Renaissance Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Illinois.
- Location
- 1675 East Ash Street, Canton, Illinois 61520
- CMS Provider Number
- 145793
- Inspections on file
- 24
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Renaissance Care Center during CMS and state inspections, most recent first.
A resident with MS and impaired mobility, care planned for 2-person transfers with a mechanical lift, was being moved from bed to a wheelchair when a bottom sling strap broke, causing a fall that resulted in an acute intertrochanteric right femur fracture and hospital admission. Facility policies and manufacturer instructions required inspection of slings before each use and prohibited bleach and high-heat laundering, but staff interviews revealed that slings had been washed with bleach, laundered with sheets, and dried on a high-heat setting, with staff uncertain of exact temperatures. CNAs reported that the sling appeared intact before the transfer, and post-incident management determined the sling straps were dry-rotted, indicating deterioration associated with improper laundering and inadequate monitoring of sling condition.
A facility failed to store refrigerated vaccination units separately from food and beverages, violating their medication storage policy. A medication fridge labeled 'Medications Only' contained a plastic container of unlabeled food and an open hydration drink, stored directly on top of influenza vaccines. Staff confirmed that food and drinks should not be stored in the medication fridge, which is designated solely for medications. The facility houses 59 residents.
The facility did not complete required background checks for five residents within the mandated timeframe due to the absence of responsible staff. The checks, including criminal history and sex offender registry screenings, were delayed by three to five days, violating the facility's Abuse Prevention Program Policy.
The facility failed to assess and document the use of bed rails for seven residents, violating safety protocols. Despite the facility's policy requiring assessments, physician orders, and informed consent, these steps were not completed. Residents with various medical conditions and fall risks used bed rails without proper documentation, posing safety risks. The facility lacked an assessment form, and no assessments or consents were completed, indicating a systemic issue in compliance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents with conditions requiring such measures, including urostomies, colostomies, and indwelling urinary catheters. Staff did not consistently wear gowns or gloves during care, and EBP signage and PPE were often absent from residents' rooms. The Infection Control Preventionist acknowledged the oversight and lack of staff education on EBP protocols.
The facility failed to perform maintenance inspections of bed rails for entrapment risks for several residents. Observations showed residents using side rails or assist rails without documented inspections in their medical records. The Maintenance Assistant was unaware of any inspections being conducted, indicating a gap in safety procedures.
The facility failed to cover urinary drainage catheter bags for two residents, compromising their dignity. One resident with intact cognition and another with severe cognitive impairment were observed with uncovered catheter bags visible from the hallway. The DON confirmed that catheter bags should be covered to maintain dignity, highlighting a lapse in the facility's policy adherence.
A resident with bilateral above-the-knee amputations and arthritis did not receive the prescribed range of motion (ROM) exercises as per the facility's policy. The resident reported not receiving assistance with ROM exercises, and CNAs confirmed they did not perform these exercises. The Restorative Aide admitted to only conducting ROM exercises once a week, contrary to the daily requirement, indicating a failure in the facility's restorative care program.
A facility failed to obtain daily weights for a resident with Congestive Heart Failure (CHF) as ordered by the physician. The resident's care plan required daily weights starting from a specific date, but records show that weights were missed on ten occasions. The facility's policy assigns responsibility for obtaining weights to the CNA or designee, with oversight by the nurse management team. This deficiency was confirmed by the DON.
A resident with severe cognitive impairment was neglected in a LTC facility, remaining soiled and odorous for an extended period. Despite claims of aggressive behaviors preventing care, staff later changed the resident without issue. Video evidence and staff interviews revealed a failure to appropriately manage the resident's behaviors, leading to neglect.
A resident was improperly restrained in a reclining wheelchair with the footrest positioned over a couch, preventing movement. Multiple staff members observed and reported the incident, which violated the facility's restraint policy. A registered nurse was terminated for not understanding appropriate responses to resident behaviors and providing conflicting statements about the incident.
