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F0908
D

Failure to Maintain Safe Wheelchair Equipment for Residents

Indio, California Survey Completed on 06-26-2025

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

The facility failed to maintain wheelchairs in safe operating condition for two residents. For one resident with spinal stenosis, joint replacement aftercare, and diabetic neuropathy, the wheelchair had multiple issues including a non-functioning left brake, a loose and wobbly left armrest, and a right wheel with a missing metal hand rim that left sharp edges exposed. The resident reported these problems, describing the situation as dangerous. The Plant Director confirmed the need for parts replacement and acknowledged that the cracked upholstery posed an infection control risk and that the broken metal and inoperative brake could result in injury. The Physical Therapy Assistant also confirmed the issues and stated that a work request had been submitted for repairs, but a suitable replacement wheelchair was not available. Another resident with osteoarthritis, right knee pain, and hemiplegia reported that their wheelchair, though previously repaired, remained shaky with a loose left wheel and cracked, peeling upholstery on the left armrest. The resident had reported these issues, and the Plant Director, upon assessment, agreed that parts replacement was needed. The cracked upholstery was again identified as an infection control issue, and the loose wheel was recognized as a risk for injury. Facility policy requires equipment to be maintained in good working order for resident safety and for staff to communicate specific accommodation needs, but these requirements were not met in these cases.

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