Inspection Reports for
Belmont Village Senior Living Sabre Springs

The complaint was substantiated based on interviews and record review. It was found that staff forcefully administered medication to a resident who refused it. Resident #1 was not interviewed due to a Major Neurocognitive Disorder and had moved out of the facility on 06/12/2025.

The investigation substantiated that a nurse/area manager forcefully administered an insulin injection to Resident #1 on 06/10/2025 despite the resident's refusal, which posed a potential safety and personal risk to residents in care.

The complaint investigation was substantiated for allegations that medications were not given as prescribed and medication records were inaccurate. The allegation that staff cut resident's medication without an order was unsubstantiated.

The investigation substantiated that medications were not given as prescribed for two residents, and medication records were inaccurate, including discrepancies between the Medication Administration Record and Controlled Drug Record. It was unsubstantiated that staff cut medication without an order, as the medication technician had nurse approval. A civil penalty was assessed for repeat violations related to medication administration and documentation.

The complaint investigation was substantiated regarding delayed staff response to Resident #1's calls for assistance. The resident was bedridden with major neurocognitive disorder and required two-person assistance. Call Light History logs showed multiple instances of response delays ranging from 45 minutes to 6 hours. Other allegations including neglect resulting in fracture and Stage 3 pressure injury, and failure to follow admission agreement were unsubstantiated.

The investigation substantiated that facility staff failed to respond timely to Resident #1's calls for assistance, with documented delays up to six hours. However, allegations of neglect resulting in fracture and Stage 3 pressure injury, as well as failure to follow the resident's admission agreement, were found to be unsubstantiated. A civil penalty was assessed for the repeat violation related to response times.

The visit was a follow-up to a complaint investigation regarding delayed medical care to resident (R1). The Department substantiated the complaint and determined serious bodily injury occurred.

The Department concluded that a civil penalty is warranted for serious bodily injury due to the licensee's failure to immediately call 9-1-1 for a resident who had fallen and was in extreme physical pain. A civil penalty of $10,000 was issued.

The investigation was opened due to a complaint regarding delayed medical care for Resident #1 after multiple falls. The complaint was substantiated with findings that the licensee did not call emergency services immediately after the falls due to refusal of care by the responsible party, posing an immediate risk to resident health and safety.

The licensee failed to immediately call 9-1-1 for R1 after a fall on September 21, 2024, and again on September 26, 2024, despite R1 expressing pain and inability to get out of bed, due to refusal of medical care by R1's responsible party. This posed an immediate health and safety risk and resulted in a citation and potential civil penalty.

The complaint investigation was substantiated based on observations and interviews. Allegations included insufficient food portions and dirty dishware being served. The licensee did not ensure adequate food quantity and proper cleaning of dishware for 25 residents, posing health and safety risks.

The investigation substantiated that residents in the memory care unit were sometimes served insufficient food portions, requiring staff to ration food, and that dirty dishware with lipstick stains was occasionally served due to dishwasher issues. Staff training on food quantity and dishware sanitation was planned.

The visit was complaint-related due to an incident involving Resident #1 eloping from the facility without staff knowledge. The complaint was substantiated by the cited deficiency.

The facility failed to ensure the safety of one resident who eloped without staff knowledge. The concierge did not notice the resident leaving, and a deficiency was cited related to basic service requirements and resident whereabouts.

The complaint investigation was substantiated. Allegations included failure to follow resident's care plan requiring two-person assist, delayed staff response times to resident calls (up to 1 hour 30 minutes), and failure to arrange appropriate medical care for the resident's second COVID-19 vaccine dose. Other allegations about unsafe environment and food service were unsubstantiated.

The investigation substantiated that staff did not follow the resident's care plan requiring two-person assistance, did not respond timely to the resident's calls for help with response times exceeding 30 minutes, and failed to arrange appropriate medical care for the resident's second COVID-19 vaccine dose. Additional allegations regarding unsafe environment and food service were unsubstantiated.

The Licensing Program Analyst observed a Covid-19 positive resident sitting in a common area with their apartment door open, indicating the facility did not follow infection control guidelines to isolate the resident. A deficiency was cited for failure to ensure isolation of Covid-19 positive residents.

The facility was generally clean, sanitary, and in good repair with compliant safety measures; however, a deficiency was cited for locking the entire perimeter, which violates fire clearance regulations. A civil penalty was assessed and a plan of correction was submitted.

The visit was complaint-related based on self-reported incidents involving Resident #1. The complaint was substantiated by interviews and record review confirming staff misconduct including rude behavior and falsification of medication records.

The facility failed to ensure Resident #1 was treated with dignity and did not receive prescribed medications due to staff misconduct. Two staff members were terminated and deficiencies were cited related to medication management and personal rights.

The complaint investigation was substantiated for allegations related to poor food quality and outdated resident medical records. Other allegations including rough handling, punishment, dignity violations, denial of personal possessions, and hygiene neglect were unsubstantiated based on interviews, observations, and record reviews.

The investigation substantiated that the facility did not ensure food quality, serving burnt and undercooked food, and failed to maintain current medical assessments for residents with Major Neurocognitive Disorder. Other allegations related to resident treatment and dignity were found unsubstantiated after interviews and observations.

The complaint investigation was substantiated for the allegation that residents were not receiving medications as prescribed. Other allegations regarding resident checks, staff training on transfers, and pendant disrepair were unsubstantiated.

The investigation substantiated that residents were not receiving medications as prescribed due to lack of documentation for missed doses and unadministered medications. However, allegations that residents were not being checked on by staff, staff were not properly trained on transfers, and pendants were in disrepair were found to be unsubstantiated based on interviews, record reviews, and observations.

