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

The facility failed to implement a fall prevention intervention as identified in the care plan for a resident with a history of repeated falls, progressive neurological condition, and Parkinson's Disease with dyskinesia. The resident, who had severe cognitive impairment as indicated by a BIMS score of 3, was care planned to wear non-skid socks as a fall prevention measure following a previous fall incident. However, during observations, the resident was found wearing regular socks without non-skid bottoms. Multiple staff members, including nursing staff and the Director of Nursing, confirmed that the resident was a fall risk and that the care plan required the use of non-skid socks. Staff observed and acknowledged that the resident was not wearing the prescribed non-skid socks at the time of the survey. The resident's representative also reported that the resident does not wear non-skid socks, despite the documented intervention on the care plan.