Rochelle Rehab & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochelle, Illinois.
- Location
- 900 North 3rd Street, Rochelle, Illinois 61068
- CMS Provider Number
- 145975
- Inspections on file
- 29
- Latest survey
- November 8, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rochelle Rehab & Health Care Center during CMS and state inspections, most recent first.
A resident was transferred to another facility without proper communication of their medical needs, leading to the resident leaving against medical advice. The transferring facility failed to inform the receiving facility of the resident's need for a private room due to an infection, resulting in inadequate arrangements and the resident's dissatisfaction.
The facility failed to provide timely 60-day discharge notices to two residents, leading to distress and rushed relocations. One resident, with a defibrillator, was given only two days' notice, causing significant emotional harm. The facility's staff confirmed that residents were informed of the closure with insufficient notice, and formal letters were only sent on the day of the survey.
Two residents with dementia were involved in an unwitnessed incident in the dining room, where one resident fell after being pushed by another. Both residents have a history of altercations and require supervision, which was not adequately provided. Staff were unaware of care plan interventions, such as the use of foam cups, and the facility lacked policies on resident safety and supervision.
A resident with a complex medical history experienced a delay in the diagnosis and treatment of shingles due to the facility's failure to properly assess, monitor, and notify the physician of a change in condition. The facility did not adhere to its skin condition monitoring policy, resulting in a lack of documentation and communication among staff, which delayed the implementation of necessary isolation precautions.
The facility failed to lock the treatment cart when not in view, did not double-lock controlled medications, and left medication cart keys accessible to residents and staff. These actions were against the facility's policies and put all 22 residents at potential risk.
The facility failed to maintain the kitchen ceiling, ensure proper food temperature monitoring, and consistently fill out food temperature and dish machine sanitation logs. The ceiling had significant damage and leaks, a thermometer was missing from a refrigerator, and inappropriate devices were used for measuring food temperatures. Logs showed multiple missing entries, indicating non-compliance with the facility's policies and procedures.
The facility failed to ensure enhanced barrier precautions were in place and did not implement their Legionella program or test facility water for Legionella. A nurse was observed providing care without appropriate PPE, and the facility's water management plan was not fully implemented.
The facility failed to provide Advanced Beneficiary Notices (ABNs) to three residents before discharging them from therapy. The Administrator and an Administrator from a sister facility could not provide any documentation showing that ABNs were given, and they were unsure if the notices were completed due to the absence of the business office manager and Social Services Director at that time.
The facility failed to ensure a timely referral to a heart specialist for a resident with multiple diagnoses and did not document an assessment of a new skin condition for another resident. The deficiencies included delays in scheduling a cardiology consult and lack of proper documentation and monitoring for cellulitis treatment.
The facility failed to implement interventions to minimize the risk of elopement for a resident with dementia and Alzheimer's Disease. Despite multiple exit-seeking behaviors, the resident's care plan was not updated, and necessary precautions were not taken, putting the resident at continued risk.
The facility failed to ensure proper care for a resident with a feeding tube, as a nurse did not check tube placement or residual volume before administering medications and feedings. Additionally, the facility did not conduct a timely nutritional assessment for the resident, who had been dependent on enteral feedings since admission.
The facility failed to administer oxygen as ordered for a resident with severe respiratory and cardiovascular issues. Staff removed the resident's oxygen during toileting, causing shortness of breath and respiratory distress, despite physician orders for continuous oxygen therapy.
A facility failed to ensure prescribed Mexiletine medication was available for a resident with heart failure, resulting in a missed dose. The medication was not delivered on time due to a need for physician reauthorization, and the facility's policies on medication administration were not followed.
A resident with multiple medical conditions did not receive ordered physical and occupational therapy services from February to April 2024 due to the facility's change in therapy service providers and corporate bankruptcy. The resident's care plan indicated significant self-care deficits, and the lack of therapy hindered his progress towards independence.
