Sayre Health Care: Fall Prevention Failures - PA
Resident 2 scored 14 on the facility's fall risk assessment in December 2025, placing her in the high-risk category. Any score of 10 or greater indicates high fall risk at Sayre Health Care Center.
Her care plan, initiated in November 2024, included specific interventions: a chair alarm activated November 11, 2025, and encouragement to use handrails or assistive devices properly. Staff assessments showed she needed supervision or physical assistance to sit up from lying down, stand from seated positions, transfer between bed and chair, and walk 10 to 150 feet.
On December 20, 2025, at 2:50 PM, a registered nurse heard Resident 2 yelling "help me, I fell." Staff found her lying on her left side in front of a wheelchair on the 700 hallway, though she lived on the 600 hallway. Documentation showed staff "assisted from the floor into wheelchair with two assist."
The facility's investigation revealed the problem: Resident 2 "was in a different wheelchair without alarm."
Her assigned wheelchair included a safety alarm designed to alert staff when she attempted to stand or move independently. The unassigned wheelchair lacked this critical safety feature.
The fall occurred despite multiple assessments documenting her high fall risk and need for assistive devices. Her November 2025 assessment indicated she used a walker and required staff supervision for basic mobility tasks.
Following the incident, facility staff implemented new interventions to prevent future falls. They added education for staff "regarding the importance of ensuring the resident is in the assigned wheelchair."
The facility revised Resident 2's fall risk care plan on December 20, 2025, the same day as her fall. The updated plan required staff to "ensure Resident 2 was always seated in her assigned wheelchair to promote proper fit and stability and ensure chair alarm is in place and activated."
But inspectors determined the facility had already failed to implement existing fall prevention measures. The December 20 fall happened because staff had not followed the interventions already established in her care plan.
Resident 2's case illustrates how equipment mix-ups can have immediate consequences for vulnerable residents. Her high fall risk score of 14 indicated she faced significant danger without proper safety measures.
The wheelchair alarm system was specifically designed for residents like her who needed supervision for basic movements. When staff placed her in an unassigned wheelchair, they removed a critical layer of protection.
Federal inspectors reviewed the incident with Sayre Health Care Center's nursing home administrator and director of nursing on April 3, 2026. The facility violated Pennsylvania regulations requiring proper resident care plans and adequate nursing services.
The inspection found the facility failed to implement interventions that could have prevented Resident 2's fall. Her care plan clearly outlined necessary safety measures, including the chair alarm that was missing from the wheelchair she was using.
Resident 2's fall from the 600 hallway to the 700 hallway suggests she had traveled some distance in the unassigned wheelchair before the incident occurred. Staff found her lying beside the wheelchair, indicating she had attempted to stand or transfer without the alarm system that would have alerted them to provide assistance.
The timing of the care plan revision on the same day as the fall shows the facility recognized the connection between the equipment failure and the incident. The new interventions focused specifically on ensuring proper wheelchair assignment and alarm activation.
For Resident 2, the fall represented a breakdown in the safety systems designed to protect high-risk residents from preventable injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sayre Health Care Center from 2026-04-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
SAYRE HEALTH CARE CENTER in SAYRE, PA was cited for violations during a health inspection on April 3, 2026.
Resident 2 scored 14 on the facility's fall risk assessment in December 2025, placing her in the high-risk category.
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.
Frequently Asked Questions
- What happened at SAYRE HEALTH CARE CENTER?
- Resident 2 scored 14 on the facility's fall risk assessment in December 2025, placing her in the high-risk category.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SAYRE, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from SAYRE HEALTH CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395101.
- Has this facility had violations before?
- To check SAYRE HEALTH CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.