Resident 1 was found lying on his back on a fall mat beside his bed on August 28, 2025. The call bell wasn't activated. His bed was cranked up to a 90-degree angle.
Nobody witnessed the fall. Nobody wrote witness statements. Staff conducted no investigation to determine what caused the fall or how to prevent another one.
The facility's response was minimal. They added one intervention to his care plan the next day: encourage him to keep his bed at 45 degrees or below when sleeping.
Five days later, at 7:25 AM on September 2, it happened again.
This time, the resident was found naked on the floor mat beside his bed. He winced in pain when staff tried to move him. Nursing records don't indicate whether he was incontinent or when staff had last provided care.
The physician ordered an X-ray of his left hip and pelvis. At 8:44 AM, the resident complained of pain and received acetaminophen.
Again, almost nobody witnessed what happened. A housekeeper walking by saw him on the floor and alerted a nurse. That was the only witness statement available.
Staff had installed a bed bolster overlay and positioned a fall mat on the right side of his bed. They kept his bed lower than 90 degrees except during meals. After the second fall, they added a new intervention: provide a stuffed animal for comfort.
The first X-ray on September 2 showed no hip fracture. But the resident didn't get out of bed again until September 6.
On September 5, at 5:15 PM, he complained of leg pain during repositioning. The physician ordered an X-ray of his left leg. Staff gave him more acetaminophen.
The next evening, September 6 at 8:39 PM, his pain was getting worse. The X-ray revealed an acute comminuted distal femoral fracture. The bone at the end of his femur, near his knee, had broken into multiple pieces.
The physician was notified. The resident was transferred to the hospital.
Hospital documentation showed CT scans and X-rays confirmed a left periprosthetic femur fracture. He was admitted to the trauma unit for pain management and therapy. Doctors determined the fracture was too severe for surgery.
The resident was eventually discharged back to Birchwood.
Federal inspectors found no evidence that staff adequately investigated either fall or developed individualized interventions to prevent them. One fall resulted in serious injury requiring hospitalization.
During a September 17 interview, the corporate nurse consultant couldn't provide evidence that the facility had properly investigated the falls or implemented adequate prevention measures.
The inspection occurred after someone filed a complaint about the facility's care. Inspectors determined the facility caused actual harm to the resident through its failures.
The regulatory violation centers on nursing services requirements. Pennsylvania regulations mandate that nursing facilities provide adequate nursing care to prevent accidents and injuries.
Between the two falls, staff made only superficial changes to the resident's care plan. They didn't analyze why a resident with existing fall interventions continued falling from bed. They didn't examine whether positioning, medication effects, or care timing contributed to the incidents.
The resident's bed position emerged as a factor. His bed was at 90 degrees during the first fall, despite fall risk protocols. After the first incident, staff added an intervention about bed positioning, but he fell again five days later.
The second fall was more serious. Finding him naked on the floor suggests possible incontinence or inadequate assistance with toileting needs. Documentation gaps prevented inspectors from determining when staff had last checked on him or provided care.
The delay in diagnosing his fracture compounded the problem. Despite his pain complaints during repositioning on September 5, the leg X-ray wasn't ordered until the next day. The fracture wasn't discovered until September 6, four days after the fall that likely caused it.
Hospital records confirmed the severity of the injury. A periprosthetic femur fracture near a knee replacement is a serious complication requiring specialized trauma care. The multiple bone fragments made surgical repair impossible.
The corporate nurse consultant's inability to explain the facility's fall prevention efforts during the inspection highlighted systemic problems. Facilities are required to investigate falls, identify contributing factors, and modify care plans to prevent recurrence.
Instead, Birchwood's interventions remained generic: bed positioning, fall mats, and a stuffed animal for comfort. None addressed the specific circumstances that led to repeated unwitnessed falls from the same resident's bed.
The resident's prolonged bed rest after the second fall, followed by increasing pain and the eventual fracture discovery, demonstrates the consequences of inadequate fall prevention and injury assessment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Birchwood Rehabilitation & Healthcare Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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