Inspection Reports for
Belmont Village Senior Living La Jolla

The visit was triggered by self-reported incident reports involving medication errors. No adverse reactions were observed or reported. One deficiency was cited.

The facility was found to have medication administration errors where residents were given a second dose of the same medication within the same day without proper documentation. No adverse reactions were reported. One Type B deficiency was cited related to medication administration procedures.

The visit was triggered by a complaint incident report received on 2025-12-05 regarding Resident #1 eloping from the facility, sustaining a head laceration treated at the hospital. The complaint was substantiated with a Type A deficiency cited.

The facility failed to ensure Resident #1 was unable to leave unassisted, resulting in elopement and injury, constituting a Type A deficiency. A Technical Violation was also cited for an accessible body of water posing a risk to residents requiring supervision.

The complaint alleged that resident R1, who required 1:1 supervision, eloped from the facility due to lack of supervision. The investigation included an unannounced visit, records review, and interviews. The allegation was substantiated. A Zero Tolerance Violation civil penalty of $500 was assessed.

The investigation substantiated the allegation that a resident (R1) eloped due to lack of required supervision, posing an immediate health and safety risk. The facility failed to ensure R1 was supervised as needed, resulting in a Zero Tolerance Violation and a civil penalty.

The facility was found deficient in developing baseline care plans for residents' immediate needs, reconciling controlled medication records, maintaining safe and sanitary food handling practices, and following proper infection prevention and control protocols during wound care.

The visit was triggered by a complaint regarding a medication error where Staff #1 administered another resident's medications to Resident #1. The incident was substantiated as a deficiency.

A deficiency was cited for failure to ensure proper medication administration procedures, resulting in a medication error posing a potential health and safety risk to one resident. The resident was assessed and cleared by medical personnel after the incident.

The complaint investigation was substantiated for failure to provide one-on-one care as agreed. Other allegations including neglect causing serious bodily injury, delayed medical care, and failure to meet toileting needs were unsubstantiated. The resident involved was a 100-year-old male who declined further medical evaluation despite staff and EMS recommendations.

The investigation substantiated that the facility did not ensure one-on-one care was provided as agreed, posing potential health and safety risks. However, allegations of neglect resulting in serious bodily injury, delayed medical care, and unmet toileting needs were unsubstantiated based on evidence and interviews. A plan of correction was formulated with the Executive Director.

The complaint investigation found substantiated failure to provide wound care for Resident 1, who tested positive for COVID-19 and missed scheduled wound treatments. The facility acknowledged treatment omissions and lack of progress notes during the isolation period.

The facility failed to provide daily wound treatments as ordered for Resident 1, who had a surgical wound from a right below-the-knee amputation. This failure placed the resident at risk for poor wound healing and infection, with documentation and treatment gaps noted during the COVID-19 isolation period.

The facility failed to report a COVID-19 outbreak to local/state public health officials in a timely manner and did not review infection control policies and procedures annually during the outbreak. These failures increased the risk of healthcare-associated infections for staff, residents, and visitors.

The complaint was substantiated. The investigation confirmed that the medication was administered incorrectly, and the physician's order was not followed.

The facility failed to ensure that one medication, Insulin Lispro, was administered according to the physician's order for one resident. The insulin was given via injection instead of the prescribed insulin pump, resulting in the resident's blood sugar dropping below normal levels.

The facility failed to develop and implement person-centered care plans for monitoring bed alarms for three residents, resulting in potential safety risks. Additionally, the facility inaccurately assessed post-fall risk evaluations for one resident, with scores decreasing after falls, increasing the risk of future falls.

The facility was found deficient in multiple areas including failure to ensure physician acknowledgment of POLST forms, incomplete psychiatric assessments for residents on psychoactive medications, lack of complete care plans, failure to identify unnecessary medications, and unsafe medication administration practices.

The complaint investigation found substantiated issues related to failure to notify about bed hold rights and failure to develop a care plan for a resident's behavioral needs.

The facility failed to notify the resident or representative about bed hold rights upon hospital transfer for one of four residents reviewed. Additionally, the facility failed to develop and implement a care plan addressing the behavioral needs of one resident, which could affect care delivery.

The complaint involved Resident 1 feeling uncomfortable with care provided by CNA 1, including use of a washcloth that was not warm enough and improper technique during peri care. The complaint was substantiated by interviews and record review.

The facility failed to develop and implement a care plan addressing the resident's allegation of inappropriate care by a CNA. This failure had the potential for the resident to continue not receiving appropriate care and interventions.

The complaint investigation found that Resident 1 was discharged to a Veterans Assisted Living Facility without verification that a bed was available. The resident was left without a safe place to stay, and Adult Protective Services and the physician were notified after the issue was discovered. The discharge was deemed unsafe and disorganized.

The facility failed to ensure a safe discharge for Resident 1, resulting in no continuum of care and the resident having no place to sleep upon arrival at the receiving facility. Documentation and communication failures were noted, including lack of verification with the receiving facility and incomplete discharge documentation.

The complaint investigation found that licensed nurses did not perform weekly skin assessments as required, resulting in delayed identification and treatment of a pressure ulcer for Resident 1. The deficiency was substantiated with documentation and interviews.

The facility failed to perform weekly skin assessments for Resident 1, who developed an unstageable pressure ulcer. Licensed nurses missed multiple opportunities to assess the resident's skin, contrary to facility policy requiring weekly assessments.

The facility was found deficient in maintaining resident room temperatures, addressing resident grievances promptly, following physician medication orders, and verifying meal tray accuracy before serving. These deficiencies posed potential risks to resident safety, dignity, and health.