§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
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Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement safety interventions for one of 23 sampled residents. (Resident 30)
Findings include:
Clinical record review revealed that Resident 30 was admitted to the facility on July 23, 2021, and had diagnoses that included peripheral vascular disease, malnutrition, osteoporosis, generalized muscle weakness, muscle wasting, atrophy, and lower back pain. On February 27, 2024, a physician ordered that staff place padded fall mats to both sides of the resident's bed while the resident is in bed every shift. The Minimum Data Set (MDS) assessment dated October 10, 2025, revealed Resident 30 was on hospice and required staff assistance for bed mobility and transfers. Review of the care plan revealed that the resident was at risk for falls and staff was to place mats on the floor on both sides of the bed while the resident was in bed.
On October 28, 2025, at 11:40 a.m., October 30, 2025, at 2:00 p.m., and October 31, 2025 at 9:33 a.m., Resident 30 was in bed without padded mats on the floor on both sides of the bed.
In an interview on October 31, 2025, at 11:18 a.m., the Administrator confirmed that the bilateral padded fall mats were not in place.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 11/17/2025
Step 1: Bilateral fall mats added to bedside for Resident J.R.
Step 2: All residents that require bilateral fall mats have the potential to be affected. An audit was conducted to ensure that fall mats were in place as ordered. If observed not in place, fall mat placed.
Step 3: To prevent the potential for re-occurrence, the DON/designee educated all nursing staff to ensure that fall mats are in place for residents that require them.
Step 4: To monitor and maintain ongoing compliance, the DON/Designee will audit 5 residents twice weekly x 1 month, then weekly x 2 months to ensure that fall mats are in place if required. If fall mats are not in place as ordered, fall mats immediately and staff re-educated. Results will be reported to QAPI committee for review and recommendations.
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