Observations:
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of three residents reviewed (Resident 1).
Findings include:
A wheelchair transport policy dated January 8, 2026, revealed that footrests must be used when staff, family, volunteers and healthcare partners (vendors) are assisting residents who are transported by wheelchair, Broda chair or any other chair with attachable footrests to prevent accident/injury.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 13, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia.
An incident investigation dated December 20, 2025, at 10:40 p.m. revealed that Nurse Aide 1 was pushing Resident 1 in her wheelchair to her room without leg rests. The resident leaned forward and fell onto the floor. She sustained a 1.5 by 1.5-centimeter abrasion to the left side of her forehead, a 0.5 by 0.5-centimeter abrasion to left eyebrow and a 3 centimeter by 3-centimeter bruise to the left side of her forehead.
A witness statement from Nurse Aide 1, dated December 20, 2025, at 9:14 p.m. revealed that she was pushing Resident 1 in her wheelchair and she leaned forward and fell out of the wheelchair and confirmed that resident did not have leg rests on when she was pushing her.
Interview with the Nursing Home Administrator on March 5, 2065, at 3:12 p.m. confirmed that leg rests should have been in place when transporting Resident 1.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 04/06/2026
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. The resident received leg rests following the incident.
2. The Rehab Director or designee audited all residents utilizing wheelchairs for having leg rests. They were issued to any resident who did not have a set.
3. The staff will be educated on the wheelchair leg rest policy, procedure, and F-689 (Free of Accident/Hazards/Supervision/Devices) by the Director of Nursing or designee.
The residents in wheelchairs who can understand will be educated on the wheelchair leg rest policy and procedure by the Director of Nursing or designee.
The nursing home administrator or designee will review the wheel care leg rest policy and procedure with the residents during the Resident Council meeting.
The family members/ resident representatives will be sent a letter explaining the policy and procedure for the need to use wheelchair leg rests by the Nursing Home Administrator or designee.
4. 20 Residents per week will be audited for the proper use of wheelchair leg rests for 2 weeks then, 10 Residents a week for 2 weeks by the nursing home administrator or designee.
The results of the audits will be reviewed in the monthly Quality Assurance and Process Improvement meetings for 3 months.
Date of Compliance: April 6, 2026
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