A facility failed to document medication administration properly, leading to double dosing for four residents. A night shift LPN did not sign the MAR after administering medications, causing the oncoming nurse and assisting staff to administer the medications again. The affected residents received a second dose of their morning medications.
The facility failed to prevent significant medication administration errors for three residents due to a nurse's failure to document administered medications, leading to double dosing. The errors were discovered when a supervisor noticed discrepancies in the narcotic book and MAR.
Mechanical Lift Sling Deterioration Leads to Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to properly maintain and monitor mechanical lift slings, resulting in a sling strap breaking during a transfer and causing a resident to fall. Facility policy for hydraulic lifts required that all nursing staff be trained in proper use of mechanical lifts and that staff ensure sling straps are securely placed on the hooks of the carry bar prior to lifting. The manufacturer’s full body sling instructions warned that slings must be carefully inspected before each use for wear and damage, and that torn, cut, frayed, or otherwise deteriorated slings must be discarded. Additional facility guidelines for identifying deteriorated slings stated that bleach, high-temperature washing or drying, and harsh mechanical action can accelerate deterioration of sling materials, especially loop straps, and that such slings may appear intact while having compromised tensile strength. The resident involved had multiple sclerosis, muscle weakness, and an existing nondisplaced intertrochanteric fracture of the right femur at admission, and was care planned to require a mechanical lift with two staff assisting for transfers. During a transfer using a mechanical lift, two CNAs placed the sling under the resident, attached all four straps to the lift, and began lifting the resident from bed toward a wheelchair. Both CNAs reported that the sling and straps appeared intact prior to the lift. While the resident was suspended in the air and being guided toward the wheelchair, the bottom right sling strap broke. One CNA reported seeing the resident fall to the ground, and the other described the resident falling out of the sling, hitting the side of the bed, and landing on her right side. When the RN arrived, the resident was lying horizontally on her right side across the lift legs with her neck turned to the side near the nightstand. The emergency department record documented that the resident was transferred by ambulance for right hip and right arm pain after the mechanical lift sling broke during a transfer, causing her to fall onto the bed. Imaging showed an acute intertrochanteric right femur fracture and a normal humerus X-ray, and the resident was admitted to the medical-surgical floor for further treatment. Following the incident, facility staff, including CNAs and the DON, stated that management determined the sling straps were dry-rotted. Interviews with environmental and laundry staff revealed that, prior to the fall, mechanical lift slings had been bleached, washed together with sheets, and dried in a dryer with a single high-heat setting, contrary to the manufacturer’s instructions that prohibited bleach and high-temperature drying and recommended gentle laundering conditions. Staff also reported uncertainty about wash and dry temperatures and described a process in which slings were laundered and then visually checked for damage or fraying before being returned for use.
Improper Storage of Vaccines with Food in Medication Fridge
Penalty
Summary
The facility failed to ensure that refrigerated vaccination units were stored separately from food and beverages, which is a violation of their Storage of Medications policy. This policy, dated April 2016, mandates that all medications requiring refrigeration must be kept in a separate, securely fastened locked box within a refrigerator or a locked refrigerator, located at or near the nurse's station or in a refrigerator within a locked medication room. During an observation on January 9, 2025, at 11:40 AM, it was noted that the medication storage fridge on the facility's 100 hall, which was labeled 'Medications Only,' contained a plastic container of food without a label, sitting directly on top of two boxes of influenza vaccine. Additionally, an open bottle of a flavored hydration drink was found inside the same fridge. Interviews with V13, a Registered Nurse, and V19, a Licensed Practical Nurse, confirmed that food and drinks should not be stored in the medication room refrigerator, which is designated solely for medications. V13 speculated that the food, which appeared to be chili soup, might have been brought in for a resident by agency nurses who were unaware of the proper storage protocol. V16, the Infection Control Preventionist, confirmed that the influenza vaccines stored in the 100-hall medication room refrigerator could be administered to any resident in the building and reiterated that no food or open drinks should be kept in that refrigerator. The facility's Long Term Care Application for Medicare and Medicaid, dated January 7, 2025, and signed by V1, the Administrator, documents that 59 residents reside in the facility.
