/20/2026. This failure could cause residents emotional distress, a decrease in their health conditions, or exacerbation of their health conditions.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 7 residents reviewed for comprehensive care plans. The facility failed to revise Resident #1's care plan, a resident with an active Stage IV pressure ulcer, to reflect the use of a pressure-relieving mattress that was ordered by the physician on 11/8/25. This failure could place residents at risk for unclear staff guidance, inconsistent implementation of care, inadequate monitoring, delayed wound healing, and potential worsening or development of additional pressure injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 7 residents reviewed for smoking. (Resident #1)The facility failed to ensure Resident #1 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk of injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 19 of 22 confidential residents. The facility failed on 03/07/2025 to ensure 19 of 22 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 4 of 6 residents (Resident #2, Resident #63, Resident #71, and Resident #86) and 3 of 3 staff (LVN E, CNA H, CNA I) reviewed for infection control. 1. CNA H failed to follow policy and procedure for handwashing while providing peri care for Resident #2, during observations of peri care on 03/06/2025 at 1:42 PM. 2. LVN E failed to follow policy and procedure for handwashing while providing wound care for Resident #63, during observations of wound care on 03/05/2025 at 11:33 AM. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 32 residents (Resident #98) reviewed for dignity issues: The facility did not place a urinary catheter drainage bag in a privacy bag to screen/cover it from view for Resident #98 on 03/06/2025 and 03/07/2025. This failure placed residents in the facility, with urinary catheters, at risk of feeling uncomfortable or embarrassed and decreased privacy.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 32 residents (Resident #2,) reviewed for Respiratory Care. 1. The facility failed to follow physician's orders indicating Resident #2's oxygen humidification bottle should be monitored every shift and replaced or refilled as needed on 03/05/2025. 2. The facility failed to follow physician's orders indicating Resident #2's nasal cannula and oxygen tubing should be changed weekly on 03/05/2025 and 03/06/2025. These deficient practices have the potential to affect residents by placing them at an increased risk of respiratory infection, respiratory distress, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to change gloves and wash hands while preparing snack sandwiches on 03/05/2025 at 11:15 AM. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 residents (Residents #2 and #3) reviewed for infection control. 1. CNA A failed to utilize proper hand hygiene during incontinence care for Resident #2 2. CNA B failed to utilize proper hand hygiene during incontinence care for Resident # 3. These failures could place residents at risk for infection and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 2 resident for dignity and catheter care (Resident #64 and Resident #106); in that: 1. The facility failed to ensure respect and dignity to Resident #64 by LVN D knowingly leaving him lying in feces for over an hour, when he had a bowel movement during wound care. 2. The facility failed to place catheter tubing off the floor and place a cover on the catheter. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 3 of 3 residents (Resident #102, #106, and #276) reviewed for privacy issues in that: 1. Housekeeper failed to knock and introduce herself prior to entering Resident #276 room. 2. NA failed to provide privacy by not pulling curtain all the way for Resident #102 during perineal care. 3. LVN E failed to pull the privacy curtain while providing wound care for Resident #102. 4. LVN G failed to pull the privacy curtain while providing wound care for Resident #106. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were accurately acquired, received, dispensed, and administered in accordance with currently accepted professional standards for 2 of 3 medication carts (Wildflower Cart A and B) , 2 of 2 medication rooms (Wildflower Med room A and Rapid med room B) and 1 of 1 treatment cart (Treatment cart A) reviewed. 1. The facility failed to ensure that all medical supplies stored in Cart A were not past their expiration date. 2. The facility failed to ensure that all medication stored in Cart B were not past their expiration date. 3. The facility failed to ensure that all medication stored in Medication room A were not past their expiration date. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 3 medication carts (Sunflower cart C), and 1 of 2 medication rooms (Rapid med room B) reviewed. 1. The facility failed to ensure proper temperature documentation of the refrigerator in Medication room B. 2. The facility failed to ensure all medication in Medication Cart C were properly labeled. These failures placed all residents at risk of harm or decline in health due to lack of medication labeling, and inadequate temperature monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable and attractive for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (2/21/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 of Residents (Resident #52, #61, #72, and #102) observed for infection control for 4 0f 8 resident's reviewed for infection control practices (Resident #52, #61, #72, and #102). 1. CNA A failed to wash her hands before, during, and after incontinent care of Resident #52. 2. LVN E failed to wash her hands properly. She turned on water, placed soap on hands, and immediately started washing hands under running water and not allowing soap to lather. LVN E used a dirty paper towel to turn off the faucet after wound care for Resident #102. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from neglect for 1 of 1 resident (Resident #64), reviewed for neglect when LVN D failed to provide incontinent care services to Resident #64 in a timely manner. LVN D neglected Resident #64 by failing to provide incontinent care when Resident #64 had a bowel movement during wound care when LVN D was aware of R#64's bowel incontinent episode. This failure could affect all residents by placing them at risk of abuse neglect, skin breakdown, mental anguish, emotion distress, infections, and possible serious harm.

Inspectors wroteBased on interviews and record reviews the facility failed to notify, consistent with his or her authority, the resident representative(s) for 2 of 6 sampled residents (Resident #1 and Resident #4) when there was a significant change. LVN A failed to document notification of Family Member A or Family Member B when Resident #1 developed new open areas on his skin. LVN B and LVN A failed to document notification of Resident #4's Family Member C when he had a change of condition, and new orders were received. This deficient practice had the potential to place residents at risk for not having their family or legal representative notified when having a change of condition.