Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
04/01/2022
Section Cited
CCR
87463(a)
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7 | 87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...
This requirement is not met as evidenced by:
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7 | Licensee will submit plan how you will ensure Reappraisals are conducted in a timely manner when there is a change in resident condition. Submit to CCL by 4/1/22 |
 | 8
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14 | Based on records review and interviews, the licensee did not comply with the section cited above. R1’s Services Plan dated 07/24/2021 was not updated after R1 sustained multiple falls requiring hospitalization, which posed an immediate health and safety risk to residents in care. | 8
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14 |  |
Deficiency Dismissed
Type A
04/01/2022
Section Cited
CCR87207
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7 | 87207 False Claims. No...employee of a licensee shall make or disseminate any false or misleading statement...This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above.The Facility Resident Services Director stated she | 1
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7 | Licensee has agreed to do the following:
1. Schedule a training on conduct inimical and false claims. Training must be conducted by an approved vendor.
2. 2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training.
Training must take place by |
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14 | faxed incident report to the Regional Office on 08/11/2021, however, the Investigator learned that a substitute nurse filled in for the Director at the facility on 08/10/2021 and 08/11/2021, which posed an immediate health and safety risk to residents in care. | 8
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14 |  |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type B
04/05/2022
Section Cited
CCR
87211(a)(1)(B)
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7 | 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1)(B) Any serious injury...occurring while the resident is under facility supervision.
This requirement is not met as evidenced by: Based on records review, the
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7 | Licensee will review 87211 Reporting Requirements regulation and submit a memo of understanding regarding submitting incident reports timely to appropriate parties. Submit to CCL by 4/5/22 |
 | 8
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12
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14 | licensee did not comply with the section cited above. R1 had a fall on 08/07/2021 and 08/16/2021 sustaining injuries which required hospitalization, no incident reports were received for the incidents, which posed a potential health and safety risk to residents in care.
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14 |  |
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