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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365411 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Andover Village Retirement Community 486 S Main St Andover, OH 44003 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)