Failure to Implement Fall Prevention Interventions for At-Risk Resident
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 care plan interventions for a resident identified as being at risk for falls due to impaired mobility and cognition. The resident's care plan, initiated on 05/19/2025, specified the use of brake extenders with highlighted tape on the resident's wheelchair as a fall prevention measure. However, multiple observations conducted between 07/28/2025 and 07/31/2025 consistently showed that the resident's wheelchair did not have the required brake extenders with highlighted tape. This was confirmed by both direct observation and staff interviews, including with an LPN and the facility administrator, who did not provide any explanation to dispute the findings.