374603279-5-6-2021-08-AS-IESA-C3K96E-20210531230521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 05/06/2021
Date Signed: 05/06/2021 11:54:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2020 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20200722141702

FACILITY NAME:	BELMONT VILLAGE SABRE SPRINGS		FACILITY NUMBER:	374603279
ADMINISTRATOR:	INAN LINTON		FACILITY TYPE:	740
ADDRESS:	13075 EVENING CREEK DR S		TELEPHONE:	(858) 486-5020
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	184	CENSUS: 121	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director, Inan Linton		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries resulting in hospitalization due to neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natasha Persaud contacted the facility via video conference, due to COVID-19, to conclude a complaint investigation. LPA identified herself and discussed the purpose of the call with Executive Director, Inan Linton.

During the investigation, the Department briefly toured the facility, requested records, and conducted interviews with staff, residents, and outside sources. It was alleged Resident #1 (R1) sustained multiple pressure injuries resulting in hospitalization due to neglect by facility staff. R1 sustained five (5) pressure injuries. R1 was initially assessed on 11/25/19, prior to move in. The Resident Assessment and Service Plan reflected R1 required assistance with medications, showers with stand by assistance, and dressing with set up assistance. R1 was independent with toileting, feeding, and physical functioning. R1’s Nurse’s Admission Assessment dated 12/31/19, which was completed within 48 hours of move in, indicated R1 had two (2) bruises on their left arm; one (1) bruise on their right arm; two (2) bruises on their lower right leg. Continued on an LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200722141702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
	VISIT DATE: 05/06/2021

NARRATIVE

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R1’s Physician’s Report dated 02/14/20 reflected R1 used a wheelchair and needs assistance with ambulation, showering, toileting, grooming, and no history of skin breakdown. R1 was reassessed on 05/05/20, the Resident Assessment and Service Plan showed R1 required assistance with showers with stand by assistance, dressing with set up assistance, and grooming reminders. However, R1 was now independent with medications per R1’s physician, and remained independent with toileting, feeding and physical functioning.

Staff interviews and facility documentation revealed on 06/20/20, staff observed a pressure injury on the back of R1’s right leg, due to rubbing against R1’s wheelchair. On 06/21/20, the right leg pressure injury opened. A review of facility records revealed staff notified R1’s physician of the change in condition on 06/20/20 and 06/21/20, but there was no physician response until 06/23/20. On 06/23/20, R1’s physician faxed the facility an order to keep resident’s legs propped up on a pillow when in wheelchair to off load pressure on legs. On 06/25/20 black eschar intact at base of the pressure injury was observed by staff. The Mayo Clinic defines pressure injuries can be classified into four (4) stages of increasing depth and severity, known as Stages one (1) thru four (4). However, they also have additional stages that exist known as unstageable injuries. Unstageable injuries are described as covered by dead tissue or eschar that obscures the ulcer base. Therefore, eschar is known as dry, dead tissue. The facility’s Physician’s Communication form dated 06/25/20, indicated staff notified R1’s physician of the pressure injury with black eschar and suggested a Home Health (HH) wound nurse come and assess R1 but was awaiting physician’s response. The facility’s Physician’s Communication form dated 06/25/20 was completed by the physician on 06/26/20 but showed received by the facility on 06/27/20. R1’s physician responded by stating HH was needed for the pressure injury, which was ordered, and requested to see R1 briefly that day, 06/26/20, for a telemedicine visit. However, there was no further communication between the facility staff and the physician. Not until 06/30/20, was a Telemedicine visit conducted between R1 and R1’s physician. R1’s physician’s documentation from the visit revealed the pressure injury on the right lower leg was noticed a week or so ago, which was a couple days after their last Telehealth visit. It also stated R1’s physician was provided photos of the pressure injuries and requested another Telehealth visit. However, there was some delay due to trouble coordinating with facility staff for the follow up visit. R1’s physician documentation from the Telehealth visit also indicated due to R1’s medical condition, R1 has decreased in mobility and spends more time in their wheelchair; does not transfer on their own; and unable to shift in bed much on their own. Continued on an LIC 9099C.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 08-AS-20200722141702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
	VISIT DATE: 05/06/2021

NARRATIVE

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R1’s physician’s plan of care from the telemedicine visit stated the following: refer to home health for wound care; leg is to be offloaded as much as possible in the meantime; and to have staff manage R1’s medications. The physician’s plan of care indicated a change in condition referencing R1’s medications should be managed by staff. Title 22 Regulations requires a reappraisal be conducted along with a new Physician’s Report, where there is a change in condition. The facility did not comply with the regulation. Facility records indicated R1 was last re-appraised on 05/05/20, which was prior to the change in condition. On 06/25/20, when staff observed the pressure injury with black eschar, there was no immediate medical care provided to R1. R1 was seen via video by their physician on 06/30/20. However, medical care was not provided until HH’s visit on 07/02/20.

