Failure to Follow ROM and Fall Prevention Orders
Summary
A deficiency was identified regarding the facility's failure to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decline in ROM. Specifically, the facility did not consistently follow physician's orders for the application of a left ankle-foot orthosis (AFO) and bilateral elbow splints for a resident with contractures in both upper and lower extremities. Documentation showed inconsistent entries regarding the application and removal of these devices, with several dates lacking clear records of whether the devices were applied or removed. Additionally, there was no documented evidence that skin assessments were performed when the devices were applied, despite this being an intervention listed in the care plan and required by facility policy. Interviews with restorative nursing assistants (RNAs) and registered nurses (RNs) confirmed that the required documentation was missing or inaccurate. The RNAs stated that skin checks were performed before and after device application, but acknowledged that these assessments were not documented in the resident's medical record. The RNs also verified the absence of documentation for both the timing of device application/removal and the required skin assessments. The director of nursing (DON) was informed of and verified these findings. Another deficiency was identified related to accident prevention. The facility failed to implement physician-ordered floor mats on both sides of a resident's bed, which was a safety intervention intended to reduce the risk of injury from falls. This omission was contrary to the facility's falls prevention policy, which requires individualized interventions based on assessed fall risk. The failure to provide the ordered safety equipment placed the resident at high risk for serious injury from a fall.
Plan Of Correction
2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents with splints were potentially affected by this deficient practice. DON, ADON, and Unit managers conducted an audit on all residents receiving splints, braces, and ROM devices and found no other issues noted. On 8/5/2025, DON in-serviced all licensed nurses about facility policy and procedure of splint, braces, and ROM devices assessment and to add monitoring for skin integrity at least every 2 hours and as needed. On 8/6/2025-8/8/2025, DSD in-serviced all CNA and RNA about facility policy and procedure of application of ROM devices, splint, and braces to report immediately to licensed nurses if skin breakdown was noted beneath the devices. Plan of care was updated for all residents with medical devices application for splinting, braces, and ROM devices to include monitoring of skin breakdown at least every 2 hours and as needed when devices were applied on the resident. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. All new medical devices orders will be reviewed during clinical meetings to make sure RNA is following the treatment plan and monitoring for skin integrity was included in the plan of care. IDT will review monthly and as needed all residents with medical devices application and update the plan of care. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- F689 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 4 was identified as affected by this concern. On 7/21/25, the Director of Nursing (DON) or designee reviewed the use of floor mats for the resident with the interdisciplinary team (IDT). After evaluation, it was determined that floor mats were no longer indicated. The recommendation to discontinue use was communicated to the physician, and the order was discontinued. The resident's care plan was updated accordingly. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All fall risk residents using floor mats were considered potentially impacted. On 8/4/2025, DON and unit manager reviewed all residents with floor mat orders and found no other issues. On 8/4/2025, the DON and designee created a list of all residents using floor mats. The IDT reviewed each case to determine ongoing need. For residents where use was no longer clinically indicated, recommendations were made to discontinue use, and care plans were updated to reflect current interventions. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for placing floor mats for residents at risk for fall, in particular assessing residents who are no longer on fall risks and have orders for floor mats to discontinue the devices as they are potentially an accidental hazard. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee this process. Unit managers and designee will conduct routine audits to ensure appropriate placement and condition of mats, accurate documentation in the care plan, and use in accordance with current physician orders and clinical justification.
Penalty
Resources
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A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
The facility failed to provide restorative nursing services as ordered for two residents with limited ROM and mobility needs, and failed to assess and initiate restorative services for another resident with severe dementia and hand clenching. One resident with osteoporosis, chronic pain, and a hip fracture had a care plan for ROM and strengthening exercises five times weekly but received far fewer sessions over multiple weeks. Another resident with advanced physical debility and chronic hand tremors was care planned for left‑hand ROM exercises five times weekly, yet records showed inconsistent and often insufficient sessions, while the Restorative Nurse reported a fixed three‑day weekly schedule that did not match the care plans. A third resident with severe Alzheimer’s dementia was repeatedly noted to have a clenched, painful left hand with fingernail marks, and although the Restorative Nurse documented considering a palm protector, there was no documentation of restorative services being initiated, no follow‑through on the palm protector, and no further documented communication with the provider about the ongoing hand pain and clenching.
