F0688

D

Failure to Provide and Care Plan Restorative Walking Programs for Multiple Residents

Belvidere, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document restorative services, particularly walking programs, to maintain or improve residents’ range of motion and mobility. One resident, who was alert and oriented and used a wheelchair and walker, reported that he had been "cut out of therapy" and that staff did not walk him because they were too busy, despite his desire to ambulate with assistance. His restorative progress note showed he was on a walking program twice daily with specific instructions for ambulation using a two-wheeled walker, yet CNA nursing rehab task documentation for walking showed that on 11 out of 30 days the service was marked not applicable, indicating it was not provided. Additionally, his current care plan did not include his restorative walking program or the services to be provided.

Another resident with multiple diagnoses including muscle weakness, malnutrition, metabolic encephalopathy, atrial fibrillation, and dizziness had a physician order for restorative walking 15–20 minutes on first and second shifts. The MAR reflected that an LPN documented the resident was being walked twice per day, including during the survey period. However, the resident stated he was no longer walked daily since the previous restorative CNA stepped down, reporting that he previously completed 12 laps but had only been walked about three times in the last two weeks for only three laps each time. His assigned CNA confirmed that restorative walking was not occurring consistently, that no staff had walked him that day, and that staffing levels made it difficult to walk residents. CNA task documentation for this resident did not include walking on even surfaces, only on uneven or sloping surfaces, and his care plan did not include a restorative program despite an ADL self-care deficit related to limited mobility and impaired balance.

A third resident, admitted with conditions including primary disorder of muscle, difficulty in walking, abnormal posture, and muscle weakness, had a care plan for a restorative ambulation program with a goal to ambulate 110–200 feet using a four-wheeled walker with extensive assist and wheelchair follow. CNA task documentation for walking 150 feet twice daily showed the task was marked not applicable 22 out of 26 times in the last 14 days, and when the resident was walked, he required maximal assistance or was dependent. Documentation of minutes spent in walking training showed he was walked only once daily on several specific dates rather than twice daily as planned. The resident reported that staff did not walk him, while an LPN stated he was able to walk with staff assistance. Facility leadership, including the DON, ADON, and nursing staff, acknowledged that the previous restorative CNA had stepped down, that there was no designated restorative staff, that floor CNAs were now responsible for restorative services, and that there was uncertainty about which residents were on restorative programs. The facility’s Nursing Rehab policy required the interdisciplinary team to develop and implement care-planned interventions and to record nursing rehab tasks as part of daily care, which was not consistently done for these residents.