A review of facility records indicated on 07/01/20, staff observed a new pressure injury discovered on the lower left leg and faxed an urgent request to R1’s physician to notify them of the new pressure injury, requesting wound care treatment. HH was ordered by R1’s physician on 06/25/20 but R1 was not evaluated by HH until 07/02/20, 07/04/20, and 07/10/20. HH provided the facility with documentation involving the care rendered at the facility but did not provide the plan to care for pressure injuries. On 07/04/20, HH documented the five (5) pressure injuries and diagnosed them as: two (2) pressure injuries on the lower right leg were Unstageable, due to being covered 100% in black eschar; one (1) pressure injury on the bilateral buttock was a Stage I; one (1) pressure injury on the right earlobe was a Stage II; and one (1) pressure injury on the left lower lateral leg was Unstageable, due to being covered 100% in black eschar. Staff interviews and facility documentation confirmed R1 was observed with black eschar on 06/25/20 and did not receive medical review, until the Telemedicine visit on 06/30/30, which was five (5) days after the observation of the black eschar. In addition, R1 didn’t receive medical attention for the pressure injuries observed on 06/20/20-06/25/20 until evaluated and medically treated by HH on 07/02/20, which was seven (7) days later.

Investigation revealed facility staff did not inquire with HH to obtain a plan of care for the pressure injuries. Further staff interviews revealed the plan of care was requested twice, but not received, and there was no follow up by the facility. In addition, staff admitted R1’s legs were not being propped up by pillows to offload the pressure, while in their wheelchair as instructed by physician, only while R1 was in bed. Since the facility did not receive or obtain a Home Health plan of care to assist with pressure injuries; or follow physician’s orders, R1’s needs were not being met as staff were not aware what type of care to provide. Title 22 Regulations outlines the licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition. Continued on an LIC 9099C.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 08-AS-20200722141702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
	VISIT DATE: 05/06/2021

NARRATIVE

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The licensee failed to comply with this regulation by not obtaining the responsibilities to be carried out by HH and the licensee. An Outside Source interview revealed the facility’s staff stated they didn’t need a care plan, when asked, only the wound care order from the Mobile Wound Care.

The pressure injuries continued to progress. Home Health Visit Report dated 07/10/20 revealed the Mobile Wound Care would visit every Monday for debridement of the wounds, and HH would follow up every Wednesday and Friday; Next visit day will be 07/13/20 by MWC. Facility records reflected, on 07/13/20, facility staff observed an odor coming from the pressure injury. Also, staff interviews confirmed there could be an impeding infection. The Mobile Wound Care (MWC) is a subcontracted agency to assist with wounds/pressure injuries. The MWC treated R1 on 07/03/20, 07/06/20, and 07/13/20. The MWC’s documentation reflected the debridement of the wound to include cleansing and dressing of the pressure injury. In addition, on 07/13/20, MWC’s Nurse Practitioner prescribed an antibiotic that was used to treat or prevent infections. The MWC unit conducted an assessment on 07/13/20 and documented the following: local anesthesia was administered; procedure sharp debridement performed to remove devitalized tissue to the depth described as healthy bleeding tissue; Homeostasis was achieved; wound was cleaned and dressed; resident tolerated the procedure, and in stable condition; aggressive offloading recommended; a prescription for an antibiotic was called in; and will re-evaluate resident next visit.

On 07/13/20 the facility staff faxed a Physician’s Communication form to R1’s physician at 5:00pm indicating R1 complained of not feeling well; an odor coming from the wound; and wound care being handled by HH. On 07/14/20 at 10:13am, R1’s physician responded they would be talking with HH later that day and to wait to see what the wound care nurse says on 07/15/20. HH’s follow up visit was scheduled for Wednesday, 07/15/20. Facility nursing notes indicated R1 was sent to the hospital on 07/14/20 due to impeding infection. Hospital medical records documented the pressure injuries as severe and used medical maggot therapy for debridement of the pressure injuries. Once the pressure injury on the lateral lower left leg was derided, it went from unstageable to a Stage III pressure injury. As of 07/14/20, the facility still didn’t have a plan of care in place for the pressure injuries. It was confirmed that R1 was diagnosed with a Prohibited Health Condition while in care of the facility.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 08-AS-20200722141702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
	VISIT DATE: 05/06/2021

NARRATIVE

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Based on interviews conducted and records obtained, the facility failed to obtain a written Plan of Care from Home Health and the Mobile Wound Care to know how to care for R1’s pressure injuries. Therefore, there is enough corroboration and evidence to show R1 sustained multiple pressure injuries resulting in hospitalization due to neglect of not having a plan of care to follow; facility failed to follow physician’s orders, which contributed to the progression of the pressure injuries; and not seeking immediate medical attention for R1’s pressure injuries. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f). An exit interview was conducted with Executive Director, Inan Linton via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent by the Executive Director upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1].

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 08-AS-20200722141702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/07/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Executive Director agreed to ensure that all staff receive training, provided by an outside vendor, pertaining to contacting emergency medical services. The Executive Director agreed to provide the date of scheduled training to Community Care Licensing on 05/07/2021 and provide proof of training to Community Care Licensing upon
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not contact 911 or obtain emergency medical services for 1 out of 121 residents. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	completion, which will be scheduled to occur within two weeks.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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