- Date
- 7/7/2025
- Report number
- CALMS - 00084006
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 07/15/25, 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:
Compliance Specialist (CS) was unable to interview Resident 1 or make observations as s/he was no longer in the facility.
The following documents were reviewed: Resident 1 service plan dated 06/24/25 and 07/09/25 indicated the following: Resident needs staff to order, administer, and store all medications; and Staff to fax the pharmacy with any medications needing to be re-ordered or new medication changes.
An incident report dated 07/09/25 indicated the following: The facility nurse was notified by med tech that the resident had been sent to the hospital for a possible stroke on 07/07/25. Med tech stated that the resident had been missing his/her morning dose of 2.5mg Eliquis since 06/26/25. The nurse had not been notified that s/he was out of the medication. The resident was not placed on alert for the missed Eliquis. ln addition to the missed Eliquis dose, the resident had missed Metoprolol 50mg tablet from 06/27/25 through 07/02/25. The resident was not placed on alert for missed doses of Metoprolol. Eliquis and Metoprolol both required a refill script from a primary care provider. Primary care provider had been faxed on 06/24/25, 06/25/25, and 07/02/25 for new scripts. Med tech called on 07/03/25 for a new script of Eliquis to be sent to the community. The investigation conducted by the facility indicated the facility had followed Resident 1’s service plan. An interview with Staff 1 (Executive Director) indicated the facility had not followed the resident's service plan regarding the re-ordering of mediation.
The facility’s failure to ensure the implementation of services was substantiated