- Date
- 1/25/2026
- Report number
- CALMS - 00101732
- 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 01/29/26, the facility's failure to ensure the implementation of services was substantiated for 1 of 1 sampled residents (#1).
Findings include but are not limited to: Resident 1's Service Plan dated 12/17/25 indicated that when the resident was in their wheelchair, their footrests should be in place and secure.
An Incident Report dated 01/25/26 and a video recording dated 01/25/26 indicated the following: The footrests were not in place when the resident fell out of their wheelchair; and It was not clear whether the fall occurred as a result of the missing footrests.
Staff 1 (Executive Director) indicated the following: The footrests were not in place when the resident fell out of their wheelchair; and the resident's feet were not touching the floor when they fell.
Staff 2 (Caregiver) and Staff 4 (Resident Care Coordinator) indicated that the footrests should have been in place while the resident was being escorted in their wheelchair.
The facility's failure to ensure the implementation of services was substantiated.