§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
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Observations:
Based on review of facility policy, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident was free of neglect during care which resulted in actual harm of an acute non-displaced fracture of the lateral malleolus and medial malleolus ( a recent break located on the outer side of the ankle at the end of the fibula and the inner side of the ankle at the end of the tibia with the bone fragments not shifting out of their normal position) for one of four residents reviewed (Resident R1).
Findings include:
The "Abuse, Neglect, and Exploitation" policy, dated 1/5/26, revealed "It is the policy of the Rouse Home to prevent, report, and investigate all allegations of abuse, neglect, or misappropriation of property relative to all residents in our care."
Resident R1's clinical record revealed an admission date of 11/1/25, with diagnoses that included dementia (a decline in mental abilities severe enough to interfere with daily life), depression, and weakness.
Resident R1's Functional Self Performance Deficit care plan, date initiated 4/14/26, revealed, "Broda chair (a specialized chair used for residents who require pressure relief, advanced postural support, and long-term sitting) with pommel cushion (cushion with a raised center section) with footrest and footbuddy (a cushioned wheelchair accessory used to support the lower legs and feet) on at all times."
Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E1, dated 5/25/26, at 1:25 p.m. "Resident was being pushed up the hallway to lunch when her right foot dropped and got caught under her Broda chair. Resident c/o (complained of) 8/10 pain (pain scale ranging from 0-10, with 10 being the worst pain ever experienced). Right ankle swollen. Pain medication administered, right ankle elevated, ice pack applied, RN (Registered Nurse) and family notified. VS (Vital Signs) baseline. X-ray ordered. Staff teaching done on the importance of using footrests. Will continue to monitor."
Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 1:32 p.m. "LPN reported resident's right leg buckled under wheelchair, c/o pain, ibuprofen administered. Writer assessed resident. Resident assisted into bed by two nursing staff, very heavy assist as resident will not bear weight on right leg. FOB (foot of bed) elevated. Writer observed right with significant swelling, bruising. Resident with c/o pain."
Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 2:34 p.m. "Transfer resident to ER (Emergency Room) to be evaluated and treated for right ankle trauma. Writer called diagnostics x-ray to inquire if x-ray could be performed in house today. After one-hour diagnostics had not returned phone call ..."
Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 3:15 p.m. "Resident R1 has left the facility. The resident was transferred to the hospital...Reason for Transfer/Condition: trauma to right ankle with c/o pain, will not bear on right extremity, significant swelling with bruising to right ankle..."
Resident R1's clinical record revealed x-ray scan results dated 5/25/26, at 5:58 p.m. indicating an acute non-displaced fracture of the lateral malleolus and medial malleolus.
Resident R1's clinical record revealed a nursing note written by RN Employee E3, dated 5/25/26, at 11:11 p.m. "Patient returned from ER at 10:30 p.m. Doctor made aware. Patient to be non-weight bearing to right lower extremity. Ice and elevate right extremity. Keep splint on at all times. Follow up with Ortho (specialize in treating bone fractures) in morning."
Resident R1's clinical record revealed a nursing note written by RN Employee E4, dated 5/26/26, at 8:20 a.m. "OT (Occupational Therapy) eval for positioning in new chair support of LE (Lower Extremity) r/t (related to) acute ankle fracture."
The facility investigation revealed that CNA (Certified Nursing Assistant) Employee E5 provided a written statement with an incident date of 5/25/26, which revealed, "[He/she ]helped another aide get [Resident R1] to the restroom, once they got [him/her] off and into [his/her] chair the aide told [him/her] to take [him/her] to the dining room. When wheeling [him/her] to the dining room [his/her] right leg dropped and got caught under [his/her] wheelchair. [He/she] immediately informed the nurse of what happened ...Was missing footrests."
The facility investigation revealed that LPN Employee E6 provided a written statement with an incident date of 5/25/26, which revealed, "Heard [Resident R1] crying out and aide apologizing. Resident was grasping [his/her] leg and grimacing. Aide was comforting resident. After a few minutes noticed resident's, right ankle was very swollen and was discolored and resident was expressing that it was painful...foot pedals were missing."
The facility investigation revealed that CNA Employee E7 provided a written statement with an incident date of 5/25/26, which revealed, "[He/she] was walking back on the hall from taking a resident to the dining room for lunch to get another resident when [he/she] saw CNA Employee E5 pushing Resident R1 to the dining room and [he/she] put [his/her] foot down and it got caught under the Broda chair...footrests were not on chair."
Review of facility orientation documents dated 10/22/25, for CNA Employee E5 revealed he/she received training related to Resident Abuse Policy and Procedure, indicating he/she understood the policy is to prevent neglect relative to all residents.
Review of facility orientation documents dated 11/8/25, for CNA Employee E5 revealed he/she received training related to safe transports related to a Broda chair and reviewed the facility's Foot Rest Policy.
Interview with the Assistant Director of Nursing and the Nursing Home Administrator on 6/18/26, at approximately 4:45 p.m. confirmed CNA Employee E5 failed to place the leg rests on Resident R1's Broda chair per his/her care plan and facility policy during transport on 5/25/26, causing harm to Resident R1.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 07/31/2026
Preparation and implementation of this Plan of Correction does not constitute an admission by the facility of the truth of the allegations, conclusions, or citations contained in the Statement of Deficiencies. The facility submits this Plan of Correction to demonstrate its good faith effort to comply with applicable federal and state regulations.
Corrective action for the resident found to be affected.
Resident R1 was immediately assessed by licensed nursing staff following the incident. The physician and resident representative were notified. The resident was transferred to the emergency department for evaluation and treatment, where diagnostic imaging confirmed a right ankle fracture. Upon return to the facility, physician orders were implemented, including non-weight-bearing status, pain management, and orthopedic follow-up evaluation. An interdisciplinary review of Resident R1's care plan was completed to ensure all required safety devices, including the Broda chair footrests and Foot Buddy, were clearly identified and reinforced. All staff received immediate re-education regarding Resident R1's transportation requirements. including
The incident was investigated in accordance with the facility's Abuse, Neglect, and Exploitation policy. Appropriate personnel actions were taken in accordance with facility policy.
Identification of other residents who have the potential to be affected:
The Director of Nursing/ designee completed an audit of all residents utilizing Broda chairs and other wheelchairs requiring footrests during transport. Resident care plans were reviewed to ensure transportation and safety interventions were accurately reflected, and direct observations were completed to verify that required footrests were present and properly utilized during resident transport. Any identified concerns were corrected immediately.
The facility has implemented the following corrective actions:
Re-educated all nursing staff, certified nursing assistants, rehabilitation staff, and other personnel responsible for resident transport regarding:
Safe wheelchair and Broda chair transport procedures.
Proper application and use of footrests and positioning devices.
Review of the Wheelchair Footrest Policy.
Review of Abuse, Neglect, and Exploitation policy emphasizing neglect prevention.
Resident-specific care plan compliance during transportation.
The Administrator/Director of Nursing or designee will conduct audits as follows:
Five observations per week of resident transports for four weeks.
Three observations per week for an additional four weeks.
Monthly observations thereafter for three months.
Audits will verify:
Footrests and leg rests are attached during transport.
Resident-specific positioning devices are used according to the care plan.
Staff follow safe transport procedures.
No residents are transported without required assistive devices.
Audit findings will be reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months. Trends will be analyzed, and additional education or corrective action will be implemented if compliance falls below 100%.
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