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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Failure to Complete Ordered Passive ROM Exercises: A resident with moderate cognitive impairment, CVA-related left hemiplegia/hemiparesis, and total dependence for mobility had a physician order for passive ROM to the left arm two to three times daily. During observation, an NA provided routine ADL care but did not perform the ordered ROM despite posted instructions in the room. Staff interviews and EMR review showed the restorative task was not documented as completed, and the DON and OT/PT director could not verify that the ordered ROM had been carried out.
Restorative nursing programs were canceled for multiple residents with contractures and major ROM limitations without documented clinical rationale. A resident with severe contractures had repeated gaps in PROM and splint documentation, while other residents with cerebral palsy, hemiplegia, quadriplegia, or brain injury had PROM, AROM, walking, and aquatic programs discontinued. Staff reported the LTC lacked a consistent restorative program, had no restorative aide, and did not have enough trained staff to provide the interventions.
Failure to Implement Restorative Nursing Program: A resident with CVA, hemiplegia, hemiparesis, and severe cognitive impairment did not consistently receive the planned restorative nursing services needed to maintain mobility. PT discharged the resident to the RNP and directed daily ROM exercises, and a physician also ordered active-assisted to passive ROM, but review of the task report, documentation report, and MAR showed no documented evidence that the restorative ambulation program had been implemented. The DON confirmed the facility did not consistently carry out the planned restorative nursing program as recommended by PT.
Failure to provide and document splinting and ROM services: A resident with muscle weakness and bilateral hand contractures had hand splints observed stored in a basin near the bedside, while the chart lacked a splint wearing schedule and did not show documentation that the splints were applied. OT discharge instructions established a restorative splint and brace program, with staff educated to don and doff the splints, complete skin checks, and provide passive ROM before splint use, but TARs and nurse aide documentation did not reflect the resident wearing the splints.
Failure to use therapy-ordered positioning equipment for a resident who needed help maintaining alignment in bed. The resident had morbid obesity, DM, bladder CA, and CKD, and PT documented dependence for repositioning, a tendency to lean left, and staff education on using a wedge cushion and bolster for supine positioning. During survey, the resident said staff did not place the equipment in the bed unless asked, and observations showed the wedge and bolster stored elsewhere while the resident was in bed; a CNA confirmed the equipment was not being used as intended.
Failure to Measure and Maintain ROM for Two Residents: Two residents with significant mobility and ROM limitations did not receive fully documented OT ROM measurements, and one resident also missed PROM and splinting after PT/OT discharge. One resident with hemiplegia, contractures, and severe cognitive impairment had OT evals that noted impaired ROM in both arms but did not objectively measure the joints, and RNA services for PROM and splint use were not provided as ordered for a period after therapy ended. Another resident with muscle weakness, CABG history, atrial fibrillation, and a healed fracture had an OT eval that noted right shoulder ROM impairment but did not include goniometer measurements.
Failure to Complete Ordered Passive ROM Exercises
Penalty
Summary
The facility failed to ensure physician-ordered passive range of motion (ROM) exercises were completed for a resident with moderate cognitive impairment, cerebral infarction with left-sided hemiplegia and hemiparesis, and dependence on staff for mobility. The resident’s physical therapy order directed staff to complete passive ROM to the left arm two to three times daily and to follow restorative nursing instructions posted in the room. The care plan also directed nursing staff to provide passive ROM exercises to the left arm two to three times daily and to refer to the restorative rehabilitation handout posted on the wall and closet. During observation, a nursing assistant provided the resident’s personal care, including bathing, grooming, and oral care, but did not perform the ordered passive ROM exercises even though the instructions and photographs were posted in plain view. Staff interviews showed they relied on the EMR task tab to confirm whether restorative care had been completed, but the task was not documented as completed. The DON and OT/PT director were unable to verify in the EMR that the resident’s passive ROM exercises had been completed, and the facility’s documentation for restorative nursing showed missing or absent entries for the resident’s passive ROM care.