Failure to provide ordered restorative exercise programs for multiple residents. Residents with dementia, impaired mobility, paraplegia, fractures, and limited ROM had FMPs for ROM, strengthening, standing, and ambulation, but restorative logs showed few completed sessions, missed ambulation, and documented refusals. Staff said restorative aides were often pulled to the floor, nursing staff handled ambulation, and documentation did not always reflect whether residents were offered the exercises.
A resident with intact cognition, ADL self-care deficits, and dependence on staff for ambulation and transfers did not receive the ordered restorative ROM program recommended by therapy. Although therapy issued recommendations for active ROM exercises to the lower extremities and nursing notes indicated that restorative referrals were received and that the resident was "continuing" a restorative program, there was no documentation that the specific exercises were carried out. Staff interviews revealed that therapy referrals to restorative were not effectively communicated, the restorative aide reported never receiving a PT referral and confirmed the resident did not receive restorative services, and nursing leadership acknowledged a lapse in administering the restorative program over an extended period, contrary to the facility’s restorative nursing policy.
A resident with chronic respiratory failure, morbid obesity, osteoarthritis, muscle weakness, and abnormal gait had an active PT plan with goals for ambulation and a prescribed frequency of five sessions per week to improve mobility and independence. The resident, who was cognitively intact and dependent for transfers and ADLs, reported receiving PT only about twice weekly despite wanting more therapy. Review of therapy records showed the resident did not receive PT on three consecutive days, with inconsistencies between the Daily Activity Schedules, Daily Treatment Logs, and Service Log Matrix, and no valid documented reasons for the missed sessions. The PT, DOR, DON, and ADM acknowledged that PT services should meet the ordered frequency and be documented and billed timely, and that missed treatments could slow rehabilitative progress, yet the resident’s ordered PT frequency was not met.
A resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and a history of stroke and temporal lobectomy did not consistently receive ordered ROM/PROM. The care plan directed daily ROM with AM/PM cares, but the care assignment sheet and EMR task tabs lacked matching directions, and ROM was documented only a few times over the review period. Staff interviews showed the RNA provided PROM only several times per week, nursing staff were unaware of the twice-daily ROM direction, and the ADON acknowledged discrepancies between the care plan, care list, and EMR documentation.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Failure to Provide and Assess Restorative Nursing Services for Residents With Limited ROM
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as ordered and to assess and initiate restorative services when indicated, in accordance with its Restorative Nursing Program policy. The policy, revised 10/19/25, states the program’s purpose is to maintain or improve residents’ optimal physical, mental, and psychological function. For one resident with age-related osteoporosis, chronic pain, and a left hip fracture, the care plan initiated 5/22/25 directed restorative nursing services 5 times per week, including seated marching with 2‑lb ankle weights, long arc quad exercises with 2‑lb weights, and sit‑to‑stand repetitions. However, review of restorative records from 2/1/26 through 4/25/26 showed the resident received significantly fewer sessions than ordered in multiple weeks, including weeks with zero or only one session, indicating the resident was not offered services as per the plan of care. Another resident with advanced physical debility, chronic pain, and chronic bilateral hand tremors had a restorative nursing program that included active ROM to the left hand (opening the hand wide, using a squeeze ball, and finger‑to‑thumb pinches), with a care plan initiated 6/25/25 specifying restorative services 5 times weekly and monthly/as‑needed review by the restorative nurse. Restorative records from 2/1/26 through 4/26/26 showed inconsistent provision of these services, with some weeks having no sessions and others fewer than five, despite the care plan requirement. During an interview on 4/30/26, the Restorative Nurse stated that residents receiving restorative services were scheduled only on Tuesdays, Thursdays, and Saturdays, and confirmed upon review of the schedules that these two residents did not receive restorative services as indicated in their plans of care. A third resident with severe Alzheimer’s dementia was observed on 4/28/26 lying in bed with the left hand closed in a fist. The resident’s representatives reported they had notified staff and were told occupational therapy would be consulted for a hand splint, and that they frequently placed a stuffed animal in the resident’s hand to help keep it open. Progress notes documented that on 4/13/26 staff noted the resident had been clenching the left hand, and the Restorative Nurse assessed that both hands were clasped but could be opened on request. A 4/20/26 note documented that the Restorative Nurse again assessed the left hand, which could be opened after touch but caused the resident to say “ow,” with fingernails making marks on the palm; the Restorative Nurse documented consideration of a palm protector. The DON later confirmed there were no further notes regarding a palm protector, restorative services had been discontinued on 4/26/26, there was no documentation that the resident was on restorative services, and there was no further communication with the physician beyond a notification in February 2026 about the resident’s hand pain and clenching. This reflects a failure to assess and initiate restorative services for this resident despite documented hand clenching and pain.
