Belmont Village Sabre Springs

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff forcefully administered medication to resident in care

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged that staff forcefully administered medication to a resident in care. It was reported a nurse/area manager forcefully administered an insulin injection to Resident #1 on 06/10/25. R1 receives medication management from the facility staff. Staff interviewed reported R1 was known for refusing medications but not their insulin. A review of R1’s Medication Administration Records (MARs) for June 2025 indicated R1 refused medications and or insulin on 06/01/25; 06/02/25; 06/08/25; and 06/10/25. Further staff interviews showed that R1 had agitation at times and will refuse medications. Facility’s Progress Notes dated 06/10/25 indthe state’s words, verbatim · CDSS document, Aug 5, 2025 · control 08-AS-20250612101952

Allegation investigated: Staff are falsifying documentation

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff are falsifying documentation. It was reported that multiple medication technicians (med tech) are falsely documenting the Medication Administration Record (MARs) as the medications were administered when they were not. An outside source reported it was discovered the medications were present after the time they were documented as administered. On 05/30/25, LPA reviewed multiple medications and did not observe leftover medications or medications not administered. The outside source indicated multiple residents did not receive their medications due to their MARs being falsified as given. Those residents were interviewthe state’s words, verbatim · CDSS document, Aug 5, 2025 · control 08-AS-20250522103519

Allegation investigated: Neglect resulting in resident sustaining pressure injury Neglect resulting in resident sustaining an infection in the mouth Staff do not seek medical attention to residents in a timely manner Residents are not treated with dignity Facility does not provide activities for residents in care Facility has rodents Facility is in disrepair

Licensing Program Analyst (LPA) Natasha Persaud contacted the facility via telephone to commence a complaint investigation regarding the above-mentioned allegations. LPA spoke with Executive Director, Tracy Knepple and discussed the elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency and LPA observations. It was reported to CCL neglect resulting in resident sustaining pressure injuries, neglect resulting in resident sustaining an infection in mouth, staff do not seek medical attention in a timely manner, residents are not treated with dignity, facility does not provide activities to residents in care, facility has rodents and facility is in disrepair. Continued on an LIC 9099C. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2025 · control 08-AS-20240327115517

Allegation investigated: Facility staff did not respond timely to resident's calls for assistance

Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged facility staff did not respond timely to Resident #1’s (R1) calls for assistance. R1’s Physician Report dated February 13, 2024, indicated R1 had a Major Neurocognitive Disorder, bedridden status, and receiving hospice services. The report also reflected R1 required assistance with bathing, dressing/grooming, toileting, feeding, and medication management. R1’s Service Plan dated May 3, 2024, indicated R1 required assistance with bathing, dressing/grooming, toileting, feeding, two person transfers, and medication management. Facility’s PAL (Personal Assistance Liaison) Approach Chart and Service Plan dated June 2024 indicated R1 required assistancthe state’s words, verbatim · CDSS document, Apr 10, 2025 · control 08-AS-20240806141711

Allegation investigated: Medications not given as prescribed Licensee did not ensure resident medication records were accurate

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged medications were not given as prescribed for Resident #1 (R1) and Resident # 2 (R2). It was reported R1 was not given the correct dose of morphine, R2 was provided medication patches that belonged to Resident # 3 (R3), and medications were missing. R1 was receiving hospice services. Staff interviews revealed hospice was changing the morphine orders from half tab to full tab and back to half tab, as frequent as three (3) times in one (1) week. Staff explained the medication orders went directly to the pharmacy contracted by the facility. Once the order was placed, it appeared in their medication administration system, ACCUflo. Staff followed the ACCUflo system tothe state’s words, verbatim · CDSS document, Apr 10, 2025 · control 08-AS-20250312121604

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not ensuring residents are provided with sufficient amounts of food Staff provide dirty dishware to residents

