Kimball County Manor
Kimball County Manor in Kimball, NE — inspection on August 27, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
identified or implemented, stating they did not believe the fall occurred because the resident would not have been able to get off the floor without assistance. C. A record review of Resident 2's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident 2 had diagnoses of dementia, hemiplegia (one-side paralysis), and weakness. A record review of Resident 2's MDS, dated [DATE], revealed the resident had a BIMS score of 5/15, which indicated sever cognitive impairment. Resident 2 required full assistance with toileting and dressing. Resident 2 also required moderate assistance with bed mobility and transfers. A record review of an Event Report for Resident 2 with a date of 7/8/2025 revealed the resident was self-ambulating to the bathroom when they bent down to retrieve a tissue from the floor and lost their balance, resulting in a fall.
The intervention implemented was the application of gripper socks while ambulating.
There was no evidence of a root cause analysis beyond balance was conducted or additional fall prevention interventions were developed to address the mobility deficit. An interview on 8/27/2025 at 10:45 AM with the NHA and DON revealed that the root cause of Resident 2's fall on 7/8/2025 was identified as a loss of balance and underlying weakness.
The NHA and DON confirmed the fall was unwitnessed, and since it was unclear whether the loss of balance was related to the resident's foot slipping, no additional interventions beyond gripper socks were developed or implemented.
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