Maple Heights Health & Rehab: Wheelchair Safety Failure - PA
The August 27 inspection at Maple Heights Health & Rehab Center found the violation at 11:50 in the morning. Resident 8, a cognitively impaired man who needed staff assistance for his personal care, was being transported by Nurse Aide 3 through the facility in a high-back wheelchair. His physician had ordered, in writing since May 15, that he use bilateral elevating leg rests whenever he was moved or taken outside. No leg rests were on the chair.
When the inspector asked Nurse Aide 3 about it on the spot, she confirmed she had not applied the leg rests before transporting the resident. She said she should have.
That was the whole of the explanation.
The nursing home administrator, interviewed that same afternoon at 2:21 p.m., confirmed what the aide had already acknowledged: the leg rests should have been used as ordered, and they were not.
Elevating leg rests on a wheelchair are not a comfort feature. For residents with certain diagnoses, they keep legs supported and stable during transport, reducing the risk that limbs shift, drag, or are injured when a chair moves through doorways, turns corners, or stops abruptly. Resident 8's quarterly assessment, completed May 16, documented that he had dementia severe enough to impair his daily functioning and that he required staff help for personal care. He was not in a position to notice the missing equipment himself, ask for it, or protect his own legs during transport.
The physician order had been in place for more than three months by the time inspectors watched it go ignored.
Federal inspectors rated the violation as causing minimal harm or potential for actual harm, and noted it affected few residents. One resident was identified in the review of ten. The citation falls under the regulatory requirement that nursing homes remain free from accident hazards and provide adequate supervision to prevent accidents.
What the inspection captured was not a complicated systems failure or a disputed clinical judgment. A nurse aide moved a resident. The chair was missing equipment his doctor had ordered. The aide knew it was missing. She transported him anyway.
The administrator's confirmation that afternoon did not include, in the inspection record, any account of how long the leg rests had been going unused, whether this had happened before, or what the facility intended to do differently. The record contains what inspectors observed and what staff said when asked. It stops there.
Resident 8 made it to his bedroom for lunch. What the inspection report does not say is whether his legs were injured, whether anyone checked, or whether the leg rests were applied before his next trip down the hall.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maple Heights Health & Rehab Center, LLC from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 2, 2026 · Our methodology
Maple Heights Health & Rehab Center, LLC in EBENSBURG, PA was cited for violations during a health inspection on August 27, 2025.
The August 27 inspection at Maple Heights Health & Rehab Center found the violation at 11:50 in the morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.