Failure to Provide Pertinent Information During Resident Transfer
Penalty
Summary
The facility failed to provide pertinent medical information for a resident transferring to an alternate facility, resulting in the resident leaving the receiving facility against medical advice (AMA). The resident, who had diagnoses including acute cystitis, type 2 diabetes, hypertension, heart failure, and chronic kidney disease, was transferred without the receiving facility being informed of the need for a private room due to an infection requiring contact isolation. The resident expressed dissatisfaction with the lack of communication and preparation, stating that they were not given a choice and were not informed about the arrangements at the new facility. The facility's administration believed that all necessary communication had been completed, but the receiving facility's administrator reported not being informed of the resident's specific needs, such as the requirement for a private room. The Director of Nursing at the transferring facility admitted to not being able to speak directly with anyone at the receiving facility before the transfer. The facility was unable to provide a policy outlining the information that must be relayed during a patient transfer, indicating a lack of proper procedures in place to ensure smooth transitions for residents.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives before transferring or discharging them, as required by regulations. Specifically, two residents, R1 and R2, were not given the mandated 60-day notice prior to their discharge. R1, who had been residing in the facility for two years and had a defibrillator, was informed on a Monday that she had to leave by Wednesday, causing her significant distress. Her daughter, V7, was also informed of the closure with only two days' notice, leading to a rushed and stressful search for a new placement for R1. The facility's business manager, V5, and the director of development, V3, communicated the closure to residents and their families, but the formal 60-day notice letters were only mailed on the day of the survey, well after the initial communication. R2 was transferred to an assisted living facility without receiving the required notice. The facility's administrator, V1, and other staff members confirmed that residents were told they had to move out within two days due to the facility's closure. The regional director of operations, V4, acknowledged that the residents should have been given a 60-day notice and that the letters were being sent out on the day of the survey. The facility's policy on transfer and discharge procedures was not followed, as it mandates notifying residents and their families of transfers and the reasons for them, except in cases of late payment or nonpayment.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to implement safety interventions for two residents, R1 and R2, who were involved in an unwitnessed incident in the dining room. R1, diagnosed with vascular dementia and other cognitive impairments, has a care plan addressing potential aggression, while R2, diagnosed with dementia and Alzheimer's, has a care plan for disruptive behaviors. On the day of the incident, the administrator heard yelling and found R2 on the floor next to R1's wheelchair. R1 claimed to have pushed R2 away after R2 scratched her cheek, leading to R2's fall. The incident was not witnessed by staff, and both residents have a history of altercations. Interviews with staff revealed that R2 is known to get up from her wheelchair without assistance and has a history of walking alone, while R1 does not like others in her personal space. Staff members, including the CNA Supervisor and Social Service Director, acknowledged that R1 and R2 require supervision when together, especially in the dining room, and should be separated when showing increased confusion. Despite this, the facility did not ensure adequate supervision or implement necessary interventions to prevent the incident. The facility's failure to follow care plan interventions was further highlighted by the use of inappropriate dining utensils. R1 and R2 were supposed to use foam cups due to a history of throwing meal cups, but staff were unaware of this requirement. The Registered Nurse confirmed that care plan interventions are discussed in meetings, yet the necessary changes were not implemented. The facility was unable to provide any policies related to resident safety and supervision, indicating a lack of structured guidance for staff in managing such situations.
