- Date
- 8/13/2025
- Report number
- CALMS - 00087016
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on the interview and record review, conducted during a site visit on 08/21/25 to 08/22/25, the facility's failure to implement monitoring requirements was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
A review of Resident 1’s interim service plans (ISP) for August 2025 indicated the following:
08/13/25 at 01:28 pm, ISP had not listed an event or interventions, however, included 16 staff signatures of acknowledgment. 08/13/25 at 06:10 pm ISP included 21 staff signatures of acknowledgment.
A review of staff schedules for 08/13/25 through 08/16/25 indicated 12 direct care staff working who had not read and signed Resident 1's ISP dated 08/13/25 at 06:10 pm.
An interview with Staff 1 (Executive Director) stated the following:
Resident 1 had temporary service plans (TSP) in August 2025 with interventions. Added monitoring to Resident 1’s August 2025 medication administration record. The TSP binder is to be read and signed by staff each shift.
Interview with Staff 2 (Caregiver) confirmed they are not given time to read the TSP binder each shift.
The facility's failure to implement monitoring requirements was substantiated.