Restorative Nursing Programs Canceled Without Clinical Rationale
Penalty
Summary
The facility failed to ensure residents with contractures received necessary restorative nursing care to maintain or improve functional potential. Management canceled passive range of motion (PROM), active range of motion (AROM), walking, aquatic, and other restorative programs for multiple residents without documenting a clinical rationale in the progress notes. The facility also lacked trained or dedicated staff to deliver restorative care interventions, and staff statements reflected that restorative care was not being consistently provided. Resident #2 had severe cognitive impairment, functional ROM limitations in all extremities, and diagnoses including right elbow contracture, hemiplegia/hemiparesis, and dystonia. The record showed prior OT and PT, but no restorative care during the look-back period. The care plan addressed contracture-related skin integrity risk and included positioning devices, splints, and rolled washcloths. Documentation showed multiple missed entries for restorative PROM and splint/brace tasks across March, May, and June 2026. The record also showed the facility discontinued bilateral resting hand splints and later used rolled washcloths and a cervical cushion/towel roll, with additional gaps in documentation. Staff and family reported that Resident #2 had worsening stiffness, contractures, and reduced function, and therapy staff stated the facility lacked staff to perform PROM or AROM programs and had not had a restorative program since July 2025. Residents #5, #6, #7, #8, and #10 also had significant functional limitations and diagnoses associated with contractures, cerebral palsy, hemiplegia, quadriplegia, or brain injury. Resident #5 had no restorative program in place since admission. Resident #6 had a PROM program to both upper extremities that management canceled, with no progress note documenting why. Resident #7 had a walking program and AROM grip-strength program canceled without explanation. Resident #8 had a PROM program for upper and lower extremities canceled without explanation. Resident #10 had an assisted AROM aquatic program and a PROM program canceled without documented rationale. Staff statements confirmed CNAs did not have time to do restorative care, no restorative aide was staffed, the pool program was stopped because there was no lifeguard, and the facility had not maintained a consistent restorative program for months.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident. Resident 115 was admitted with diagnoses including cerebral infarction, hemiplegia, and hemiparesis, and the Quarterly MDS dated April 9, 2026, showed the resident was severely cognitively impaired with a BIMS score of 02. The facility’s Restorative Nursing Programs Policy stated that maintenance and restorative services would be provided to maintain or improve residents’ abilities to the highest practical level, and that residents would receive maintenance nursing services as needed by CNAs. The clinical record showed that PT services were provided from March 22, 2025, through April 18, 2025, and the PT discharge summary recommended referral to the facility’s RNP to maintain the resident’s functional abilities. The discharge summary directed staff to provide ROM exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily, and a physician order dated September 29, 2025, directed active-assisted to passive ROM exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily. Review of the electronic task report, Documentation Survey Report v2, and MAR revealed no documented evidence that the restorative ambulation program had been implemented. The DON confirmed on June 30, 2026, that the facility failed to consistently implement the planned restorative nursing program for Resident 115 as recommended by PT to maintain the resident’s functional abilities and deter declines to the extent possible and to ensure the resident’s goals for ambulation were met.
Failure to Provide and Document Splinting and ROM Services
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate services, equipment, and assistance to increase range of motion and/or prevent further decrease in range of motion. Resident 7 had diagnoses including muscle weakness and contractures of the right and left hand. Observations on June 23, 2026, June 24, 2026, and June 25, 2026, showed bilateral hand splints in a basin near the resident’s bedside rather than in use. The resident had a physician order for bilateral hand/wrist splint skin checks every shift dated September 7, 2025, but the record did not include an order for a splint wearing schedule. The care plan included a focus for assistance/potential to restore to maximum level of function for mobility, but it did not include interventions for a splinting program. The resident received OT from March 23, 2026, through April 29, 2026, and the OT discharge summary stated the resident could tolerate bilateral resting hand splints for six hours daily, staff were educated on donning and doffing splints and skin checks, and a Restorative Splint and Brace Program was established for daily use. The facility’s restorative education form showed staff were educated that the resident was to wear the splints daily up to eight hours a day and that passive ROM to the fingers, wrists, and elbows was to be provided before donning the splints because the resident was totally dependent on staff for splint donning/doffing and hygiene. However, the treatment administration records and nurse aide task documentation did not show that the resident wore the splints, although nurses documented the ordered skin checks every shift. The DON confirmed there was no order indicating the splint wearing schedule and no documentation showing the splints were applied.