Delayed Diagnosis and Isolation for Shingles
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician of a change in condition for a resident, leading to a delayed diagnosis of herpes zoster (shingles) and implementation of isolation precautions. The resident, who had a complex medical history including congestive heart failure, type 2 diabetes, and dementia, was noted to have a rash on 09/15/2024. However, the physician was not notified until 09/17/2024, when a registered nurse assessed the resident and sent a picture of the rash to the physician, who then diagnosed shingles and ordered treatment. The delay in diagnosis and treatment was compounded by a lack of adherence to the facility's skin condition monitoring policy. The policy required that any new skin abnormalities be documented in the nurses' notes and a quality assurance (QA) form be completed. However, no progress notes or QA forms were completed for the resident's rash until after the diagnosis was made. This lack of documentation and communication among the nursing staff contributed to the delay in implementing necessary isolation precautions. Interviews with staff revealed confusion and miscommunication regarding the resident's condition. The Director of Nursing acknowledged that there was confusion about the diagnosis and that the nursing staff did not follow the expected procedures for notifying the physician and documenting the skin condition. The failure to follow the facility's policy and procedures resulted in a delay in the resident receiving appropriate care and isolation measures for shingles.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure the treatment cart was locked when not in view of the nurse on duty, failed to ensure controlled medications were under a double lock in the medication cart, and failed to ensure the keys for the medication cart were not accessible to residents and staff. On multiple occasions, the treatment cart was observed unlocked and unattended, containing various medications including controlled substances. The Director of Nursing (DON) acknowledged the importance of keeping the cart locked, especially given the presence of residents with dementia, but the issue persisted over several days. Additionally, the surveyor found a set of keys left on the counter at the nurse's desk, which were accessible to residents and staff. The DON admitted to leaving the keys on the counter and confirmed that it was against the facility's policy. The facility's policies on medication administration and storage clearly state that medication carts must be locked when not in view and that controlled substances must be double-locked, but these protocols were not followed, putting all 22 residents at potential risk.
Facility Fails to Maintain Kitchen Safety and Food Temperature Monitoring
Penalty
Summary
The facility failed to ensure the ceiling over the serving window and the dishwashing area was free from damage and falling debris. The ceiling had missing drywall and paint, with a large hole above the serving window showing exposed lumber and the roof of the building. This damage had been present for years, and when it rained, the ceiling leaked, causing paint chips or plaster to fall onto the workspace. The facility had not repaired the ceiling despite being aware of the issue, and the Maintenance Director confirmed that no work had been done to fix it since he started working at the facility. The facility's Maintenance Director had communicated the issue to the regional maintenance person, but no action had been taken to resolve it. The facility also failed to ensure a thermometer was present in one of the refrigerators to monitor its temperature. During an observation, the Dietary Cook was unable to locate the temperature gauge in the refrigerator and had to place a new one inside. Additionally, the facility did not use a thermometer that measures internal food temperatures to obtain temperature readings prior to serving. Instead, a laser radiation device, which is not suitable for measuring internal temperatures, was used. This resulted in inconsistent temperature readings, with a significant difference between the laser device and the meat thermometer. The newly hired Dietary Manager confirmed that the laser device was not appropriate for measuring food temperatures. Furthermore, the facility failed to ensure staff were consistently filling out the food temperature logs and the dish machine's chemical sanitation levels as per their policies and procedures. The logs showed multiple missing entries for food temperatures and dish machine chemical tests across several months. The Dietary Manager acknowledged that all food items served should have their temperatures logged, and a thermometer should always be in the refrigerators and freezers to ensure food safety. The facility's policies and procedures for food temperatures, equipment temperatures, and ware-washing were not being followed, leading to potential risks for foodborne illnesses and contamination.
