Federal inspectors found that Ararat Nursing Facility failed to ensure nursing staff had the competency to provide mobility care to residents, resulting in actual harm to Resident 119 and potential harm to three other residents with limited range of motion.
The facility's Director of Nursing admitted that all 13 restorative nursing assistants lacked the competency to accurately perform their duties, including providing range of motion exercises, applying splints, and detecting declines in mobility.
Resident 119 had been living at the facility since May 2017 with diagnoses including Alzheimer's disease, dementia, osteoporosis, and difficulty swallowing. By May 2024, she was severely impaired in daily decision making, rarely expressed ideas or wants, and was completely dependent on staff for eating, toileting, bathing, and transfers.
When occupational therapy discharged her in August 2022, Resident 119's range of motion included right shoulder flexion to 90 degrees and left shoulder flexion to 50 degrees. She could extend her right elbow to 20 degrees and left elbow to 30 degrees. Both hands had full range of motion.
Physical therapy discharged her in October 2022 with recommendations for nursing assistants to provide range of motion exercises and apply a right knee extension splint. At discharge, her right knee extended to 20 degrees.
But the facility's Joint Mobility Assessments from March 2023 through August 2024 showed no changes in her condition, despite significant deterioration occurring.
When inspectors observed Resident 119 in August 2024, they found dramatic declines. Her right shoulder flexion had dropped from 90 degrees to 50 degrees. Her left shoulder flexion fell from 50 degrees to 66 degrees. Both hands, previously with full range of motion, now had contractures preventing complete extension.
The deterioration was even worse in her legs. Her right knee, which extended to 20 degrees at physical therapy discharge, now only extended to 73 degrees. Her left knee extended to just 17 degrees. She had developed new contractures in both hips that hadn't existed at therapy discharge.
During an inspection observation on August 7, inspectors watched as Restorative Nursing Assistant 2 performed range of motion exercises on Resident 119. The assistant could not lift either arm to shoulder height and could not fully extend either elbow, which remained bent.
When the assistant bent and extended the resident's right hip and knee simultaneously, Resident 119 moaned with a facial grimace. The assistant then applied the right elbow splint upside down and positioned the right knee splint incorrectly, placing it toward the ankle rather than on the knee.
Physical Therapy Assistant 1 examined the splints and found the right knee splint was set to 30 degrees of extension, but Resident 119's knee was bent to approximately 90 degrees. "The right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee," the assistant told inspectors.
The misfit splint created dangerous pressure. When the Director of Rehabilitation removed it, inspectors observed redness on the skin directly under the strap area of Resident 119's right kneecap.
The physical therapy assistant warned that an inappropriately fitted splint "could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores and dislocation of the right knee."
The problems weren't isolated to one nursing assistant. When Restorative Nursing Assistant 5 applied splints the next morning, she removed the right knee and left elbow splints after just 15 minutes due to skin redness.
Physical Therapist 1 confirmed that Resident 119 had developed contractures in both knees and stated the right knee extension splint "could cause injury to Resident 119's right leg if applied to the right knee."
The facility's assessment system had completely failed to detect these changes. Registered Nurse Supervisor 1 stated that Joint Mobility Assessments from March 2023 to August 2024 "indicated Resident 119's ROM limitations remained the same and did not change."
The Director of Nursing explained why: "Resident 119's JMAs were the same because the RN Supervisors were not competent to assess joint mobility and therefore did not notice any changes in Resident 119's ROM."
She acknowledged that none of the registered nurses, including herself, had competency assessments to perform Joint Mobility Assessments, despite facility policy requiring the Director of Nursing to monitor their completion and accuracy.
The nursing assistant responsible for Resident 119's care, RNA 5, admitted she didn't report the splint problems to supervisors even though she was supposed to. She told inspectors that "Resident 119 resisted ROM because Resident 119 was in pain and had facial expressions of pain whenever RNA 5 touched Resident 119."
When physicians finally ordered new occupational and physical therapy evaluations on August 8, 2024, the therapists documented the extensive deterioration. Occupational Therapist 2 found that Resident 119 had developed flexion contractures in both hands and worsening contractures in both shoulders and elbows.
Physical Therapist 2 noted that Resident 119's hips, which had full range of motion at discharge in 2022, were now significantly limited. The therapist stated that "Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown."
Both therapists confirmed that the therapy department had never been notified of the resident's declining range of motion, despite facility staff observing the deterioration during routine care.
The Director of Nursing's review of staff competency files revealed the scope of the problem. Seven of 13 restorative nursing assistants had no competency evaluations whatsoever for providing RNA services. Six others were evaluated by the Director of Staff Development, who was not competent in RNA services.
"Thirteen of 13 RNAs did not have the competency to accurately perform their duties, including providing ROM, applying splints, and detecting declines in ROM and mobility," the Director of Nursing stated.
The consequences extend beyond Resident 119. The Director of Nursing explained that contractures develop due to immobility and "could cause discomfort and pain, and increased a resident's risk of skin impairments." She noted that "contracture prevention was important for a resident's quality of life to prevent any restrictions in movement."
The facility's policies clearly outlined requirements for staff competency. The Range of Motion Exercise Guidelines policy specified that ROM "should be delivered by trained staff to maintain or increase ROM of a joint and to prevent or reduce contractures."
The Joint Mobility Assessment policy required assessments "upon admission, quarterly, and during a significant change in the resident's condition to identify any limitation in joint mobility and risk of contractures."
But implementation failed catastrophically. Resident 119 went nearly 22 months without proper therapy intervention while her condition deteriorated under the care of incompetent staff who couldn't recognize the decline or properly apply the equipment designed to prevent it.
The facility also failed to maintain a hazard-free environment for eight other residents, with staff leaving medications unsecured at bedsides, placing wheelchairs on unstable surfaces, and abandoning transfer equipment in resident rooms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-08-09 including all violations, facility responses, and corrective action plans.
