- Date
- 1/25/2026
- Report number
- CALMS - 00101733
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to use restraint properly
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 01/29/26, the facility's failure to document the use of supportive devices with restraining qualities was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to:
Staff 2 (Caregiver) and Staff 4 (Resident Care Coordinator) indicated the following: Resident 1's wheelchair was capable of reclining; and Staff had been trained to recline the wheelchair when escorting the resident.
Staff 1 (Executive Director) indicated the following: Resident 1 would not have been able to manipulate the reclining angle of the wheelchair independently.
Resident 1's Service Plan dated 12/17/25 indicated the following: The resident was unable to use a recliner on their own.
Documentation was not provided to indicate that the facility registered nurse, a physical therapist, or occupational therapist had conducted a thorough assessment, or that the facility had instructed direct care staff on the correct use and precautions related to use of the reclining wheelchair.
The facility's failure to document the use of supportive devices with restraining qualities was substantiated.