The cornerstone of the program was structured individual assessment and treatment. For living space and personal safety, the assessment sought to identify and correct potential problems with the resident’s bed, floor surfaces, clutter, lighting, accessibility of objects, and bathroom equipment. For wheelchairs, there was a detailed review of the fit, maintenance, brakes and other safety features, foot- and leg-rests, seat and back, forward motion protection, posture of the resident, and propelling and reaching. A routine wheelchair maintenance program also was suggested. For psychotropic medication use, the program recommended reevaluation of medication use and assessment of behavior, as well as changes in drug regimens when needed (with sample letters for contacting the prescribing physician and consulting pharmacist and model schedules for gradual dose reduction) and appropriate nonpharmacologic interventions. For transferring and ambulation, the assessment included direct observation of transferring (from a bed, wheelchair, lounge chair, and toilet) and ambulation or self-propelling in a wheelchair, inspection of equipment height and stability and footwear, and review of the quality of staff assistance with transferring and foot care. This evaluation provided the basis for instruction of staff and residents in safer transfer techniques (including managing unsafe behavior related to cognitive impairment27) and potential recommendations for occupational and physical therapy, medical consultation, or routine staff assistance during transfers, repair, or modification of equipment (including wheelchair seating modifications).