Violation Details: CALMS - 00083114

Records Request Print
Date
10/25/2024
Report number
CALMS - 00083114
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0036(2)(g)
Findings
Based on an interview and record review, conducted during a site visit on 06/12/25, the facility's failure to ensure the implementation of services was substantiated. Fall interventions had not been in place on 10/25/24, Service plan dated 10/08/24 listed 13 fall interventions; Progress notes from 10/25/24 revealed staff had not attempted all 13 fall interventions. The incident report dated 10/25/24 confirmed that the fall happened due to fall interventions not being used. It was determined the facility failed to ensure the implementation of services. An investigation determined a licensing violation had occurred.