Inspection Reports for
Vista Terrace of Belmont by Cogir

The complaint investigation was substantiated for failure to safeguard resident's personal belongings and illegal rate increase. The allegations of staff violating personal rights and providing false assessments to support eviction were unsubstantiated. The allegation of illegal eviction was unfounded.

The investigation substantiated allegations that the facility failed to safeguard a resident's personal belongings during an evacuation and improperly increased the resident's level of care rate without proper notice. Allegations of staff violating personal rights and providing false assessments to support eviction were unsubstantiated. The allegation of illegal eviction was unfounded as proper notification was provided.

The visit was complaint-related, following incidents involving failure to provide medication to Resident 1 and inappropriate behavior by an agency CNA toward Resident 2. The CNA was removed from the facility and is no longer allowed in the community. Resident 2 was not injured and no personal belongings were missing. The complaint was substantiated by the findings.

The facility failed to provide Resident 1 with prescribed medication, posing an immediate health and safety risk, and an agency CNA was found to have acted inappropriately toward Resident 2. A civil penalty of $1,000 was issued for a repeat violation related to medication administration.

The complaint investigation was substantiated for medication administration errors, failure to report incidents to the licensing agency, and bed repair issues. Other allegations related to assistance with medical care and call button response were unsubstantiated.

The investigation substantiated that medication errors occurred where a resident was given fewer tablets than prescribed, the facility failed to report these incidents to the licensing agency, and a resident's bed was not in good repair causing it to collapse. Other allegations such as failure to assist with medical care and delayed call button response were unsubstantiated.

The visit was complaint-related due to medication errors reported on 2025-06-22 and 2025-06-26 involving incorrect dosages administered to Resident 1. The complaint was substantiated as deficiencies were found.

The facility failed to provide Resident 1's medication as prescribed, including administering 150mg of Lacosamide instead of 100mg and initially providing only one tablet of Gabapentin instead of three. A civil penalty was assessed for repeat violations.

The complaint was substantiated based on the preponderance of evidence standard. The investigation included interviews with staff, residents, and the administrator, and observations of the facility's outdoor passageways and elevator accessibility.

The investigation found uneven pavement, uneven bricks, and overgrown greenery on outdoor passageways posing safety risks, and delays in staff assisting residents with elevator access, sometimes exceeding 10 minutes, causing residents to miss appointments. The allegations were substantiated.

The visit was complaint-related due to an incident reported on 2025-04-26 involving a medication administration error. A civil penalty of $250 was issued for a repeat violation within the last 12 months.

The facility failed to provide Resident 1's medication as prescribed by the physician, administering 100mg of Lacosamide instead of the prescribed 150mg. This deficiency was cited as a repeat violation and a civil penalty was issued.

The visit was complaint-related due to a reported incident where the AM shift med-tech did not administer Resident 1's medication as prescribed. The violation was substantiated and a repeat violation within the last 12 months was noted.

The facility failed to administer Resident 1's Lacosomide (100mg) medication at 8am on April 20, 2025, as ordered by the physician, posing an immediate health and safety risk. A repeat violation was cited and a civil penalty was issued.

The complaint was substantiated based on the preponderance of evidence that medication was not dispensed as prescribed. The allegation involved delayed administration of Carbidopa medication to Resident 1 on 2/25/25.

The investigation substantiated that Resident 1 did not receive Carbidopa medication at the prescribed times on 2/25/25, receiving it late at 8:24am and 11:15am instead of the scheduled 6am and 10am doses. This posed an immediate health and safety risk.

The complaint was substantiated. Staff did not inform residents of the planned fire inspection, causing panic and stress among residents. Four staff and four residents interviewed confirmed lack of notification and communication.

The investigation substantiated that staff did not notify residents about the fire inspection conducted on 2024-11-07, causing residents to feel scared, nervous, and unsafe. The Maintenance Director admitted allowing the inspection to proceed without resident notification.

The complaint investigation was triggered by allegations that facility staff did not dispense medications as prescribed to a resident and did not discuss resident reappraisal with the responsible party. The allegations were determined to be unfounded after review of medication records, interviews with staff and the resident's physician, and observation.

The investigation found that the allegations regarding medication dispensing errors and failure to discuss resident reappraisal were unfounded based on interviews, record reviews, and observations. However, a deficiency was cited for failure to administer medications at specific times between February and March 2024, posing an immediate risk to residents.

The complaint investigation was substantiated based on interviews and evidence gathered. The allegations involved violations of residents' personal rights and insufficient staffing to meet resident needs during a power outage.

The investigation substantiated the allegations that residents lost access to hot water after a power outage and that there was insufficient staffing to meet residents' needs during that time. These deficiencies posed potential health, safety, and personal rights risks to residents.

The complaint was substantiated. The facility failed to properly dispose of expired medications and medications for residents no longer at the facility. The issue was linked to delays in waste pickup due to unpaid invoices with the previous waste company. A new medical waste contract was signed on March 4, 2024.

The allegation was substantiated. The Licensing Program Analyst observed expired medications and medications for residents no longer residing at the facility stored in a locked cabinet. The facility acknowledged the issue was due to delays in medical waste pickup caused by unpaid invoices with the previous waste company. A new contract was signed to address the disposal.

The facility was found to be clean and in good repair overall, with no residents present due to closure. Some minor issues were noted, including a leaking faucet in the beauty salon and absence of 2-day perishables due to closure. A follow-up visit was planned to verify water temperature compliance and faucet repair.

The facility failed to maintain a signed admission agreement and complete resident records for Resident 1, whose file was misplaced. Additionally, Resident 1's physician's report was outdated, not reflecting a change in condition discussed during a care conference.

The complaint was substantiated. The facility failed to maintain the electrical system after a January 2023 power outage and did not purchase an additional generator as planned, leading to a second power failure in April 2023 and emergency evacuation of residents.

The facility experienced a power outage starting 2023-04-24, which was the second such incident since January 2023. The main breaker system was diagnosed as faulty, and although the facility ensured resident safety during the outage, it failed to maintain the electrical system in good repair after the January incident, resulting in an emergency evacuation of all 36 residents on 2023-04-28.

The visit was complaint-related due to a report of missing narcotics. The med-tech involved was terminated and the police department was notified.

The facility med-tech had a hospice nurse sign for medication destruction without the nurse being present and did not obtain authorization to destroy medications. The med-tech was terminated, police were notified, and in-service training was conducted regarding medication destruction.

The visit was complaint-related, following up on a medication error incident reported to the licensing agency. The violation was substantiated as a repeat violation within 12 months.

The facility Med-Tech missed a dosage of Resident #1's prescribed morning medication as ordered by their physician. This was a repeat violation within 12 months, resulting in a $250 civil penalty.

The visit was complaint-related, following an incident reported to the Community Care Licensing Division on October 6, 2022, regarding missed medication dosages. The deficiency was substantiated and cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

The facility Med-Tech missed a dosage of prescribed medication for two residents as ordered by their physicians. The error was acknowledged by the Med-Tech who reported rushing during the medication administration.

The investigation was triggered by complaints regarding medication mismanagement and a resident AWOL incident. The deficiency was substantiated based on interviews and record review indicating lack of supervision led to the resident AWOL.

The facility conducted an immediate investigation into the missing medication but did not find it. The facility had no prior medication mismanagement issues. However, the facility failed to ensure basic services due to lack of supervision, resulting in a resident with mild cognitive impairment leaving the facility unassisted and being AWOL for about an hour.