Federal inspectors found that ARK Healthcare & Rehabilitation at Governor's Ho failed to accurately assess Resident #74, who has severe protein calorie malnutrition, Marfan syndrome, osteoarthritis, and Alzheimer's disease.
The resident's nursing aide told inspectors on December 24 that Resident #74 required staff assistance with wheelchair mobility and "could not self-propel while sitting on a wheelchair." She said he hadn't been able to move his wheelchair himself "for over a year after he/she broke a hip."
Yet the facility's quarterly assessment coded him as independent for wheelchair mobility.
The contradiction appeared twice in official records. Both quarterly assessments reviewed by inspectors showed Resident #74 was dependent on staff for toileting, personal hygiene, dressing, and transfers, and was non-ambulatory. But both assessments listed him as independent with his wheelchair.
Physical therapy records directly contradicted the assessments. The September evaluation identified Resident #74 as "dependent on staff for wheelchair mobility." Occupational therapy notes from May showed he required "partial to moderate assistance with wheelchair mobility."
When inspectors observed the resident on December 24 at 10:10 AM, he sat in a locked wheelchair with leg rests in place near the nurse station.
Two occupational therapists who worked with Resident #74 told inspectors the assessments were wrong. The first said the resident required "max assistance to total dependent with wheelchair mobility" and "was not independent with wheelchair mobility."
The second occupational therapist was more direct: Resident #74 was "totally dependent for personal hygiene, toileting, transfer, non-ambulatory, and wheelchair mobility." She said he "was not independent with wheelchair mobility in the nursing unit and had a pending order for a customized wheelchair."
The facility's MDS coordinator, who was responsible for coding the mobility assessments, told inspectors she would observe residents during required look-back periods and code assessments based on her observations. She maintained that Resident #74 was independent with wheelchair mobility.
Her assessment directly contradicted physician orders from May that directed staff to provide one-person assistance with bed mobility and two-person assistance with transfers, noting the resident was non-ambulatory.
The resident's care plan from October documented his "limited physical mobility related to weakness and impaired balance" and directed staff to provide one-person assistance for bed mobility and toileting, plus two-person assistance for transfers.
Federal regulations require qualified clinicians to code assessment data based on the type and amount of assistance provided by helpers to accurately reflect residents' functional abilities.
The nursing aide who worked regularly with Resident #74 on the day shift confirmed the resident was dependent on staff for personal hygiene, toileting, and dressing, and required two people to help with transfers.
She said he was not ambulatory.
The inspection found the facility failed to ensure accurate resident assessments, creating potential for minimal harm. The deficiency affected some residents at the 36 Firetown Road facility.
Accurate mobility assessments determine care planning, staffing levels, and federal reimbursement rates. When facilities code dependent residents as independent, they may receive inadequate resources to provide proper care while potentially collecting higher Medicare payments.
The December 30 complaint inspection revealed the assessment failures had persisted across multiple quarterly evaluations, despite clear documentation from therapy staff and direct care workers that Resident #74 could not operate his wheelchair independently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ark Healthcare & Rehabilitation At Governor's Ho from 2025-12-30 including all violations, facility responses, and corrective action plans.