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, and interviews were conducted with staff, residents, and outside sources. It was alleged staff are not ensuring residents are provided with sufficient amounts of food in the memory care unit. Today, 03/26/25, LPA observed lunch being served to the residents. There was a hot food cart brought over by the main kitchen. The hot food cart contained large trays of different food items for the residents, which needed to be portioned out and served individually to each resident. Today, the hot food cart had a large tray of yams, roasted vegetables, and salmon. The salmon was shredded up into small pieces. Per the kitchen staff, the salmon is a 4oz fillet. The kitchen has been made aware to serve the items whole,the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 08-AS-20250318170800

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure supervision was provided resulting in resident elopement

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Executive Director, Tracy Knepple. During today's visit, LPA briefly toured the facility, and interviewed staff and residents. It was alleged staff did not ensure supervision was provided resulting in resident elopement. It was reported that on 11/04/24 at approximately 5:30am, an outside source observed a woman with gray hair wearing a floral bathrobe opened up and no brassiere, walking down the street by the facility. The outside source was unable to confirm if the woman was a resident at the facility and continued to drive away without assisting the woman. The Executive Director's (ED) interview revealed there were no resident elopements on 11/04/24. Staff interviews confirmed there were no elopements on 11/04/24. Resident interviews stated they were not aware of any elopements and denied elopithe state’s words, verbatim · CDSS document, Nov 13, 2024 · control 08-AS-20241108133911

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: -Facility did not provide adequate food service resulting in resident becoming ill -Facility is not clean and in good repair

Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple. During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the facility did not provide adequate food service resulting in resident becoming ill. An outside source reported that on 8/15/2024 around noon, they had lunch with their friend/resident at the facility. Both individuals became ill, with symptoms including vomiting and diarrhea, and it was suspected it was due to the salmon served at lunch. Neither individual sought medical attention nor were aware of anyone else getting sick. Multiple caregiver interviews revealed they eat the food served at the facility and have never gotten ill. The Chef Manager was observed on 08/28/24, eating the salmon served by the facility. The Chef Manager explained he eats the food althe state’s words, verbatim · CDSS document, Sep 26, 2024 · control 08-AS-20240822100509

Allegation investigated: -Staff did not follow resident's care plan -Staff did not respond to resident in a timely manner -Licensee did not arrange appropriate medical care for resident

Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple. During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not follow resident's care plan. It was reported Resident #1 (R1) was receiving the highest level of care the facility offered. The level of care included two (2) persons assist but the facility was not following that. Outside sources also reported R1’s family members had to help with transfers as the facility was not providing the agreed service. R1’s Admission Agreement dated 03/03/21 confirmed the level of care being provided was Enhanced Personal Care II (EPC), which was the highest level the facility provided. The EPC II refers to all activities of daily living, to inclue two (2) persons assist. R1’s Assessment and Service Plan dated 03/03/21 refthe state’s words, verbatim · CDSS document, Sep 26, 2024 · control 08-AS-20210513114116

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not follow physician's orders

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple. During the investigation, LPA toured the facility, reviewed records, and interviewed staff, residents, and outside sources. It was alleged the facility staff did not follow physician's orders. It was reported Resident #1’s (R1) Consistent Carbohydrate Diet (CCD) was not being followed. R1’s Physician’s Report dated 12/08/23 indicated R1 required a low no added salt diet. On 06/17/24, R1’s physician wrote an order for a “Low-carb diet and decaf coffee only.” The Executive Director (ED) explained the facility received a copy of the order and it’s entered in the computer system to alert the kitchen of the requirement. The ED’s interview revealed the facility offers six (6) diets and Low carbohydrate falls under the category of CCD. ED also explained the facility does not add salt to their food. Therefore, the physicithe state’s words, verbatim · CDSS document, Aug 21, 2024 · control 08-AS-20240804095825

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee did not ensure food is of good quality Licensee did not ensure resident records are current

