Aviata At The Palms

ROM and/or mobility, unless a decline is for a medical reason.

observation, record review and interviews, the facility failed to ensure a resident with contractures

(Resident # 1) of one resident observed.

Findings include:On 02/23/2026 at 9:45 AM Resident #1 was observed lying in bed right hand was observed with fingers touching palm, no splint or support. On 02/23/2026 at 12:14 PM Resident #1 was observed lying in bed. He was unable to verbally communicate but able to shake his head when asked questions.

His right hand was observed with fingers touching palm, with no splint or support.On 02/23/2026 at 2:00 PM Resident #1 was observed lying in bed.

His neck pillow was observed lying on top of the sheet over the stomach.

The right hand was observed with fingers touching palm with no splint or support.Review of Resident #1's admission Record revealed an admission to the facility initially on 10/09/2025 and readmitted on [DATE] with diagnoses to included but not limited to unspecified displaced fracture of surgical neck of right humerus, subsequent encounter fracture with routine healing, Type 2 Diabetes Mellitus without complications, affecting right dominant side, functional quadriplegia.Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 has impairments on one side of his upper and lower extremity and has no mobility devices.Review of Resident #1's Therapy Funding Verification Form, dated 2/23/2026, revealed Resident #1 was approved minutes for Physical and Occupational Therapy, per discipline for 30 minutes times, three visit for four weeks.On 02/23/2026 at 2:15 PM an interview was conducted with Staff A, License Practical Nurse, (LPN), Staff A stated Resident #1 is not receiving range of motion or routine care from nursing for his contracted hand, therapy is usually responsible for contractures.

Staff A stated to her knowledge when a resident has any kind of contracture therapy screens the residents first.

Then therapy will either continue the resident on therapy services or refer them to restorative therapy.On 02/23/2026 at 2:30 PM an interview was conducted with Staff B, Restorative Therapy.

Staff B stated Resident #1 is not on her case load for restorative therapy.

Staff B stated when therapy refers a resident for restorative, therapy will put the information in the electronic medical record.

Staff B, Restorative Therapy stated checking the system daily for any changes to the schedule.

Staff B stated Resident #1 was never referred to restorative therapy.On 2/23/2026 at 2:40 PM an interview was conducted with the Rehab Director.

The Rehab Director stated he has not screened resident #1 for his contracted hand.

The Rehab Director stated nursing is responsible for managing Resident #1 contracted hand.On 02/23/2026 at 4:04 PM an interview was conducted with the Director of Nurses, (DON).

The DON said Resident #1 was admitted with right hand contracture.

The DON stated nursing cannot do anything for a resident's contracted hand.

Nursing would only take over splint management once therapy has done an evaluation and provides education to nurses on how to safely manage the resident's hand.

Review of the facility policy titled, Contractures, Prevention dated 11/30/2014, revealed: Policy: Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed.

Procedure. RANGE of Motion: Resident with inactive extremities should have range of motion done to those extremities as part of their daily care.