Failure to Implement Infection Control and Legionella Programs
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were in place, failed to implement their Legionella program, and failed to test facility water for Legionella. These deficiencies were identified through observation, interview, and record review, and have the potential to affect all 22 facility residents. The facility's application for Medicare and Medicaid showed there were 22 residents in the facility at the time of the survey. On multiple occasions, a registered nurse (RN) was observed providing care to residents without wearing appropriate personal protective equipment (PPE) such as gowns. This included changing an infected pressure injury dressing, administering tube feedings, and providing care to a resident using a continuous positive airway pressure (CPAP) machine. There were no enhanced barrier precaution signs posted, and no PPE was available outside the rooms. The Administrator/Infection Preventionist and the Director of Nursing were both unaware of the requirements for enhanced barrier precautions for residents with wounds, gastric tubes, or CPAP machines. Additionally, the facility failed to implement their Legionella program and did not test the facility water for Legionella. The Maintenance Director, who started in February, was not provided any training regarding the Legionella program and was unaware of the need for such a program until recently. The facility's water management plan and Legionella policy and procedure were not fully implemented, and there was no documentation of a risk assessment or testing for Legionella. The facility's water temperature logs were incomplete, and the Maintenance Director had only recently started taking water temperatures weekly instead of monthly. The facility had ordered a Legionella testing kit but had not yet conducted any testing.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to ensure residents were provided an Advanced Beneficiary Notice (ABN) prior to therapy discharging them for three residents reviewed. On the morning of 4/24/24, the Administrator was asked for the ABNs for the last three residents admitted to the facility. By the afternoon, the Administrator and an Administrator from a sister facility stated they did not have any documents to provide regarding ABNs being given to the three residents. They mentioned that the business office manager and the Social Services Director were not employed at that time and they did not know if the ABNs were done or not. No documentation was provided to show that ABNs were given to the three residents in question. On 4/25/24, the facility provided instructions for the ABN form, which indicated that the ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. The instructions also stated that the ABN must be reviewed with the beneficiary or their representative, and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance for the beneficiary or representative to consider the options and make an informed choice. The notifier must retain a copy of the ABN delivered to the beneficiary on file.
Failure to Ensure Timely Specialist Referral and Proper Documentation
Penalty
Summary
The facility failed to ensure a resident was referred to a heart specialist as ordered and failed to document an assessment of a new skin condition for two residents. One resident, a [AGE] year-old female with multiple diagnoses including congestive heart failure and respiratory failure, had a physician's order for a cardiology consult dated 2/6/24. Despite multiple hospital admissions for chest pain and heart failure, the appointment was not made until 4/25/24, with the appointment scheduled for August 2024. This delay in scheduling could potentially exacerbate the resident's condition. Additionally, the facility did not provide a policy for consults and referrals when requested by the surveyors. Another resident, admitted with cellulitis of the left lower limb, began Clindamycin treatment on 4/20/24. However, there was no documented assessment of the rash or inflammation in the nursing progress notes for several days. The resident reported that the rash was initially red and warm to the touch but improved with antibiotics. The nurse who assessed the rash did not document the assessment or vital signs, and there was no shift charting or temperature monitoring as required. The facility's nursing documentation guidelines were not followed, leading to a lack of proper monitoring and documentation of the resident's condition.
Failure to Implement Elopement Interventions for Resident with Dementia
Penalty
Summary
The facility failed to implement interventions to minimize the risk of elopement for a resident diagnosed with dementia and Alzheimer's Disease. The resident, identified as R20, was observed attempting to exit the facility on multiple occasions without proper documentation or updated care plan interventions. On one occasion, the resident was seen walking out the front door and later the side door, with no documentation of these incidents in her medical record. The Director of Nursing confirmed the resident's elopement risk but acknowledged the lack of documentation and intervention updates. The resident's care plan had not been updated since October of the previous year, despite multiple exit-seeking behaviors documented in March and April. The facility's policy on missing residents indicated that reasonable precautions should be taken to minimize elopement risks, but these were not effectively implemented. The care plan interventions, such as disguising exit doors and identifying wandering patterns, were not followed, and the resident's chart did not include the necessary frequent checks by CNAs. This lack of action and documentation put the resident at continued risk of elopement and potential harm.
