The resident, identified in inspection records as R1, had suffered a displaced intertrochanteric fracture of the right femur before arriving at the facility. A physician had ordered active range-of-motion therapy to both upper and lower extremities, twenty repetitions for 15 minutes, five times weekly.
No therapy was documented between September 20 and September 24, according to the resident's daily task audit report reviewed by federal inspectors.
Director of Nursing V2 told inspectors she was familiar with the resident's case. The patient had been sent to the hospital due to high creatinine levels and was classified as a "hospital contract resident" without insurance coverage.
"Physical therapy will not pick her up because she cannot pay for it," V2 explained during the November 29 inspection. Instead, the facility's restorative therapy program was supposed to provide 15 minutes daily of therapy, the extent of coverage under the hospital contract.
V2 acknowledged the resident "was in a lot of pain so whatever she could tolerate that was what was done for her." But when inspectors asked for documentation of the ordered therapy, V2 could find none.
"If it is not documented then it is not done," V2 told inspectors.
The facility's restorative nurse, V4, confirmed that any therapy provided should be documented and echoed the same principle. "If it is not documented, then it is not done."
V4 admitted she had only worked with the resident during an initial evaluation and never provided the ongoing therapy. She said certified nursing assistants should have incorporated range-of-motion exercises into daily care activities to prevent decreased mobility.
Administrator V1 told inspectors she "vaguely remembers" the resident, who stayed at the facility for only a few days. V1 confirmed the resident had fallen at home and sustained the femoral fracture, and that restorative aides or certified nursing assistants were supposed to work with residents according to physician orders.
"If there is no documentation then technically the task was not done," V1 stated.
The resident was admitted to Ryze West in September and discharged on September 26, 2025, according to facility records.
During the inspection, surveyors observed no restorative aides assisting residents with walking on the facility's second and third floors. The lack of documented therapy violated federal requirements that nursing homes provide appropriate care to maintain or improve residents' range of motion and mobility unless a medical decline prevents it.
The citation represents a broader pattern inspectors have documented at nursing facilities nationwide, where ordered rehabilitation services go unprovided, particularly for residents whose insurance coverage is limited or nonexistent.
For R1, the consequences of missed therapy sessions during recovery from a serious hip fracture could be lasting. Range-of-motion exercises are critical for preventing joint stiffness, muscle weakness, and further mobility loss following fractures, especially in the hip and femur area.
The facility's own staff acknowledged the fundamental problem: without documentation, there's no proof therapy occurred. And in this case, the missing documentation reflected missing care for a resident whose fractured femur required consistent, gentle movement to prevent permanent disability.
The inspection found that Ryze West failed to ensure rehabilitation orders were followed, affecting at least one resident out of three whose rehabilitation services were reviewed. The violation was classified as causing minimal harm or potential for actual harm to few residents.
Federal inspectors concluded their review on December 1, 2025, leaving R1's case as evidence of how insurance status can determine the quality of post-fracture care residents receive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ryze West from 2025-12-01 including all violations, facility responses, and corrective action plans.