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 who was dependent on staff for nearly all activities of daily living, including bed mobility, was left unattended in a raised bed by a CNA who exited the room to retrieve linens. During this time, the resident fell between the bed and the wall, resulting in lower back and left leg pain, and a provider subsequently ordered an x-ray due to suspected fracture. The resident's care plan had identified a risk for falls and included an intervention to utilize a low bed, which was not followed at the time of the incident. Additionally, environmental hazards were observed in two separate unit hallways. One closet in a corridor was found with a missing doorknob and jagged, splintered wooden edges. In another unit, an unlocked storage room containing electrical panels and a locked biohazard cabinet was accessible, as well as an unlocked electrical room with a non-functional keypad lock and jagged, splintered wood beneath the keypad. These conditions were confirmed by the surveyor with facility leadership.