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F0908
D

Failure to Maintain Resident Wheelchair in Safe Condition

Belen, New Mexico Survey Completed on 11-18-2025

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 resident with a history of repeated falls, generalized muscle weakness, and a need for assistance with personal care was observed sitting in a wheelchair that was not maintained in safe operating condition. The back bar of the wheelchair was detached and hanging on one side, and the resident reported that the wheelchair had been broken for an extended period. The resident's care plan included interventions for assistance with activities of daily living, transfers, and mobility due to limited mobility. A Licensed Practical Nurse noticed the broken wheelchair and verbally informed the night nurse to notify therapy staff, but did not document the issue in the resident's progress notes. The Physical Therapist stated that staff were expected to submit a work order in the maintenance reporting system to repair the wheelchair and to place the resident in a different wheelchair until repairs were completed. The therapist confirmed that the wheelchair was missing a securing knob and was unsafe for use.

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