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F0907
D

Failure to Provide Adequate Space for Wheelchair Mobility

Los Angeles, California Survey Completed on 12-23-2025

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 provide adequate space and equipment to meet the needs of two residents who both required wheelchairs for mobility. Observations and interviews revealed that the room shared by these residents did not allow sufficient space for them to maneuver their wheelchairs without bumping into each other. Both residents had medical conditions affecting their mobility, including hemiplegia, hemiparesis, generalized muscle weakness, and foot drop. Documentation indicated that both residents had intact cognition or fluctuating capacity to make decisions, and both required moderate assistance with activities of daily living. The lack of space led to repeated incidents where their wheelchairs collided, causing frustration and making it difficult for them to move around their room safely and comfortably. Staff interviews, including those with the Social Services Director and the Administrator, confirmed that the room arrangement did not accommodate the residents' needs, resulting in miscommunication and disagreements between the residents. The facility's own policy required adaptation of the physical environment to meet individual needs and preferences, but this was not implemented in this case. The deficiency was directly observed by staff and corroborated by resident statements, with specific incidents such as a water pitcher being knocked over due to the lack of space.

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