- Date
- 1/23/2026
- Report number
- CALMS - 00101715
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate 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 02/05/26, the facility's failure to implement monitoring requirements was substantiated for 1 of 1 residents (#1).
Findings include, but are not limited to: A review of Resident 1’s interim service plans (ISP) for 02/02/26 indicated ISP listed discontinued medication, what staff should watch for, and who they should report any changes in condition to, and included 17 staff
signatures of acknowledgment. A review of staff schedules for 02/03/26 indicated 18 direct care staff working who had not read and signed Resident 1's ISP dated 02/02/26.
An interview with Staff 1 (Executive Director) stated the following: Resident 1 had temporary service plans (TSP) for 02/02/26 with interventions. The TSP binder is to be read and signed by staff each shift.
The facility’s failure to implement monitoring requirements was substantiated.