Failure to Conduct Timely Background Checks for New Admissions
Penalty
Summary
The facility failed to adhere to its Abuse Prevention Program Policy by not completing required background checks for five residents within the stipulated time frame. The policy mandates that a criminal history background check, Illinois Sex Offender Registry check, and Illinois Department of Corrections Registry check be conducted prior to or within 24 hours of a resident's admission. However, for residents R107, R108, R109, R110, and R157, these checks were completed three to five days after their admission, contrary to the facility's policy. The deficiency was attributed to the absence of the Admissions Coordinator and the Vice President of Operations, who were responsible for conducting these checks. Their absence during the admission of these residents resulted in the delay of the necessary background screenings. This oversight was confirmed through interviews, where it was acknowledged that the checks were not performed within the required timeframe due to the responsible personnel being off-duty during the admissions.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for seven residents, leading to a deficiency in compliance with safety protocols. The facility's policy requires a thorough assessment of the need for side rails, including a risk assessment for entrapment, obtaining a physician's order, and securing informed consent from the resident or their representative. However, the facility did not complete these necessary steps for any of the seven residents reviewed, as confirmed by the Director of Nursing. Each of the seven residents had specific medical conditions and fall risks that necessitated careful consideration before the use of bed rails. For instance, one resident with chronic respiratory failure and diabetes was using 1/2 side rails for mobility and safety without a documented assessment or consent. Another resident with severe cognitive impairment and a high risk for falls was using an assist rail without the required documentation or physician's order. These omissions were consistent across all seven residents, indicating a systemic issue in the facility's adherence to its own policies. The observations and interviews conducted during the survey revealed that the facility did not have an assessment form for side rails, and no assessments or consents were completed for the residents using them. This lack of documentation and oversight poses a significant risk to resident safety, as the facility did not evaluate the potential for entrapment or other hazards associated with the use of bed rails. The deficiency highlights a critical gap in the facility's compliance with regulatory requirements for resident safety and care planning.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for five residents, leading to deficiencies in infection prevention and control. The facility's Infection Control Policy mandates the use of Standard and Transmission-Based Precautions, including Enhanced Barrier Precautions for residents with certain conditions. However, observations revealed that staff did not consistently wear gowns or gloves when providing care to residents who required EBP due to conditions such as urostomies, colostomies, indwelling urinary catheters, and diabetic foot ulcers. For instance, one resident with a urostomy and colostomy reported that staff did not wear gowns or gloves during care, and there was no EBP signage or PPE available in the room. Another resident with an indwelling urinary catheter was not listed on the facility's EBP list, and staff confirmed that EBP precautions were not implemented as required. Additionally, a resident with a diabetic foot ulcer did not have EBP signage or PPE in their room, and staff did not wear the necessary protective equipment during care. The facility's Infection Control Preventionist acknowledged the oversight in implementing EBP for residents with conditions that could lead to infection. The Preventionist admitted that PPE was not available in every room and that staff were not fully educated on the need to wear gowns and gloves during close contact activities, such as transfers or incontinence care. This lack of adherence to EBP protocols resulted in a failure to adequately protect residents from potential infections.
Failure to Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to conduct maintenance inspections of side rails and assist rails for entrapment zones and risks for seven residents. Observations revealed that residents were using side rails or assist rails in various positions, but their medical records lacked documentation of maintenance inspections for these rails. This deficiency was noted for residents who were either lying in bed or sitting up with rails in the raised position, indicating a lack of routine safety checks. During an interview, the Maintenance Assistant admitted to not being aware of any inspections being conducted for side rails or assist rails to check for entrapment risks. The assistant stated that their role was limited to applying the rails and fixing them if they broke, highlighting a gap in the facility's maintenance procedures for ensuring the safety of bed rails and preventing potential entrapment hazards.
