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F0689
D

Failure to Use Required Wheelchair Leg Rests During Resident Transport

Ebensburg, Pennsylvania Survey Completed on 08-27-2025

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 was identified when a resident with cognitive impairment and a diagnosis of dementia, who required staff assistance for personal care, was transported in a wheelchair without the physician-ordered bilateral elevating leg rests. The resident's care plan specified the use of these leg rests for transport and when outside. During an observation, a nurse aide transported the resident from a common area to the resident's bedroom for lunch without applying the leg rests. The nurse aide confirmed that the leg rests were not used as required, and the nursing home administrator also acknowledged that the leg rests should have been applied according to the physician's order but were not.

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