Inspection Reports for
Cogir of Stock Ranch

The complaint investigation was substantiated for medication mismanagement but unsubstantiated or unfounded for other allegations including falsifying medication records and failure to meet residents' hygiene and care needs.

The investigation substantiated the allegation that staff were mismanaging residents' medication, finding discontinued medications retained and ordered medications missing. The allegation of falsifying medication administration records was unsubstantiated. Multiple allegations related to resident care needs such as showering, incontinence, repositioning, pressure injury prevention, hygiene, bedding cleanliness, and room sanitation were found to be unfounded.

The complaint investigation was substantiated for failure to meet reporting requirements due to missing incident reports for a resident's fall. The allegations of questionable death and multiple falls resulting in serious bodily injury were unsubstantiated.

The investigation substantiated the allegation that the facility failed to meet reporting requirements by not submitting an incident report for a resident's fall on 2025-02-13. The allegations of questionable death and multiple falls resulting in serious bodily injury were found to be unsubstantiated based on the evidence and interviews.

The facility was found to be clean, well-maintained, and compliant with safety and health regulations. No deficiencies were cited during the inspection, although a technical violation was noted for one elevator permit not being displayed and a medication order discrepancy was identified and addressed with education to the administrator.

The visit was triggered by a complaint investigation involving a medication audit conducted on 03/28/2024, which revealed discrepancies in medication counts and improper medication handling.

Deficiencies were found related to inaccurate medication documentation and improper medication storage practices, including pre-pouring medications up to four days in advance and storing them in locked cabinets accessible only to specific staff. These practices pose potential health and safety risks to residents.

The visit was complaint-related due to an absent without leave incident involving a resident who left the facility unassisted despite a physician's report indicating the resident was unable to leave unassisted. The resident was located outside the facility later that night. The complaint was substantiated by the findings.

The facility failed to comply with regulations as a resident deemed unable to leave unassisted was found missing from the facility and located outside the community, posing an immediate health and safety risk. Deficiencies were cited related to staff awareness of residents' whereabouts.

The facility was found to be clean, safe, sanitary, and in good condition with appropriate staffing and required supplies. However, a deficiency was noted due to all eight staff files reviewed missing First Aid training.

The complaint investigation was substantiated for the allegation that staff did not assist residents with showering due to staffing shortages and missed scheduled showers for resident R1. The dietary needs allegation was unsubstantiated after investigation.

The allegation that staff did not assist residents with showering was substantiated based on interviews and records indicating staffing shortages and missed showers for resident R1. The allegation regarding dietary needs was found to be unsubstantiated after review of dietary plans, interviews with staff and residents, and observation of meal services.

The complaint was substantiated based on interviews and records reviewed. The fire alarm sub panel was found to be faulty, but the facility had implemented fire watch logs and was actively addressing the issue. No citation was issued due to the facility's due diligence.

The investigation found that the fire alarm sub panel was malfunctioning, but the rest of the panels were operable. The facility had taken due diligence by hiring a third-party company to conduct daily fire watch logs and submitted these to the Fire Department. The allegation was substantiated, but no citation was issued due to the facility's proactive measures. The facility will be monitored by the Licensing Program Analyst.