Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with chronic obstructive pulmonary disease, generalized muscle weakness, and impaired lower extremity function was admitted to the facility and identified as having an activities of daily living (ADL) self-care performance deficit related to impaired balance. The resident initially refused physical therapy services, expressing a preference to remain in bed and engage in leisure activities, and as a result, no restorative program was recommended at that time. Documentation indicated that the resident limited their own range of motion beyond what they could perform independently. Subsequently, the resident communicated a desire to begin a restorative therapy program during a social services check-in. However, there was no documentation of follow-up with nursing regarding this request, and the unit manager was unaware of the resident's interest in restorative therapy. The director of nursing services confirmed that a referral and assessment should have been completed but were not, due to a lack of communication. This failure resulted in the resident not receiving necessary services to maintain or improve their range of motion and mobility.