Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/23/2022
Section Cited
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7 | 87463(a)-Reappraisals:
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. | 1
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7 | Plan of Correction shall include ensuring that residents have gotten appraisals and reappraisals performed and provide staff training. In addtiion, Licensee/Administrator shall provide a written summary on how future compliance will be met. |
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14 | This requirement was not met as evidenced by:
Based off of document reviews, there was no reappraisal completed for Resident #1 which presents a potential health, safety and personal rights risk to residents in care. | 8
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14 | Plan of Correction due on December 23, 2022. |
Type B
12/23/2022
Section Cited
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7 | 87506(a)-Record Keeping:
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. | 1
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7 | Plan of Correction shall include updating ALL resident records and provide staff training. In addtiion, Licensee/Administrator shall provide a written summary on how future compliance will be met. |
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14 | (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
Based off of document reviews, the facility did not retain a copy of the Admission Agreement in the file which presents a potential health, safety and personal rights risk to residents in care. | 8
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14 | Plan of Correction due on December 23, 2022. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
12/19/2022
Section Cited
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7 | 87211(b)-Reporting Requirements:
(b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). | 1
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7 | Plan of Correction shall include retraining ALL staff regarding Reporting Requirements and Mandated Reporting requiremenets. In addition, Licensee/Administrator shall provide a written summary on how future compliance will be met moving forward. |
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14 | This requirement was not as evidenced by:
Based off of interviews and a review of the SOC 341, the SUSPECTED elder abuse was not properly reported via an incident report or a SOC 341. This is an immeidate health, safety and personal rights risk to residents in care. | 8
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14 | Administrator requested an extension for December 28, 2022. LPA granted extension. |
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