Failure to Provide Ordered Restorative Exercise Programs
Penalty
Summary
The facility failed to provide ordered restorative exercise programs for 6 of 6 residents reviewed for restorative exercise services. The report identified that residents with functional maintenance programs (FMPs) were not consistently receiving the exercises and mobility activities that had been ordered after discharge from therapy, and the restorative logs showed very limited completion of the programs over the review period. The facility’s own policy stated that residents with limited ROM or mobility would receive appropriate treatment and services to increase or maintain ROM and mobility, and that a trained nursing assistant would complete restorative care and document the time provided. For one resident, the record showed severe cognitive impairment, inability to ambulate, osteoporosis, Alzheimer’s disease, weakness, and a history of fractures. Therapy orders and restorative instructions directed upper and lower extremity exercises, standing, and transfer-related activities, but the restorative logs documented only one completed exercise session and three refusals over the review period. When the resident was observed with therapy staff, she became visibly weak and shaky toward the end of the exercises. For another resident with intact cognition, paraplegia, chronic pain, and impaired ROM to both lower extremities, the restorative plan called for upper and lower extremity ROM and stretching, but the logs showed only five exercise sessions and one refusal during the review period. A third resident with severe cognitive impairment and non-ambulatory status had a restorative plan to maintain lower extremity ROM and strength, including NuStep, seated exercises, and standing with a walker, yet the log showed only three completed sessions and three refusals out of 105 opportunities. Another resident with dementia, repeated falls, dizziness, and osteoarthritis had orders for daily PT and OT FMP exercises, but the restorative logs showed no completed restorative exercises and three refusals during the review period. A resident with dementia and diabetes had a restorative plan for passive ROM, stretching, and assistance with movement, but received restorative exercises only twice during the review period. One additional resident with a walking program as part of FMP received only two exercise sessions and no ambulation services during the period reviewed. Staff interviews indicated that restorative aides were frequently pulled to the floor for resident care, that nursing assistants were expected to provide ambulation, and that documentation did not always reflect refusals or whether residents had been offered the exercises.
Failure to Implement Ordered Restorative ROM Program
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as recommended by the therapy department to maintain or improve a resident’s range of motion and mobility. The resident had intact cognition, required partial to moderate assistance with dressing and hygiene, and was dependent on staff for ambulation and transfers. The MDS assessment indicated that the resident did not receive therapy or restorative services during the seven days prior to the assessment, despite having care plan interventions directing staff to encourage participation in exercise and physical activity for strengthening and improved mobility. The clinical record showed multiple physician orders for PT and OT evaluations and treatment over several months, and a therapy recommendation dated 12/19/2025 for restorative staff to administer active ROM exercises to the resident’s bilateral lower extremities one to five times per week. Nursing progress notes documented that therapy recommendations for a restorative exercise program were received on 12/4/2025 and again on 12/23/2025, with copies reportedly provided to the rehab aide for scheduling. Notes from a CNA/restorative aide on 12/6/2025 and 12/26/2025 stated that the resident continued with a restorative program and that there were no concerns, but there was no documentation that the specific recommended ROM exercises were actually implemented or performed. Interviews revealed discrepancies and gaps in carrying out the restorative program. The DON reported that the resident had a foot pedal machine in her room that she used when she allowed staff to get her up, and that therapy typically wrote restorative programs that the facility followed, but acknowledged that the facility failed to administer the resident’s therapy from mid-December through February. The occupational therapy aide stated that after therapy services ended in early December and January, therapy made a referral to restorative for a home program and later recommended lower extremity exercises when the resident admitted not using the pedal machine. The restorative aide reported having no referral from PT for this resident and confirmed the resident did not receive restorative services, while the LPN overseeing therapy acknowledged reviewing the restorative recommendation and her prior note but confirmed that the restorative aide denied receiving a copy. This sequence of events demonstrates that the interdisciplinary team did not ensure the restorative program was implemented as recommended, contrary to the facility’s Restorative Nursing Program Policy.
