Health inspection·May 12, 2022

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure one resident (Resident #17) received restorative range of motion (ROM) and ambulation programs per the plan of care. This affected one (Resident #17) of two residents (Residents #1 and #17) reviewed for restorative nursing and had the potential to affect all 54 (Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #20, #21, #22, #23, #25, #26, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #57, #58, #60, #63, #64, #66, #319 and #320) residents with planned restorative nursing programs. The facility census was 65. Findings include: Review of the medical record for Resident #17 revealed an admission date of 03/28/18 and diagnoses of chronic obstructive pulmonary disease (COPD) hyperlipidemia, heart disease, hypertension and diabetes. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. He was independent in the areas of bed mobility and transferring and was unsteady with walking. He had no impairments to his upper and lower extremities. Restorative therapy was provided for passive ROM for four days during the review period and active ROM as provided for two days during the review period. He did not receive any training in walking or ambulation during the review period. Review of the current summary of physician orders revealed the resident may participate with restorative programs per the plan of care as needed (PRN). Review of the care plan dated 02/28/22 revealed a plan for decreased ambulation, decreased duration and unsteady gait to include a goal to maintain an ambulation distance of 50 feet for at least 15 minutes six to seven times per week, and to document the response, distance and tolerance. Review of the care plan dated 02/28/22 also revealed a plan to maintain Resident #17's ROM in his arms and legs by participating in ROM exercises for 15 minutes six to seven times per week. Review of the Physical Therapy (PT) Discharge summary dated [DATE] revealed Resident #17 received physical therapy from 02/21/22 through 03/03/22 for strengthening, balance, bed mobility, transfers and ambulation. The summary further indicated Resident #17 walked 0 feet when he started PT on 02/21/22 and walked 50 feet upon discharge from PT services on 03/03/22. The discharge summary included a referral to restorative nursing for ambulation and active ROM to maintain the current level of Page 1 of 2 365411 365411 05/12/2022 Andover Village Retirement Community 486 S Main St Andover, OH 44003

F 0688 functioning and prevent further decline. Level of Harm - Minimal harm or potential for actual harm Review of the tasks from 04/12/22 to 05/11/22 documented by the State Tested Nursing Aides (STNAs) revealed ROM exercises completed on 04/27/22 and documented as refused on 04/14/22, 04/17/22, 04/28/22 and 05/11/22. Walking exercises were documented for 15 minutes on 04/27/22 and marked as refused 04/14/22, 04/17/22, 04/28/22 and 05/11/22. For a total of 30 days reviewed restorative ROM and ambulation were both provided just one day and documented as refused four times. Residents Affected - Few Interview on 05/11/22 at 1:08 P.M. with Registered Nurse (RN) #524 confirmed Resident #17 was ordered to receive restorative programs for active ROM and ambulation six to seven times a week to maintain current function and prevent decline. She verified she was not aware restorative ROM and ambulation were only provided to the resident on just one occasion from 04/12/22 to 05/11/22. Review of the policy labeled Restorative Nursing dated March 2017 revealed restorative nursing programs would be maintained until the goals were met or success was determined to no longer be attainable. Restorative programs would be provided for any resident identified as in need of the service. The procedure for implementing a restorative nursing program included daily documentation of the program. 365411 Page 2 of 2