Inspection Reports for
Cogir on Napa Road

The visit was complaint-related due to two elopement incidents: R1 eloped on 2/9/26 and R2 eloped on 2/28/26. Both residents were not allowed to leave unassisted per physician reports. The incidents were substantiated with deficiencies cited.

The facility was found noncompliant with regulations as two residents (R1 and R2) eloped from the facility, posing immediate health and safety risks. The facility acknowledged the incidents and planned corrective actions including staff training and installation of a gate to prevent future elopements.

The facility was found to be clean, well-maintained, and in compliance with regulations. No deficiencies were cited in medication management, resident and staff records, environmental safety, or kitchen operations. Fire safety systems were inspected and found operational with one alarm replaced immediately after failure.

The complaint was substantiated. Allegations included unmet incontinence care needs and inadequate staffing on the Memory Care night shift. Witness interviews and record reviews supported these findings.

The investigation substantiated the allegations that residents' incontinence needs were not being met and that the facility was understaffed on the night shift, posing potential health, safety, and personal rights risks. The facility addressed these issues by terminating inadequate staff, hiring new caregivers, and increasing staffing levels on the night shift.

The visit was complaint-related based on incident reports received on 8/29/25 and 9/15/25 involving medication omission and a resident fall. The fall was recorded on video and reviewed by the Licensing Program Analyst. The complaint was substantiated with deficiencies cited.

The inspection found two Type A deficiencies: one involving a resident missing four days of prescribed medication, and another involving improper staff assistance leading to a resident fall and injury. The facility was cited for failure to assist residents with self-administered medications and insufficient competent staff support for ambulation and transferring.

The complaint alleged staff financially abused residents and failed to secure residents' personal property. The investigation included review of video footage, law enforcement reports, and facility records. The staff member involved was arrested and admitted to theft. Despite this, the allegation was deemed unsubstantiated due to lack of preponderance of evidence to prove the violation.

The investigation found that a staff member (S4) was caught stealing money and other items from residents, was arrested, and admitted to thefts involving multiple residents. The facility complied with reporting and security regulations, maintained secure locks and keys, and terminated the staff member immediately upon discovery. However, there was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.

The visit was complaint-related due to incidents involving resident infections, falls, and theft. The falls incident involved use of furniture as restraints without staff knowledge, resulting in suspensions and training. The theft incident involved a staff member stealing money from a deceased resident's belongings, leading to arrest and termination. No deficiencies were cited.

The investigation found that a resident with a staphylococcus aureus infection was properly treated and returned to the facility with no deficiencies cited. Another resident experienced falls related to improper use of furniture as restraints, leading to staff suspensions and in-service training on restraints and personal rights. A staff member was caught stealing from a deceased resident, was arrested, and terminated. No deficiencies were cited in the report.

The complaint involved suspected abuse of a resident (R1) by an outside agency caregiver (I1) who pulled the resident by the wrist causing them to fall and hit their head and shoulder. The resident was left on the floor until assisted by a Cogir caregiver (S1). Statements from involved staff were collected and video evidence was requested. The Health and Wellness Director was interviewed and tasked with submitting further documentation. No deficiencies were substantiated.

The investigation included interviews and review of statements and video evidence related to the incident. The Licensing Program Analyst requested additional documentation and declarations from facility staff and corporate contacts. No deficiencies were cited during this visit.

The facility was found to be clean, well-maintained, and in compliance with regulations. No deficiencies were cited during the inspection, and all required resident and staff documentation was present. The facility's infection control and emergency disaster plans were reviewed with no new updates.

The facility was found to be clean, well-maintained, and in compliance with safety and health regulations. No deficiencies were cited during the inspection. Documentation for residents and staff was complete, medication storage was secure, and emergency preparedness plans were reviewed with no new updates.

The complaint alleged that the facility administered incorrect medication to a resident. The allegation was substantiated based on interviews, record review, and evidence that resident R1 received another resident's medication and was taken to the emergency room. The facility notified R1’s responsible party and submitted a Special Incident Report.

The investigation substantiated the allegation that a medication technician administered another resident's medication to resident R1, who was taken to the emergency room as a precaution and discharged the same day. The facility reported the incident and took steps to ensure resident safety.

The facility was found to be clean, well-maintained, and compliant with safety and health regulations. All required resident and staff records were present and up to date. No deficiencies were cited during this inspection.

The visit was triggered by an incident report forwarded on June 13, 2023, concerning a resident vomiting discolored blood. Proper reporting requirements were met, and the resident transitioned back from the medical facility. The incident was discussed and reviewed during the inspection.

No deficiencies were cited during the Case Management-Incident Inspection. The resident's Primary Care Physician and Responsible Party were notified, and the care plan was updated accordingly.

The facility was found to be clean and in good repair with no deficiencies cited. Safety equipment such as fire extinguishers, smoke and carbon monoxide detectors were operational. Medications and toxins were secured, and infection control measures including daily disinfection and sufficient PPE were in place.

The complaint alleged staff engaged in illegal activity on facility grounds. The allegation was found unsubstantiated due to lack of preponderance of evidence to prove or disprove the claim.

The investigation found the facility to be clean and safe with no obstructions. After reviewing staff files, incident reports, and interviewing staff and residents, the allegation could neither be proven nor disproven and was therefore unsubstantiated.

The complaint alleged the facility did not follow the sheriff's evacuation order during the January 2023 storm. The allegation was found to be unfounded, meaning it was false or without reasonable basis.

The investigation found the allegation to be unfounded after reviewing evacuation orders and conducting interviews, confirming the facility was never under a mandatory evacuation order.

The facility was found to be clean and in good repair with no deficiencies observed. Infection control measures including COVID screening and vaccination status were reviewed and found compliant. Medications and toxins were securely stored, and fire safety equipment was inspected and operational.

The facility was found to be clean and in good repair with proper infection control measures in place. No deficiencies were observed during the inspection.

The facility was found to have appropriate furnishings, safety features including fire safety equipment and emergency generator, secured medications, and sufficient food supplies. Staff files and resident records were reviewed and found compliant with mandated reporter documentation, background clearances, and training requirements.

The applicant and administrator successfully completed Component II of the licensing evaluation, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. No deficiencies or violations were noted in the report.