Failure to Provide Ordered PT Frequency and Document Services for a Resident
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.