Failure to Float Heels and Reposition a Dependent Resident
Summary
The facility failed to follow resident #79’s individualized care plan for repositioning and heel elevation to prevent skin breakdown. During multiple observations, the resident was found lying flat on her back with a pillow beneath her legs, but her heels and feet were still touching the bed or resting on the pillow’s surface rather than being floated. The resident stated she was never repositioned by staff, that she lay flat on her back very frequently, and that staff were supposed to keep her heels from touching the bed but often forgot to do so. Resident #79 stated she was dependent on staff for help and would rarely get out of bed for activities. On a later observation, staff member L stated the resident’s heels were boggy, and the resident’s heels were observed to be slightly red, her entire back was red, and her left arm and fingers were noticeably swollen. The care plan, initiated 7/15/25, directed staff to use bilateral heel suspension boots to float the heels while in bed and to assist the resident to turn and reposition regularly to offload pressure points, but the boots were not observed when the resident was in bed.
Penalty
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Failure to Maintain Restorative Mobility Program: A resident with Parkinson's disease and limited mobility was supposed to receive restorative walking twice daily, but documentation showed the program was inconsistently offered and the distance walked declined over time. Staff said they sometimes lacked time to complete the program and would chart NA, and there was no documented report of the decline to the restorative nurse or MD.
Failure to Maintain ROM With Splint Use: A resident with hemiplegia/hemiparesis and a contracted hand had an OT-recommended resting hand splint program, but there was no physician order, no care plan, and no evidence of a splint application program. The resident said staff rarely applied the splint and that it had become painful to use because the hand had stiffened; staff interviews showed inconsistent awareness of the splint recommendation, and the DON stated she had no idea the resident was supposed to wear a splint.
Failure to Consistently Provide Ordered Restorative ROM Services: Staff did not consistently carry out physician-ordered restorative ROM programs for three cognitively intact residents with mobility limitations. One resident with muscular dystrophy, one with diabetes and gait instability, and one with right-sided weakness all had ordered active and/or passive ROM through all joints and planes, but documentation showed multiple missed or unexplained not-applicable entries and variable treatment times. Residents reported the exercises were not being provided as ordered, and an NA stated ROM was sometimes done only incidentally during routine care rather than as the formal restorative program ordered by the physician.
A resident with cognitive impairment and unilateral extremity impairment had a physician order for a resting hand splint to the R hand for up to 3 hours daily, 5 days a week, with skin checks and premedication if needed. Staff observed the splint off the resident and on the bedside drawer during one observation, and RNA documentation did not show when the splint was applied or removed or how long it was tolerated; the RNA stated he did not document those times.
A resident with stroke, hemiplegia/hemiparesis, encephalopathy, severe cognitive impairment, and contractures of all extremities did not consistently receive ordered/expected contracture management. Observations showed no washcloths or offloading devices in place on the hands or wrists, while staff gave conflicting accounts about whether the devices were ordered, who was responsible for applying them, and whether they were used all the time. Therapy staff said the resident had become more contracted after returning from the hospital and that they were trying to maintain ROM, but the resident’s hands and arms were not consistently positioned with the devices described in the care plan.
A resident with limited mobility, heart failure, and low back pain had a care plan for active ROM twice daily and ambulation with a front wheeled walker and CGA, but chart review showed no documented evidence that these services were provided over several months. The resident said walking depended on staff availability, and the OT and DON stated the facility did not currently have a restorative nursing program in place, so no active ROM or ambulation orders were implemented.
Failure to Maintain Restorative Mobility Program
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Resident 39 was cognitively intact, had diagnoses including Parkinson's Disease, and used a walker and wheelchair. A quarterly MDS dated April 24, 2026 indicated the resident was independent with transfers and ambulation, but a later quarterly MDS showed the resident required substantial or maximum assistance for transfers and ambulation. The resident's restorative nursing care plan directed staff to report and document any decline in ability and to report abnormal assessment findings, decline in function, or complications associated with restorative activities to the physician. The restorative nursing program required the resident to walk 100 feet twice daily for 15 minutes, 7 days a week. Documentation showed the resident walked an average of 75 feet in May 2026, then declined in June and July to walking only 15 to 50 feet, with restorative nursing not consistently offered as scheduled and, in early August, not offered at all. There was no documented evidence that the resident's decline was reported to the restorative nurse or physician. The resident stated staff sometimes took him for a walk depending on staffing and time, and a nurse aide stated they did not have enough time to ensure completion of the restorative program and would document NA when they did not have time. Therapy staff confirmed the resident had been placed on restorative nursing to help prevent decline related to Parkinson's disease, and a therapist stated the resident had declined in mobility.
Failure to Maintain ROM With Ordered Splint Use
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain and prevent further decrease in range of motion for a resident with limited ROM. Resident #8 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and an OT evaluation and discharge summary documented a contracture and recommended a functional maintenance program for splint use, including wearing a resting hand splint on the left hand for 2 hours on and 2 hours off. However, the resident’s current physician orders contained no order for a splint, brace, or ROM to the left hand, and the comprehensive care plan contained no care plan related to limited ROM or splint use. During observation, the resident’s left hand was contracted and no splint was in place. The resident stated staff rarely put the splint on him and that an attempt to apply it was painful because his hand had become stiff again. Record review showed no evidence of a program to apply the splint, and the resident was not on the restorative nursing list. Staff interviews reflected inconsistent awareness of the splint recommendation: the OT stated nursing was verbally informed, the CNA stated restorative, a nurse, or a CNA usually applied the splint, the assigned RN stated the resident did not have a brace or splint, the Director of Therapy stated recommendations were communicated to nursing, and the DON stated she had no idea the resident was supposed to wear a splint.
