Avir at Heritage Oaks

In the surveyor’s words

From the most serious findings on record at Avir at Heritage Oaks, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Aug 8, 2026

  Based on observation, interviews and record review, the facility failed to notify the residents physician regarding a change in the resident's condition, for 1 of 10 residents (Resident #1) reviewed for changes in condition. LVN A failed to notify the physician when Resident #1 complained of abdominal pain, and penile pain on 7/31/2026 at approximately 8:00 PM and bleeding from the penis after attempting to re-insert a Foley catheter on 8/1/2026 at approximately 3:30 AM. LVN A did not notify the physician of Resident #1's changes until 6:19 AM on 8/1/2026. An Immediate Jeopardy (IJ) was identified on 08/07/2026 at 4:38 PM. The IJ template was provided to the facility on [DATE] at 4:46 PM. […]

• Immediate jeopardy, isolatedF689Mar 1, 2022

  Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents (including elopements) for one (Residents #1) of four residents reviewed for elopements.in that: The facility neglected to replace Resident #1's wander guard after he cut it off and failed to monitor the wander guard's placement per the facility's elopement protocol and the physician's order, which resulted in Resident #1 wandering away from the facility undetected at approximately 2 A.M. in 43-degree weather. The facility failed to implement elopement procedures after an exit door's alarm was activated, which resulted in staff not being aware Resident #1 left the facility. There was no search for Resident #1. […]

• No harm, potential for more than minimal, widespreadF727May 6, 2026

  Based 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. Findings included: Record review RN time punches provided by facility undated for RN coverage revealed no RN hours for 4/24/2026 and 4/25/2026. During an interview on 5/06/2026 at 12:18 p.m. with ADM, she stated there was no RN coverage for 4/24/2026 and 4/25/2026. During an interview on 5/06/2026 at 01:53 p.m. […]

• No harm, potential for more than minimal, patternF584Jun 22, 2026

  Based 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. Findings include:During an interview on 06/18/26 at 12:36 pm, R#6 indicated his showers were at night on Tuesdays, Thursdays, and Saturdays. […]

• No harm, potential for more than minimal, patternF804Jun 22, 2026

  Based 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. The findings included: Observation and confidential interview on 06/18/26 at 1:18 pm , Resident #1 was offered his noon meal in a Styrofoam container. This container included a Philly Steak, mashed potatoes, tossed salad and pudding. […]