The complaint investigation was substantiated for the allegation that staff do not respond timely to residents’ calls for assistance. The allegations that staff left residents in wet and soiled diapers for extended periods and did not provide breakfast to residents were unsubstantiated.

The investigation substantiated that staff did not respond timely to some resident calls for assistance, with response times ranging from 1 minute to 1 hour and 40 minutes, posing a potential health and safety risk. The allegations that staff left residents in wet and soiled diapers for extended periods and did not provide breakfast were found to be unsubstantiated based on interviews and record reviews.

The complaint was substantiated involving multiple pressure injuries resulting in hospitalization due to staff neglect. An immediate civil penalty of $500 was assessed on June 23, 2022, and an additional civil penalty of $9,500 was issued on June 7, 2024 for serious bodily injury.

The Department found that the licensee failed to contact 9-1-1 or obtain emergency medical services when an imminent threat to a resident's health was observed, failed to obtain a written plan of care, failed to conduct a reappraisal, failed to train and supervise staff, and failed to ensure staff followed physician's orders, contributing to serious bodily injury requiring hospitalization and maggot debridement therapy.

The complaint investigation addressed three allegations: 1) Facility bathroom was not maintained cleaned (unsubstantiated), 2) Residents alarm system was not operable (substantiated), and 3) Facility did not administer medication as prescribed (substantiated). The investigation included interviews with residents, staff, and outside sources, records review, and observations. The medication administration issues involved missed doses, incorrect discontinuations, and failure to assist with self-administration. The alarm system was found to have been repaired in 2022 but was initially inoperable.

The allegation regarding unclean bathrooms was unsubstantiated after interviews and observations confirmed cleanliness. However, allegations that the resident alarm system was inoperable and that medications were not administered as prescribed were substantiated based on interviews, records review, and observations. Deficiencies were cited related to medication administration and alarm system maintenance.

The complaint was substantiated. The incident involved a medication error by staff leading to a resident ingesting incorrect medications, causing vomiting but no serious illness. Staff provided remedial training following the incident.

The investigation found that a newer staff member (S1) mistakenly gave R1 medications intended for R2, causing R1 to vomit but not suffer serious illness. One deficiency and one technical violation were cited, and a plan of correction was developed.

The inspection found that the facility lacked an auditory device or staff alert feature to monitor one exit door, and two delayed-egress doors in the memory care unit were missing required signage, posing potential safety risks to residents. Two Type B deficiencies were cited and plans of correction were developed.

The visit was triggered by a complaint investigation that found Resident #1 did not have a current Medical Assessment on file, violating requirements for annual reassessment of dementia care needs.

The facility failed to have a current annual Medical Assessment on file for Resident #1, which posed a potential health and safety risk. The last assessment was dated September 2021 and lacked required updated medical conditions and care needs.

The visit was complaint-related, triggered by incidents involving Resident #1 eloping from the facility and Resident #2 sustaining injuries from a fall. The complaint was substantiated by observed deficiencies.

The facility failed to ensure the safety of Resident #1 who eloped from the facility despite known exit-seeking behavior and lack of safety measures. Resident #2 was found on the floor with multiple injuries and required hospital evaluation. Deficiencies were cited related to basic services and dementia care assessments.

Complaint received on January 24, 2022; deficiency originally Type A, amended to Type B; visit was related to this complaint.

An amended report was issued to the Executive Director correcting a previously cited Type A deficiency to a Type B deficiency related to the complaint.

The complaint alleging neglect/lack of supervision of Resident #1 was substantiated on 05/06/2021. The Department determined the violation resulted in injury to the resident and issued a $500 civil penalty under HSC 1569.49(c)(1).

The Department found that the licensee failed to contact 911 or obtain emergency medical services for Resident #1 when they developed a Stage II pressure injury that progressed to unstageable, posing an immediate health and safety risk. A $500 civil penalty was issued for this violation resulting in injury to the resident.

The complaint was substantiated. The allegation was that the facility was not following COVID-19 guidelines by not requiring negative COVID tests for visitors. The investigation confirmed that visitors were allowed entry without negative tests during the specified period.

The investigation found that the facility did not require negative COVID tests from visitors between January 18, 2022 and February 7, 2022, which substantiated the allegation. The licensee failed to provide safe and healthful accommodations to all 154 residents, posing a potential personal rights risk.

The complaint investigation revealed that Resident #1 sustained five pressure injuries resulting in hospitalization due to neglect by facility staff. The injuries were documented by Home Health and Mobile Wound Care services. The facility failed to obtain a plan of care, follow physician's orders, and request required exceptions for prohibited health conditions.

The investigation found that the facility failed to obtain a plan of care from the Home Health Agency, did not follow physician's orders to off-load pressure on the resident's legs, and did not request a prohibited health condition exception for unstageable pressure injuries. These failures posed an immediate health risk to the resident.

The complaint was substantiated. Resident #1 sustained multiple pressure injuries resulting in hospitalization due to neglect. The facility failed to follow physician's orders, did not obtain a plan of care from Home Health and Mobile Wound Care, and delayed medical attention. The preponderance of evidence supported the allegation.

The investigation found that the facility failed to follow physician's orders and did not obtain or follow a plan of care from Home Health and Mobile Wound Care, contributing to the progression of multiple pressure injuries on Resident #1, resulting in hospitalization. The facility also failed to provide immediate medical attention and did not contact emergency services as required.