Failure to Ensure Proper Feeding Tube Care and Timely Nutritional Assessment
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube. Specifically, a registered nurse did not check the placement or residual volume of the feeding tube before administering medications and bolus tube feeding. This was observed during a morning medication administration, where the nurse admitted to not checking the residual volume because the resident drinks water, which typically results in about 70 milliliters of residual. However, the resident's physician order required checking the enteral tube residual volume four times daily before bolus feedings and holding the feeding if the residual was over 150 milliliters. The resident's care plan also mandated checking for tube placement and gastric contents/residual volume per facility protocol. The facility's Enteral Feedings Policy specified that tube placement should be confirmed via aspiration of residual or air instillation method before any flush or medication administration. Additionally, the facility did not conduct a timely nutritional assessment for the resident upon admission. The resident, who had been dependent on enteral feedings since admission, only had a dietitian review on 4/19/24, which was the only nutritional assessment done since admission. The facility's Enteral Feedings Policy required the dietitian to monitor all diet orders for tube feedings and recommend changes as needed. The dietitian's review noted that the resident was at risk for weight loss and gain due to dependence on enteral feedings. The facility administrator acknowledged that the nutritional assessment should have been completed sooner.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident (R7) who has multiple comorbidities including respiratory failure, chronic obstructive pulmonary disease, and congestive heart failure. Observations over several days showed that staff removed R7's oxygen during toileting, causing her to become short of breath. On multiple occasions, R7 was observed without her oxygen while ambulating to and from the toilet, which led to episodes of shortness of breath. Staff, including a CNA supervisor, incorrectly believed that R7 could have her oxygen off during these times, despite her physician's order for continuous oxygen at 4 liters per minute. The Director of Nursing confirmed that the oxygen should not be removed, especially during exertion, as it could lead to severe health risks for R7. R7's medical records and care plans indicated a history of severe respiratory and cardiovascular issues, necessitating continuous oxygen therapy. Previous incidents documented in R7's health status notes showed that interruptions in oxygen therapy had led to severe shortness of breath, chest pain, and dangerously low oxygen saturation levels. Despite these documented needs and physician orders, the facility's staff failed to ensure that R7's oxygen was administered consistently, leading to repeated episodes of respiratory distress.
Failure to Ensure Medication Availability
Penalty
Summary
The facility failed to ensure prescribed medications were available for a resident with heart failure and hypertension. The resident had an order for Mexiletine 150 mg capsules to be taken three times daily for heart failure. On the day of the survey, the Registered Nurse (RN) could not find the medication in the medication cart or room and informed the Director of Nursing (DON). The DON stated the medication was en route from the pharmacy, but it had not been delivered by the time the medication was due. The RN had sent a request to the pharmacy the previous day, but the medication was not delivered on time because it needed physician reauthorization. The resident missed the 2:00 PM dose, and the physician was notified and instructed to hold the dose until the next scheduled time. The facility's policy requires medications to be prepared and administered within one hour of the designated time. The Administrator stated that for medications taken three times a day, the nurse should request a refill early enough to allow time for physician reauthorization if needed. The facility's Medication Administration Record (MAR) confirmed that the resident did not receive the 2:00 PM dose of Mexiletine on the day in question. The facility's policies on medication administration and conformance with physician orders were not followed, leading to the deficiency.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide therapy services as ordered for a resident (R13) who was admitted with multiple diagnoses including gastrostomy status, pneumonitis, dysphagia, encephalopathy, sepsis, peripheral neuropathy, cervical disc disorder, epilepsy, and chronic pain syndrome. Despite having physician orders for physical therapy (PT) and occupational therapy (OT) to be provided multiple times a week, the resident did not receive these services from February to April 2024. The Director of Therapy confirmed that there were no current orders to evaluate and treat R13 for PT or OT, and the facility administrator acknowledged that therapy services were not available during this period due to the corporation filing for bankruptcy and changing therapy service providers. R13 expressed that he had not received therapy since an orthopedic appointment where therapy was ordered. The resident's care plan indicated significant self-care deficits requiring assistance for transfers and repositioning. Despite these needs, therapy services were discontinued without a clear rationale, and the facility lacked a policy for consults and referrals. The resident council meeting minutes from February and March also noted the absence of therapy services during those months. The failure to provide the ordered therapy services resulted in the resident being unable to progress towards a more independent setting and remaining dependent on facility care.
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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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