Failure to Cover Urinary Catheter Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents by not covering their urinary drainage catheter bags with privacy bags, as observed during a survey. Resident R4, who has an intact cognitive status with a BIMS score of 15/15, was found with an uncovered urinary drainage catheter bag visible from the hallway, containing amber-colored urine. This observation was made despite the facility's policy to ensure privacy and dignity for all residents. Similarly, Resident R48, who has severe cognitive impairment with a BIMS score of 2/15, was also found with an uncovered urinary drainage catheter bag visible from the hallway, containing yellow-colored urine. The Director of Nursing confirmed that the catheter bags should be covered to promote dignity, indicating a lapse in adherence to the facility's dignity and privacy policy.
Failure to Implement Restorative ROM Program
Penalty
Summary
The facility failed to implement a restorative range of motion (ROM) program for a resident identified as R20, who was reviewed for limitations in range of motion. The facility's policy required that all residents be assessed for risk factors for contractures and that a program be developed and included in the care plan. However, R20, who had bilateral above-the-knee amputations and limitations in raising his arms due to arthritis, reported not receiving the prescribed ROM exercises from staff. The resident expressed a desire for staff to assist with exercises, indicating a lack of adherence to the facility's policy. Observations and interviews revealed that the Certified Nursing Assistants (CNAs) responsible for R20's care did not perform the required ROM exercises. The Restorative Aide, V17, acknowledged that the resident's program required daily hand-over assistance for ROM exercises but admitted to only performing them once a week, with CNAs expected to cover the remaining days. This inconsistency in providing the necessary ROM exercises highlights a deficiency in the facility's implementation of its restorative care program.
Failure to Obtain Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure that physician-ordered daily weights were obtained for a resident with Congestive Heart Failure (CHF). The resident, identified as R31, had a physician order dated 1/08/25 for daily weights due to CHF, with the order starting on 10/24/2024. The facility's Weights policy, dated 9/1/19, outlines the responsibility of the Certified Nursing Assistant (C.N.A.) or designee to obtain weights monthly and as ordered, with the nurse management team responsible for monitoring timely completion. However, R31's Weights and Vitals Summary Logs from 10-24-24 through 1-8-25 show that the resident was not weighed daily as ordered on ten occasions. This deficiency was verified by the Director of Nursing (V2) on 01/07/25 at 12:15 PM.
Neglect of Resident Due to Mismanagement of Behaviors
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident being visibly soiled and having an odor. The resident, who is severely cognitively impaired and uses a reclining padded wheelchair for mobility, was found in a soiled state by a registered nurse (RN) at approximately 5:45 PM. The RN noted that the resident was wet and soiled, and had slid down in her wheelchair. Despite the resident's behaviors of aggression, the RN and a certified nurse aide (CNA) were able to change and clean the resident without any issues. The incident was reported by the resident's Health Care Power of Attorney, who noticed the resident's condition during a visit. The facility's investigation revealed that the resident had not been changed or toileted from the time she got up until she was attended to by the RN and CNA. The RN on duty at the time of the incident claimed that the resident's aggressive behaviors prevented staff from providing care, but this was contradicted by other staff members who stated that the resident was not exhibiting behaviors at the time care was provided. The facility's video footage confirmed that the resident remained in her wheelchair without being changed for an extended period. Interviews with staff members revealed a lack of understanding and appropriate response to the resident's behaviors, leading to the neglect. The RN responsible for the resident's care was found to have given instructions to leave the resident in her soiled state due to her behaviors, which was not consistent with the facility's policy on abuse and neglect.
