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F0688
E

Failure to Implement Physician-Ordered Ambulation for Resident

Glendora, California Survey Completed on 11-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care to maintain or improve a resident's range of motion and mobility by not implementing a physician's order for ambulation. The resident, who had a history of cerebral infarction, difficulty walking, and traumatic brain disorder, was admitted and later readmitted to the facility. Assessment records indicated the resident required supervision or assistance for daily activities and had moderate cognitive impairment. A physician's order was in place for a Restorative Nursing Assistant (RNA) to ambulate the resident five times a week using a front wheel walker, as part of a restorative nursing program following discharge from rehabilitation services. Despite the physician's order, record reviews and staff interviews confirmed that the resident did not receive the prescribed ambulation in the hallway five times a week. Documentation for August, September, and October did not show evidence that the ambulation was provided as ordered. The RNA confirmed that the ambulation was not performed as required. The facility's policy stated that restorative services should be provided to maintain or improve residents' abilities, but this was not followed for the resident in question, resulting in a decrease in the resident's ability to walk.

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