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F0689
D

Failure to Apply Wheelchair Leg Rests During Resident Transport

Ligonier, Pennsylvania Survey Completed on 09-05-2025

Penalty

No penalty information released
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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 deficiency occurred when a resident, who was cognitively intact and required staff assistance for daily care due to abnormalities of gait and mobility, was transported in a wheelchair without the required leg rests in place. The resident's physician had ordered that wheelchair leg rests be used to secure the resident's feet during transport. On observation, a registered nurse transported the resident down the hallway to the activity room without applying the leg rests. The nurse confirmed at the time that the leg rests should have been used, and the Nursing Home Administrator also confirmed that the leg rests were required as ordered.

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