Failure to Consistently Provide Ordered Restorative ROM Services
Penalty
Summary
The facility failed to consistently implement physician-ordered restorative nursing services for three residents with impaired mobility. The deficiency involved restorative range of motion (ROM) programs that were ordered to help maintain or improve mobility, but were not consistently carried out as directed or documented as completed. The report cites the Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual and facility policy requiring restorative nursing services to be planned, monitored, evaluated, documented, and delivered by trained staff. Resident 85 had muscular dystrophy and was cognitively intact. A physician ordered passive ROM to both lower extremities twice daily, three sets of 10 repetitions through all joints and planes, and physical therapy recommended bilateral lower extremity passive ROM daily in the same format. The resident’s care plan included restorative nursing services with passive ROM to both upper and lower extremities. However, the resident stated staff assisted with dressing, hygiene, and transfers but did not routinely perform the prescribed repetitive passive ROM exercises. July 2026 restorative documentation showed passive ROM services on only some days, and a nurse aide stated she only stretched the resident’s legs twice during personal care and did not perform the ordered program. Resident 15 had diabetes and gait instability and was cognitively intact. Physician orders directed active ROM to both lower extremities every day using two sets of 15 repetitions and active ROM to both upper extremities every day using three sets of 10 repetitions. The resident stated staff were not providing restorative exercises for either upper or lower extremities. The July 2026 restorative documentation included entries marked not applicable on several dates without any explanation, and treatment times varied from five to 15 minutes without documentation explaining the differences. A nurse aide stated ROM was sometimes done during dressing and grooming, but could not explain the ordered program or what exercises through all joints and planes meant. Resident 64 had right-sided weakness and was cognitively intact. Physician orders directed active and passive ROM to the right upper extremity and both lower extremities, three sets of 10 repetitions daily. The resident stated staff were not providing restorative exercises and wanted therapy to become stronger and improve the ability to return home. July 2026 restorative documentation showed multiple dates marked not applicable without explanation, and treatment times varied from five to 15 minutes without documentation explaining the variation. The DON was unable to provide evidence that Residents 15 and 64 consistently received the ordered restorative nursing services or that nursing assistants had been instructed on how to perform the ordered ROM programs in accordance with the physician orders.
Failure to Document and Follow Ordered Hand Splint Use
Penalty
Summary
The facility failed to provide RNA services as ordered for Resident 178, who was admitted on 2/2/23 and had fluctuating capacity to understand and make decisions, moderate cognitive impairment, and impairment on one side of the upper and lower extremity. A physician order dated 3/13/26 directed RNA to apply a resting hand splint to the resident’s right hand for up to three hours every day, five times a week, as tolerated, with skin checks and premedication if indicated. During observation on 7/27/26 and 7/30/26, the splint was not on the resident’s hand and was seen on the bedside drawer during one observation. The resident’s July 2026 RNA documentation showed the splint was applied five days a week and noted an average wear time of four hours with skin checks completed, but it did not show when the splint was applied, when it was removed, or how long the resident tolerated it each day. During interview, RNA 1 stated he applied the splint for approximately four hours each day but acknowledged he did not document the application and removal times or the duration of tolerance. The DON was informed of the findings and acknowledged them.
Failure to Consistently Implement Contracture Management
Penalty
Summary
The facility failed to ensure a resident with severe contractures received appropriate treatment and services to maintain range of motion and prevent further decline in the right and left hands and arms. Resident #6 had diagnoses including stroke, hemiplegia/hemiparesis, and encephalopathy, with severely impaired cognitive skills, upper and lower extremity impairment on both sides, and dependence for all ADLs. The resident’s care plan included interventions for contractures, including weekly ROM by therapy and use of washcloths in the right thumb and index finger and against the shoulder and hand on the right. Observation on 07/28/26 and 07/29/26 showed the resident lying in bed with no offloading device observed on the arms or wrists and no washcloths observed in or around the hands or wrists. On one observation, bordered gauze was on the right palm, and on another, a blue round offloading device was seen in the wheelchair rather than on the resident. Staff interviews showed inconsistent understanding and implementation of the resident’s contracture management measures. One LVN stated the resident was supposed to wear the devices all the time, while another LVN stated there was no order for an offloading device and that therapy applied it. A CNA stated she had used towels or the blue device, while another CNA stated she did not put anything in the resident’s hands and that the blue brace was only sometimes present. Therapy and management staff also described differing approaches to the resident’s contractures. The DOR stated the resident was receiving PT, OT, and ST through PASARR services and that staff had been in-serviced on positioning devices and using a pillowcase in the hands or between the arm and chest. OT staff stated the resident had become more contracted since returning from the hospital and that they were trying to maintain ROM, but splinting could rest against the thumb and cause a wound. The DON stated CNAs and nurses were responsible for placing washcloths and the round foam device, and that the washcloths should be changed daily. The facility’s contracture management guidance stated that repositioning devices and adaptive devices were used to reduce the risk of pressure injury development.
Failure to Provide Restorative Nursing Services for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Resident 6 was cognitively intact, had diagnoses including heart failure and low back pain, and the care plan identified a potential for decline in ROM. The care plan directed active ROM to all extremities twice daily, six to seven days a week for at least 15 minutes, and ambulation up to 100 feet with a front wheeled walker and contact guard assist. The resident’s MDS also indicated the need for supervision or touching assistance with transfers and ambulation. Review of nurse aide documentation and Treatment Administration Records for April through July 2026 showed no documented evidence that the resident received active ROM or assistance with ambulation. The resident stated that she sometimes walked in the hall with her walker, depending on what staff were available to help her. The OT stated that the facility previously had an active restorative nursing program but did not currently have one in place, and that no active ROM or ambulation orders were put into place for Resident 6 because there was no restorative nursing program. The DON confirmed that the facility did not currently have a restorative nursing program in place, although one should have been in place.
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