F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, staff interview, and a review of facility documentation, it was determined that the
facility failed to implement safety interventions to prevent falls for one of four sampled residents. (Resident
3)Findings include: Clinical record review revealed that Resident 3 had diagnoses that included left and
right below the knee amputations. According to the Minimum Data Set assessment dated [DATE], Resident
3 required assistance for transferring from surface to surface (wheelchair to chair). On October 5, 2025, at
3:38 p.m., a nurse noted that Resident 3 was being transferred from his wheelchair to the weight chair by
NA1 and NA2. The wheelchair rolled from under the resident and the resident was lowered to the floor. The
nurse noted that the cause of the fall from her observation was that the bilateral wheelchair brakes were
broken and did not fully engage prior to the transfer. Review of facility documentation dated October 5,
2025, regarding the fall revealed that the bilateral wheelchair brakes were broken. In an interview on
January 21, 2026, at 5:00 p.m., the Director of Nursing confirmed that the staff should have ensured that
the brakes on the resident's wheelchair were engaged and working and that the wheelchair was not going
to roll when they attempted to transfer the resident. CFR 483.25(d) AccidentsPreviously cited 3/12/25 28
Pa. Code 211.12(d)(1)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
395817
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395817
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/21/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yardley Rehabilitation and Healthcare Center
1480 Oxford Valley Road
Yardley, PA 19067
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident and staff interviews, review of facility policy, and clinical record review, it was determined that the
facility failed to provide adequate treatment and care for a peripherally inserted catheter (a thin plastic tube
inserted into a vein using a needle) in accordance with professional standards of practice for one of two
residents. (Resident 4) Findings include: According to the Association of Vascular Access, at a minimum,
the clinician overseeing the care of the resident conducts a daily peripheral intravenous catheter (PIVC)
assessment. Clinicians must routinely inspect the insertion site and assess the functionality of the PIVCs
for signs of complications and document assessment results. Clinicians must perform a daily evaluation for
the ongoing need of the PIVC. Healthcare teams must review a resident's vascular access needs as part of
a comprehensive, interdisciplinary evaluation to ensure effective communication and appropriate care
planning. Further, clinicians should notify the provider if the PIVC is not used for 24 hours or more and
remove PIVCs when they are no longer required for the plan of care. Review of the facility policy entitled,
Peripheral Intravenous (IV) Catheter Removal last reviewed January 20, 2026, indicated that staff were to
evaluate the continued need for vascular access during provider visits and care planning. Staff were to
remove the peripheral intravenous catheter if vascular access was no longer clinically indicated or it was
not used for more than 24 hours. Staff were to document the date and time of procedure, and resident
tolerance. Clinical record review revealed that on December 25, 2025, Resident 4 had nausea and
vomiting. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 4 had no
cognitive impairment and required supervision/touching assistance for most activities of daily living and
transfers. During an interview, January 21, 2026, at 11:25 a.m., Resident 4 stated that she had an IV
catheter placed on December 25, 2025, because she had nausea and vomiting, but that the IV was never
used and wasn't removed until a couple days later. A physician's order dated December 25, 2025, directed
staff to place a peripheral intravenous catheter for hydration. Another physician's order dated December 25,
2025, directed staff to provide sodium chloride solution 0.9% and to use 100 milliliters per hour
intravenously every shift for rehydration for one day and to give one liter of normal saline solution. The
order's start date was December 25, 2025, at 11:00 p.m. and the order's discontinue date was December
26, 2025, at 11:06 a.m. According to the Medication Administration Record for December 2025, the
medication was never provided. A nurse practitioner's note dated December 26, 2025, revealed that the
PIVC was available in case of need but was not currently being used. There were no further evaluations or
assessments or notes found supporting the need to continue the PIVC. According to the resident and the
investigation of the Assistant Director of Nursing, the PIVC line was not removed until December 29, 2025.
Review of the clinical record revealed a lack of documentation to support that the resident's peripheral
intravenous line was removed and that the condition of the catheter or the skin surrounding the intravenous
site was assessed. During an interview January 21, 2026, at 5:30 p.m., the Assistant Director of Nursing
confirmed that the peripheral intravenous line was not removed until December 29, 2025, and that the
policy should have been followed. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395817
If continuation sheet
Page 2 of 2