Resident Restrained by Wheelchair Positioning
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, was free from physical restraints, as required by their policy. The incident involved R1 being positioned in a reclining wheelchair with the footrest over the seat of a couch, which restricted her ability to move. This situation was observed by multiple staff members, including certified nurse aides and registered nurses, who reported that R1 was unable to get out of her chair due to the positioning of the footrest. The facility's policy on physical restraints, dated 9/23/15, does not clearly define situations that could be considered a physical restraint, but it does state that restraints should only be used when necessary and after all alternatives have been documented as ineffective. The incident occurred on 5/19/24, and several staff members provided written statements and interviews confirming the positioning of R1's wheelchair. The administrator on call reviewed video footage and confirmed the positioning of the wheelchair, which would have prevented R1 from lowering the footrest. A registered nurse, V3, was implicated in the incident, with conflicting statements about the positioning of R1's wheelchair. V3 was later terminated from employment after it was determined that she did not understand the appropriate response to resident behaviors and was not truthful about her instructions and responses regarding R1 on the day of the incident.
Medication Administration Documentation Failure
Penalty
Summary
The facility failed to follow proper procedures when documenting medication administration for four residents (R1, R2, R3, and R5). On the morning of 5/7/24, a day shift nurse called in sick, leading to a series of medication administration errors. The night shift nurse (V5) stayed over to pass medications but did not sign the Medication Administration Record (MAR) for several residents. As a result, the oncoming nurse (V14) and other assisting nurses administered medications again, leading to double dosing for some residents. R1, R2, and R5 received a second dose of their 8:00 AM medications because V5 did not document the initial administration. R1's medications included Amlodipine, Aspirin, Doxepin, Flonase, Loratadine, Protonix, Vitamin B Complex, Gabapentin, Oxybutynin, Polysaccharide Iron, Tizanidine, and Tylenol. R2's medications included Fluoxetine, Furosemide, Omeprazole, Apixaban, Carvedilol, Polysaccharide Iron Complex, Potassium Chloride, Pregabalin, and Umeclidinium-Vilanterol. R5's medications included Fluticasone Furoate Vilanterol, Fish Oil, Folic Acid, Furosemide, Lasix, Levothyroxine, Loratadine, Myrbetriq, Omeprazole, Primidone, Multivitamin with Mineral, Amino Acids Protein Hydrolysate, Tamsulosin, Colace, and Sodium Bicarbonate. The incident was discovered when V6, the Nursing Supervisor, noticed that R2's Lyrica had already been signed out in the narcotic book by V5. Upon further investigation, it was confirmed that V5 had administered medications to six residents but failed to document it in the MAR. This led to the oncoming nurse (V14) and other assisting nurses administering the medications again, resulting in double dosing for R1, R2, and R5. The facility's policies and procedures for medication administration were not followed, leading to these errors.
Significant Medication Administration Errors
Penalty
Summary
The facility failed to prevent significant medication administration errors for three residents (R1, R2, and R5) due to a series of actions and inactions by the nursing staff. On the morning of the incident, a day shift nurse called in sick, prompting the night shift nurse (V5) to stay over and assist with the medication pass. V5 administered medications to six residents but failed to document the administration in the Medication Administration Record (MAR). This oversight led to the oncoming nurse (V14) administering the same medications again to three of these residents (R1, R2, and R5), resulting in double dosing. The error was discovered when the nursing supervisor (V6) noticed that a medication had already been signed out in the narcotic book but not documented in the MAR. R1, who has a complex medical history including Type 2 Diabetes Mellitus, Hypertension, and Chronic Obstructive Pulmonary Disease, received a double dose of twelve different medications. Similarly, R2, who suffers from Chronic Heart Failure, Diabetes, and Chronic Kidney Disease, was given a double dose of nine medications. R5, diagnosed with Seizures, Crohn's Disease, and End Stage Renal Disease, received a double dose of fifteen medications. The nursing staff immediately assessed the residents and found no adverse reactions at the time. However, the failure to document medication administration as per the facility's policy led to these significant medication errors. Interviews with the involved staff revealed that V5 did not have a clear explanation for failing to document the medication administration, attributing it to being tired and hurried after working a 14-hour shift. The facility's policies and procedures clearly state that medications must be documented immediately after administration, a step that was neglected by V5. This lapse in following established protocols resulted in the medication errors, highlighting a critical deficiency in the facility's medication administration process.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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