Failure to Use Ordered Positioning Equipment
Penalty
Summary
The facility failed to ensure therapy-ordered positioning equipment was used for a resident who needed assistance maintaining body alignment in bed. Resident #39 was admitted with diagnoses including morbid obesity, diabetes mellitus, bladder cancer, and chronic kidney disease. The resident’s quarterly MDS showed mild cognitive decline and substantial assistance was required for all ADLs except eating. The resident’s care plan was silent regarding positioning, and there was no physician order specifically addressing positioning equipment. Physical therapy documentation stated the resident was dependent for repositioning to maintain straight alignment in bed and that staff were educated on bolster placement to keep the resident centered and prevent a left lateral lean. A later PT note documented that the resident was provided a different wedge cushion due to discomfort with the prior one and that staff training was provided on supine positioning and use of the wedge cushion. However, during the survey the resident stated staff failed to place the wedge or bolster in the bed unless she asked for it, and observations showed the wedge cushion in the wheelchair and the bolster in the recliner while the resident was in bed. A CNA confirmed the equipment was not in the bed and stated it should be used when the resident was in bed.
Failure to Measure and Maintain ROM for Two Residents
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve ROM and mobility for two residents with limited ROM. One resident had a history of traumatic subarachnoid hemorrhage, left-sided hemiplegia, aphasia, dysphagia, contractures, and severely impaired cognition. The resident’s MDS indicated ROM limitation in both arms and legs and dependence for multiple ADLs. OT evaluations dated 5/6/2025 and 11/11/2025 documented impaired ROM in both shoulders, elbows/forearms, wrists, and hands, but neither evaluation included objective measurements of the impairments. The DOR stated that therapy staff are trained to measure joints with a goniometer and that the absence of measurements prevented monitoring for changes in ROM. For the same resident, PT and OT services ended on 8/19/2025, and physician orders dated 9/3/2025 directed RNA staff to provide PROM to both arms and legs five times per week as tolerated and to apply resting hand splints, elbow extension splints, knee extension splints, and ankle splints five times per week for four to six hours as tolerated. The OT discharge summary recommended 24-hour care, and the PT discharge summary recommended a restorative nursing program. However, the DOR stated the OT discharge summary did not include RNA services, and the resident did not receive ROM exercises and splint application from 8/10/2025 to 9/3/2025. During observation, the resident was lying in bed, unable to speak, with elbow and hand splints in place; PROM was later provided to both shoulders, elbows, wrists, and hands, and the resident’s elbows could not be fully straightened, with fixed bent positions noted in some fingers and knuckles. A second resident had diagnoses including muscle weakness, atherosclerosis of CABG grafts, atrial fibrillation, and a healed traumatic fracture. The resident’s MDS indicated unclear speech, severely impaired cognition, and dependence for toileting, showering, dressing, rolling, transfers, and sit-to-stand transfers. The OT evaluation dated 4/16/2026 documented a history of CABG, right humeral fracture, and right shoulder anterior dislocation with closed reduction, and noted right shoulder ROM impairment, but did not include objective ROM measurements. The DOR and the evaluating OT both stated that goniometer measurements are part of OT training and are used to establish baseline ROM and monitor improvement or decline, and the OT stated the resident’s right shoulder ROM should have been measured because it could affect ADLs.
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