Inspection Reports for Belmont Village Senior Living Cardiff by the Sea

Unannounced complaint investigation visit conducted in response to allegations including neglect causing an unstageable wound, failure to ensure medical care, retaining a resident requiring higher level of care, and medication administration errors.

All allegations were found to be unsubstantiated based on review of medical records and documentation. The wound was attributed to a medical condition treated by outside providers, medical care was ensured by facility staff following instructions, the resident was appropriate for the facility level of care, and no medication errors were documented.

The complaint investigation was unsubstantiated for all allegations: neglect causing unstageable wound, failure to ensure medical care, retaining resident requiring higher level care, and medication administration errors.

Licensing Program Analysts conducted an unannounced visit to continue a Required Annual Inspection of the facility.

The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited during the annual inspection. All safety equipment and environmental conditions were compliant.

An unannounced required annual inspection was conducted to review the facility's compliance with licensing regulations.

No deficiencies were cited during the visit. Due to time constraints, a return visit is needed to complete the annual inspection.

An unannounced Case Management Visit was conducted to correct/amend a prior facility evaluation report.

No deficiencies were observed or cited during the visit. The prior report was formally amended and discussed with the Licensee.

The visit was an unannounced Case Management – Incident inspection conducted in response to two self-submitted LIC624 Incident Reports regarding medication errors involving two residents.

The inspection found that staff errors led to two residents receiving incorrect medication doses, but no adverse health consequences occurred. One deficiency was cited for failure to assist residents with self-administered medications as prescribed, and a technical violation was issued regarding reporting requirements.

The visit was triggered by two medication error incidents reported by the licensee involving Resident #1 receiving an overdose of a blood thinner and Resident #2 receiving medication prescribed for another resident. Both incidents were investigated, and no adverse health consequences were found. The complaint was substantiated by evidence of process errors by staff.

An unannounced complaint investigation was conducted based on allegations that the licensee did not follow infection control protocol for a scabies outbreak and did not treat for pests.

The investigation found no evidence to substantiate the allegations. Records and interviews confirmed that the facility treated residents for scabies in January 2023 and followed public health guidance. No active bed bugs or pest issues were observed during the inspection.

The complaint alleged failure to follow infection control protocol for scabies and failure to treat for pests. The allegations were unsubstantiated based on interviews, observations, and record reviews.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not meeting residents' hygiene needs and were not responding to residents' call buttons in a timely manner.

The investigation found that staff were meeting residents' hygiene needs according to individual care plans and were responding to call buttons, although sometimes with delays due to staff calling out. No witness statements confirmed the allegations, and the complaint was unsubstantiated.

The complaint was unsubstantiated based on interviews and record reviews. Allegations included staff not meeting residents' hygiene needs and not responding timely to call buttons. Interviews revealed staff were meeting needs and responding to call buttons despite occasional delays. No witness statements confirmed the allegations.

An unannounced complaint investigation was conducted due to allegations of neglect and lack of supervision resulting in a resident sustaining injuries.

The investigation found that although the resident had multiple falls, there was no preponderance of evidence to prove neglect or lack of supervision. The resident often did not use the call pendant to request assistance, and staff regularly checked in with the resident. The allegation was unsubstantiated.

The complaint alleged neglect and lack of supervision resulting in a resident sustaining injuries, including multiple falls and a forehead laceration. The investigation concluded the allegation was unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that facility staff restrained a resident in a wheelchair.

The investigation found the complaint to be unfounded as the restraint was performed by a private caregiver hired by the resident's family, not by facility staff. The facility notified all appropriate agencies as required.

The complaint was investigated and determined to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis. The allegations were not pertinent to the licensed facility.

Licensing Program Analyst Natasha Persaud conducted an unannounced collateral visit to interview a resident and briefly tour the facility.

No deficiencies were observed during the visit. An exit interview was conducted and Licensee Rights were provided to the Executive Director.

An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.

The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the inspection.

An unannounced complaint investigation visit was conducted to investigate allegations including mishandling of a resident's personal belongings, a resident sustaining a pressure injury, and financial abuse of a resident while in care.

The investigation substantiated the allegation that a resident's furniture was discarded without permission, posing a personal rights risk. The allegations of a resident sustaining a pressure injury and financial abuse were found to be unsubstantiated based on evidence and interviews.

The complaint investigation was substantiated regarding mishandling of resident's personal belongings. The allegations that the resident sustained a pressure injury and was financially abused were unsubstantiated.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).

No deficiencies were cited during the visit. A walk-through was conducted and a debriefing was held with facility leadership.

An unannounced complaint investigation visit was conducted in response to allegations received on 12/11/2019 regarding the facility's failure to meet residents' needs, maintain resident rooms in a sanitary condition, and assist with incontinence care.

The investigation included records review and interviews with staff, residents, and outside sources. The allegations were found to be unsubstantiated as evidence showed residents had call systems, rooms were clean and sanitary, and incontinence care needs were met with regular checks and assistance available.

The complaint investigation was unsubstantiated based on evidence including interviews and records reviewed. Allegations included failure to meet residents' needs, unsanitary resident rooms, and inadequate incontinence care, all of which were not supported by the investigation findings.

An unannounced complaint investigation was conducted due to an allegation that staff did not administer residents' medication as prescribed.

The investigation found that Resident #1 was not offered PRN medication during an episode of agitation and aggressive behavior on January 29, 2020, despite staff knowledge of the behavior. This failure posed a potential health risk and the allegation was substantiated.

The complaint was substantiated based on evidence that staff failed to administer PRN medication to Resident #1 during an episode of agitation and aggressive behavior on January 29, 2020. The investigation included interviews, records review, and confirmed the allegation.

The visit was a Case Management follow-up on a related concern observed during a complaint investigation regarding medication administration.

A Technical Assistance Advisory was provided to the facility regarding administration of medications after review of staff interviews and multiple resident records related to the concern.

An unannounced required 1-year visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.

No deficiencies were cited or observed during the inspection. The facility was found to be in compliance with infection control measures including disinfection, testing surveillance, screening protocols, and use of personal protective equipment.

The visit was an unannounced case management visit to deliver an amended report from a previous complaint visit dated December 20, 2019.

The Licensing Program Analyst and Licensing Program Manager conducted the visit, identified themselves to the Resident Services Director, and provided a copy of the amended report along with Licensee/Appeal Rights. An exit interview was conducted and confirmation of receipt was requested.

An unannounced case management virtual visit was conducted due to the COVID-19 pandemic following a self-reported incident regarding a resident injury.

The Licensing Program Analyst toured the facility, reviewed records, and interviewed staff. No deficiencies were cited during this visit.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing surveillance, screening protocols, and use of personal protective equipment (PPE).

During the visit, no deficiencies were issued. The team interviewed the Administrator and staff, conducted a walk-through including Memory Care areas, and provided a debriefing at the conclusion of the visit.

An unannounced complaint investigation visit was conducted following a complaint received on 2019-12-11 regarding the licensee not storing cleaning products inaccessible to residents.

The Licensing Program Analyst observed unlocked supply storage with cleaning supplies accessible to dementia residents, substantiating the complaint. This posed an immediate safety risk to 23 residents in care.

The complaint was substantiated based on observations during the unannounced visit. The allegation that cleaning products were not stored inaccessible to residents was found valid.