COGIR OF BELMONT

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPA observed a housekeeping cart on the second floor and a housekeeping cart on the third floor to be unlocked with chemicals in them which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2026 Plan of Correction Licensee/administrator shall conduct an in-service training with housekeepers to ensure cart are locked at all times and chemicals are inaccessible to residents in care. Copy of in-service sign-in sheet shall be submitted to LPA by 4/30/26.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on R1's medication list, R1 is required to receive his/her one 15mg tablet of Mirtazapine daily at 8:00pm, however the facility did not provide R1 his/her medication as prescribed by the physician which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a plan in writing on how to ensure agency med-techs are trained prior to administering medication to avoid med-errors. A civil penalty of $1,000 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25, 4/29/25, 5/6/25, 7/1/25 and 8/26/25

Deadline recorded: Sep 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on R1's medication list, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however on 6/22/25, the med-tech administered 150mg. The facility failed to provide R1's medication as prescribed by the physician. In addition, Based on R1's medication list, R1 is required to take 1 tablet of Gabapentin (100mg) at 9am, two tablets of Gabapentin at 1pm and three tablets of Gabapentin at 8pm. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm on 6/26/25 if R2 did not catch this.

Official plan of correction

Licensee/Administrator shall submit a plan in writing on how to ensure agency med-techs are trained prior to administering medication to avoid med-errors. A civil penalty of $250 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25, 4/29/25, and 5/6/25.

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on file reviewed, R1 is required to take 1 tablet of Lacosamide (150mg) medication once every evening at 8pm, however based on the MAR, the med-tech administered the wrong doasge and administered 100mg of Lacosamide to R1 which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/administrator and/or Director of Health and Wellness will conduct an intensive training with med-techs. Director of Health and Wellness will shadow med-techs and train on how to ensure medication is provided on time and according to physician's order. Training log shall be submitted to CCLD by 5/7/25 A civil penalty of $250 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25 and 4/29/25.

Deadline recorded: May 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on staff interviews, R1's physician's orders and MAR, R1 is required to take 1 tablet of Lacosomide (100mg) medication daily at 8am, however based on the MAR, the med-tech did not administer the medication to R1 which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall re-train all med-techs and submit training log to LPA by 4/30/25. A civil penalty of $250 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25.

Deadline recorded: Apr 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreement: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission... Violation of this regulation is not met as evidenced by: Based on record review, facility failed to maintain a copy of a signed and dated admission agreement for R1 prior to admission at Vista Terrace of Belmont.

Official plan of correction

Licensee/Administrator shall submit a written plan to ensure facility maintains signed and dated copies of admission agreements for each resident.

Deadline recorded: Oct 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records: 87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Violation of this regulation is not met as evidenced by: Based on record review and staff interviews, facility misplaced R1's file and are unable to provide R1's records (admission agreement, pre-appraisal, care plan) to licensing staff when R1 was residing at Vista Terrace of Belmont, prior to the emergency evacuation

Official plan of correction

Licensee/Administrator to submit a written plan in writing describing how facility will ensure complete and current resident records are maintained as indicated on CCR 87506

Deadline recorded: Oct 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment : (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. Violation of this regulation is not met as evidenced by: Based on record review, R1's physicians report is dated 12/20/2021 and R1 had a change in condition that was discussed during a care conference on 4/19/2023. Nevertheless, the facility failed to ensure R1's physician's report was current.

Official plan of correction

Licensee/Administrator to submit a plan in writing regarding how to ensure residents will follow up with their PCP is there is a change of condition or if a new physician's report is needed.

Deadline recorded: Oct 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following... Violation of this regulation is evidenced by: Based on documents reviewed and information collected, the faciliy med-tech had a hospice nurse sign for medication destruction without the hospice nurse being present for the destruction. In addition, med-tech acknowledged that he/she did not get authorization to detroy medications.

Official plan of correction

Facility conducted an in service training on 12/3/22 regarding medication destruction and provided LPA a copy of the training log. The med-tech involved in the incident was terminated.

Deadline recorded: Dec 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2) Once ordered by the physician the medication is given according to the physician's directions. Violation of this regulation is evidenced by: Based on record reviewed and staff interviews, the facility Med-Tech missed a dosage of R1's AM medication as ordered by their physician.

Official plan of correction

Resident Care Director (RCD) will conduct an in-service training regarding the consequences of med-errors and medication mismanagement. In addition, RCD wrote up the Med-Tech who conducted this error. A civil penalty of $250.00 is assessed for a repeat violation within 12 months.

Deadline recorded: Oct 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2) Once ordered by the physician the medication is given according to the physician's directions. Violation of this regulation is evidenced by: Based on record reviewed and staff interviews, the facility Med-Tech missed a dosage of R1 and R2's prescribed medication as ordered by their physician.

Official plan of correction

Executive Director and/or Resident Care Director will conduct an in-service training regarding the consequences of med-errors and medication mismanagement. In addition, a write up will me given to the Med-Tech who made this mistake.

Deadline recorded: Oct 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Violation of this regulation is not met as evidenced by: Based on the file reviewed and interviewed conducted, the facility did not ensure basic services were being met, due to lack of supervision R1 AWOL. In addition, R1 is unable to leave the facility unassisted, which poses an immediate health, safety and personal rights risk to residents.

Official plan of correction

The administrator and/or designee will provide caregiver training regarding supervision to prevent this from happening again and will submit a copy of the lesson plan and the sign-in sheet to CCL by 6/17/22.

Deadline recorded: Jun 17, 2022. A deadline is not proof that correction was completed.