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Director of Resident Care Service, Keisha Bean. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the licensee did not ensure food is of good quality by serving burnt, overcooked and undercooked food. The food is cooked and prepared in the main kitchen then delivered to memory care. The breakfast was observed on multiple occasions by staff being of poor quality and returned to the main kitchen. Staff interviews confirmed the bacon was burnt, eggs were watery and green, and the pancakes were powdery. Further staff interviews revealed the main kitchen complains that too much food is being sent back. The main kitchen also sends over hard meat and veggies that are not cooked, which those are hard for residenthe state’s words, verbatim · CDSS document, Jun 27, 2024 · control 08-AS-20240202133159

Allegation investigated: Staff do not respond timely to residents’ calls for assistance

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Director of Resident Care Service, Keisha Bean. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff do not respond timely to residents’ calls for assistance. LPA reviewed the facility’s log of resident requests for assistance initiated via individually assigned pendants. The review of requests that were initiated on November 1, 2022, through December 15, 2022, revealed that in response to five (5) resident requests initiated via pendant, had response times from (1) minute to one (1) hour and forty (40) minutes. There were multiple occasions where more than thirty (30) minutes elapsed before resident pendants were restored. Based upon a review of records maintained by or on behalf of the facility, on tthe state’s words, verbatim · CDSS document, Jun 27, 2024 · control 08-AS-20221208115812

Allegation investigated: Residents are not receiving medications

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Director of Resident Care Service, Keisha Bean. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged residents are not receiving medications. It was reported multiple residents were not receiving their medications and are given incorrect medications. Staff interviews revealed residents are given their correct medications and there are no medication errors. Resident interviews reflected they believed they were given correct medications but could not be certain. A review of multiple Medication Administrator Records (MARs) for April 2024 reflected medications dispensed and medications not dispensed for various reasons. The MARs have a symbol key indicator, which is documented for the dates the medications werethe state’s words, verbatim · CDSS document, Jun 27, 2024 · control 08-AS-20240507100826

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: - Facility bathroom was not maintained cleaned

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by receptionist Stephanie Runyon. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Tracy Knepple. The Department’s investigation consisted of interviews with residents and staff, records review of relevant documents pertinent to this investigation, and LPA observations. On March 30, 2022, it was alleged that the resident’s bathroom was not maintained cleaned. It was alleged that the resident’s bathroom floor had splashes of urine and fecal matter. Interview with residents confirmed that they did not have issues with their bathroom being cleaned or being kept clean. During an interview with the Engineer, who oversees housekeeping, they said that the housekeeping staff has a current schedule posted for the staff on the designated areas they mustthe state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20220330150813

Allegation investigated: Resident sustained fall due to lack of supervision. Staff did not meet the residents assessed needs. Care staff did not have required training.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Executive Director Tracy Knepple and disclosed the purpose of the visit. The purpose of the visit was to deliver complaint findings for the above-mentioned allegations. The Department’s investigation consisted of interviews with staff, residents and outside sources, as well as a facility records review. It was alleged that a Resident #1 (R1), who required assistance while toileting, was left alone in the bathroom by care staff in October 2021 and fell. A review of R1’s assessment records revealed that for October 2021, there was no fall registered for that month. Department interviews with residents who have lived at the facility since October 2021 demonstrated that residents had no concerns over staff not attending to their care needs. Interviews with care staff who worked during October 2021 revealed that there was no recollection of R1the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20220120172307

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: -Lack of supervision resulting in resident wandering from the facility -Staff did not treat resident with dignity -Staff can’t communicate with residents due to language barrier -Staff mismanaged residents’ medication -Staff did not meet resident’s medical needs

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above mentioned allegations. LPA met with Executive Director, Tracy Knepple. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged lack of supervision resulting in Resident #1 (R1) wandering from the facility. R1’s Physician's Report dated 06/15/23 indicated R1 had a Major Neurocognitive Disorder, confusion, wandering behavior, able to follow instructions, and was not allowed to leave the facility unassisted. R1 resided in the secured memory care unit with delayed egress doors. The delayed egress doors have signs that state “Push and hold for 15 sec. Alarm will sound door will open in 15 seconds.” R1 would read the sign, push, and hold, and once the door opened, R1 exited. Staff interviews confirmed R1 would read the sign and follow the directions then exit.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 08-AS-20230821160039

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.