- Date
- 2/26/2025
- Report number
- CALMS - 00083218
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 03/31/25, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1's service plan dated 03/06/25 indicated the following: Resident needs staff encouragement to shower twice weekly in the mornings on Sundays and Thursdays. Routine weekly housekeeping services. Staff to assist with brushing Resident 1’s hair daily. Housekeeping schedule indicated Resident 1 was to receive services on Mondays. Housekeeping checkoff list dated 08/22/24 through 03/25/25 indicated Resident 1 had not been receiving weekly housekeeping services. Resident 1's shower sheets from 01/10/25 through 03/30/35 indicated the following: There were seven occurrences within the timeframe during which no shower was documented as provided or refused. On 03/07/25, stated, "hair was severely matted, difficult to shampoo, and condition". On 03/09/25, stated, "to start de-matting hair tomorrow". On 03/10/25, stated, "hair detangled" An interview with Staff 1 (Executive Director) and Staff 4 (Resident Care Coordinator) indicated Resident 1 had a history of refusing services, including showers. Staff 1 indicated the facility had found a pattern that had been working for the last couple of weeks. Compliance Specialist had attempted to interview and observe Resident 1, however, s/he had been sleeping. The facility’s failure to ensure the implementation of services was substantiated.