Inspection Reports for Welbrook Santa Monica

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at Welbrook Senior Living Santa Monica facility.

The facility was generally well maintained with adequate supplies and safety equipment. However, a deficiency was cited due to the absence of annual training records for four staff members, which is a violation of personnel training requirements.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that a resident sustained a serious injury while in care and that the resident left the facility unsupervised.

The investigation substantiated that a resident eloped from the facility unsupervised, resulting in a serious injury (fractured hip). It was found that staff were not present on the second floor during the incident and did not hear the alarm. Another allegation that staff failed to report the resident injury to the responsible party was unsubstantiated.

The complaint investigation was substantiated for allegations that a resident sustained a serious injury while eloping from the facility unsupervised. The resident suffered an intertrochanteric osteoporotic hip fracture after being found in an alleyway. The investigation found staff were not present on the second floor and did not hear the alarm during the incident. The allegation that staff failed to report the injury to the responsible party was unsubstantiated.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.

The facility was inspected thoroughly including resident rooms, physical plant, and infection control practices. Several deficiencies were identified related to staff criminal record clearance, medical assessments for residents with dementia, staff first aid/CPR certification, and personnel health screenings.

The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff imposed restrictions on a resident's visitors and did not allow the resident to receive phone calls.

The investigation found the allegations to be unsubstantiated. Interviews and document reviews showed that restrictions were due to a conservator's directive to preclude a specific reporting party from visiting or calling a resident, not due to facility staff actions.

The complaint alleged that staff imposed restrictions on a resident's visitors and did not allow the resident to receive phone calls. The investigation included interviews with the administrator, staff, residents, and the conservator, as well as review of emails and court documents. The conservator had precluded the reporting party from visiting and calling the resident due to concerns about the resident's agitation. The allegations were found to be unsubstantiated.

An unannounced Required – 1 Year Inspection was conducted to evaluate compliance with licensing requirements and facility standards.

The facility was found to be in compliance with licensing requirements, including adequate resident accommodations, safe and clean common areas, proper functioning of bathrooms and safety equipment, sufficient food supplies, and staff records with current certifications and clearances.

An unannounced complaint investigation was conducted in response to an allegation that staff do not allow residents to make and receive confidential phone calls.

The investigation included interviews with the administrator, staff, and residents, as well as review of relevant documents and a physical tour. The evidence did not support the allegation, and all interviewed residents stated they could access the telephone privately without staff interference. The allegation was found to be unsubstantiated.

Allegation: Staff do not allow resident to make and receive confidential phone calls. The complaint alleged that staff snatched the telephone away from a resident. After investigation, including interviews and records review, the allegation was found to be unsubstantiated due to insufficient evidence.

The visit was an unannounced complaint investigation conducted in response to allegations that staff double diaper residents and that staff do not meet training requirements.

The investigation found no sufficient evidence to support the allegations. Interviews with residents, staff, and the Wellness Director, as well as record reviews, indicated that staff do not double diaper residents and meet training requirements. No deficiencies or citations were observed or issued during the visit.

The complaint investigation was unsubstantiated based on observations, interviews, and record review. Allegations included staff double diapering residents and inadequate staff training, both of which were not supported by evidence.

An unannounced complaint investigation was conducted in response to an allegation that the facility telephone was in disrepair and it was impossible to get a hold of staff.

The investigation found no evidence to support the allegation that the facility telephone was in disrepair. Staff and residents confirmed the phone system was operational, and telephone logs showed calls were received. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged that the facility telephone was in disrepair, making it impossible to reach staff, with the issue persisting for three months. The allegation was unsubstantiated based on interviews, document review, and observations.

An unannounced complaint investigation was conducted to investigate multiple allegations received on 2022-02-02 regarding staff not following hospice care plans, performing medical procedures, medication management, call button response times, reporting changes in resident condition, evacuation chairs, door repairs, staff training, and incident reporting.

The investigation included interviews, facility tours, and document reviews. No sufficient evidence was found to support any of the allegations. The department concluded that the allegations were unsubstantiated after reviewing hospice care plans, medication records, staff training, evacuation equipment, and incident reporting procedures.

The complaint investigation was triggered by multiple allegations including failure to follow hospice care plans, improper medical procedures, medication errors, delayed call button responses, failure to inform physicians of condition changes, lack of evacuation chairs, disrepair of delayed egress doors, inadequate staff training, and failure to report incidents. All allegations were found unsubstantiated based on interviews, document reviews, and observations.

The visit was an unannounced complaint investigation conducted to investigate allegations including staff mismanaging residents' medications, residents' hygiene needs not being met, and staff not allowing residents to have visitations.

The investigation found no evidence to support the allegations. Medication administration records, interviews with staff, residents, and witnesses indicated no issues with medication management, hygiene assistance, or visitation restrictions. The allegations were determined to be unsubstantiated due to lack of sufficient evidence.

The complaint investigation was unsubstantiated. Allegations included staff mismanaging residents' medications, residents' hygiene needs not being met, and staff not allowing residents to have visitations. Interviews and record reviews did not find sufficient evidence to support these allegations.

The inspection was an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool.

The facility was found to be in compliance with infection control practices, including screening protocols, PPE availability, and safety measures. No deficiencies were cited during this inspection visit, though advisory notes and technical assistance were provided.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including unlicensed staff administering insulin, lack of assistance with oxygen administration, inadequate staffing levels, failure to notify responsible parties of health changes, and unmet residents' hygiene care needs.

The investigation found that most allegations could not be substantiated due to lack of evidence or confirmation from staff and residents. Several staff denied or could not confirm the allegations, and residents with cognitive impairments were unable to confirm. The preponderance of evidence standard was not met, and the allegations were deemed unsubstantiated.

The complaint investigation addressed nine allegations including unlicensed insulin administration, failure to assist with oxygen, inadequate staffing, failure to notify families of health changes, and unmet hygiene needs. Interviews with staff and residents, review of medication administration records, and other documentation were conducted. The findings were unsubstantiated due to insufficient evidence.