The resident, identified as #93 in inspection records, was discharged from physical therapy on October 13 with specific recommendations to use a front wheeled walker and stand-by assistance for transfers to various surfaces. But when she fell again on October 30, staff discovered they had been disregarding the safety protocols entirely.
CNA #150 told inspectors during a November 19 interview that she doesn't use a gait belt or walker when transferring the resident. "I am usually taking her to the bathroom," the aide explained, despite acknowledging the resident requires one-person assistance and can bear weight.
A second aide, CNA #88, gave inspectors a similar account the same day. The nursing assistant said she doesn't use a gait belt or walker when transferring the resident, though she acknowledged using two-person assistance "if she is feeling weak."
The resident's mobility issues weren't new. Records show she was previously discharged from physical therapy in May 2023 with recommendations for stand transfers using a front wheeled walker. After her October fall, the physical therapy team had been "working on sit to stand from wheelchair to walker" because the resident "has not been steady on her feet."
Physical therapist #300 verified that all staff should use gait belts when transferring residents, according to inspection records.
The facility's Director of Nursing told inspectors that using gait belts for resident transfers "is a standard of care." But the DON wasn't aware of the physical therapy recommendation for the resident to use a walker during transfers.
The nursing director described a communication system designed to share therapy recommendations with floor staff. "Staff are educated on PT recommendations by a communication binder," the DON explained. "We also complete education with staff."
The facility also uses a Kardex system that allows nursing assistants and nurses to read updated care interventions similar to care plan requirements. But the DON said the Kardex wouldn't specifically state to use gait belts because "a gait belt should be used on all residents, there is a gait belt in every room."
That universal expectation clearly wasn't reaching the floor staff caring for resident #93.
The facility's own fall prevention protocol, revised in September 2012, requires staff to document fall risk factors and discuss each resident's fall risk. For residents who have fallen, the policy mandates that staff and physicians "continue to collect and evaluate information until either the cause of the falling is identified."
The protocol calls for identifying interventions to prevent subsequent falls and address serious injury risks. If underlying causes can't be identified or corrected, staff must try various interventions "until falling reduces or stops or until a reason identified for its continuation."
Staff and physicians are required to monitor and document residents' responses to fall prevention interventions.
But the gap between policy and practice was stark in resident #93's case. Despite clear physical therapy recommendations and the facility's stated commitment to gait belt use, two nursing assistants told inspectors they simply don't follow the safety requirements.
The resident's pattern of falls and therapy discharges suggests ongoing mobility challenges. Her May 2023 therapy discharge came with walker recommendations. Her October 2025 discharge included the same equipment requirements plus stand-by assistance. The October 30 fall that triggered the latest therapy referral occurred while staff were ignoring both sets of recommendations.
The inspection found that few residents were affected by the violation, and the level of harm was classified as minimal or potential for actual harm. But for resident #93, the consequences of staff non-compliance with safety protocols had already materialized in the form of repeated falls.
The violation was investigated under complaint number 2656988, indicating that concerns about fall prevention practices had been raised by someone outside the facility.
State inspectors documented the safety equipment sitting unused while a fall-risk resident continued to experience mobility incidents. The gait belts were available in every room. The walker recommendations were documented in therapy records. The communication systems existed to share safety requirements with floor staff.
What didn't exist was compliance with the safety measures designed to protect resident #93 from the falls that kept sending her back to physical therapy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Flint Ridge Nrsg & Rehab Ctr from 2025-11-21 including all violations, facility responses, and corrective action plans.