Failure to Provide Ordered PT Frequency and Document Services for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered PT services to maintain and improve range of motion and mobility for one resident. During observation and interview, the resident was alert, oriented, and reported being unable to walk, with a history of weight gain and leg weakness. The resident stated he wanted to lose weight and regain leg strength to walk again and reported he was supposed to receive PT five times per week but had only been going twice per week. He stated he was making progress with PT but was not getting as much therapy as he should and would like to attend PT every day if possible. Record review showed the resident had chronic respiratory failure with hypoxia, abnormal gait and mobility, morbid obesity, metabolic encephalopathy, osteoarthritis in both knees, and muscle weakness. The MDS dated 4/14/26 documented a BIMS score of 14, indicating minimal to no cognitive impairment, and showed the resident was dependent for transfers and required assistance with dressing and personal hygiene. The PT recertification and updated therapy plan dated 4/22/26–5/21/26 documented short- and long-term goals for ambulation with parallel bars and a FWW, justified continued skilled PT to facilitate independence with functional mobility, and specified a treatment frequency of five times per week, with the resident demonstrating good rehab potential. Review of the Service Log Matrix for April showed the resident did not receive PT on 4/13/26, 4/14/26, and 4/15/26. The PTA initially stated the resident received PT on 4/13/26 but it was not billed, so it did not appear on the log, and confirmed the resident was scheduled but did not receive PT on 4/14/26 and was not scheduled and did not receive PT on 4/15/26, despite the plan calling for five sessions per week. Review of the Daily Activity Schedules and Daily Treatment Logs for those dates showed inconsistencies: the DAS showed the resident scheduled on 4/13/26 and 4/14/26 but the resident was not on the DTL for those days, and the resident was not on either the DAS or DTL for 4/15/26. The PT stated PT was provided on 4/13/26 but could not recall why it was not billed, acknowledged the resident was not scheduled and did not receive PT on 4/14/26 and 4/15/26, and could not recall why the resident was not on the DAS for those days. The PT stated that if a regular resident was not on the DAS, rehab staff should follow up, that PT services must be documented and billed timely, and that missing three days of PT was not acceptable and could potentially set back rehabilitative progress if missed treatments continued. The DOR stated that treatment notes should be billed within 24 hours as standard practice and that it was the responsibility of the DOR, rehab aide, and PT to ensure residents met their ordered PT frequency. The DOR noted the PT had access to the assignment board, that the board was mapped out weeks in advance, and that lack of documentation indicated services were not provided. The DOR also stated that missed treatments could slow rehabilitative progress. The DON and Administrator both stated that PT services should meet the ordered frequency, that missed treatments could cause a decline in rehabilitative progress, and that documentation and billing should be completed in a timely manner to reflect care provided. The facility’s policy on Specialized Rehabilitative Services stated that the facility will provide rehabilitative services as indicated by the MDS and that PT is among the specialized services to be provided by qualified personnel, with treatment discontinued or transitioned to a maintenance program only after goals are met. Despite this, the resident, who was a regular PT patient with an active plan for five sessions per week, missed three consecutive days of PT services without valid documented reasons and with inconsistent scheduling and documentation, leading to the cited deficiency.
Inconsistent ROM Assistance and Documentation
Penalty
Summary
The facility failed to consistently provide range of motion (ROM) assistance for a resident with vascular dementia, aphasia, hemiplegia/hemiparesis, depression, anxiety, and personality change due to physiological condition. The resident’s comprehensive/annual MDS identified cognitive impairment but also noted the resident could understand others and make self-understood, and the resident received personal assistance with all aspects of care. The care plan, last revised on 2/28/26, directed staff to provide ROM/PROM with morning and evening cares daily by nursing/CNA, but the care plan did not identify the use of any splint to the right hand. Documentation reviewed showed the resident care assignment sheet lacked directions for staff to provide ROM, either active or passive, and lacked indication of a right-hand splint. The resident task tab in the EMR also lacked directions for nursing assistants to perform ROM with morning/evening cares, while the EMR restorative nursing task tab identified ROM with directions to document the number of minutes performed. Review of the EMR showed ROM was completed only seven times in the previous 30 days. On observation, the resident was resting in bed with a splint on the right hand and stated staff did not assist with exercises to the right side during morning and evening cares. Staff interviews and additional records showed the resident received PROM inconsistently and at a frequency different from what was reflected in the care plan. The restorative nursing aide stated she assisted with PROM three to five times a week and said the EMR task tab did not accurately reflect the frequency. Additional documentation showed therapy was offered and sometimes refused, but was not provided on multiple days in March and April, including periods when the restorative nursing aide was away from the facility. Nursing staff stated they were unaware of directions for twice-daily ROM and that it was not on the care list or task section. The assistant director of nursing acknowledged the discrepancy between the care plan, care list, and task tab, and stated the resident had previously had twice-daily ROM directions that were changed to restorative nursing, though the timing and coverage were unclear.
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