Restorative nursing: It takes a facility

In 2010, my administrator was staring at our most recent three-month FQIP (Facility Quality Measure/Indicator Report) report, when he turned to me (the rehab manager) and the director of nursing and asked: “Are we or are we not a Medicare Five-Star facility?” I replied that we are.

His response: “Then why do we continue to accept failure month after month in our physical functioning quality measures? Our three-month FQIPreport ranked us in the 95th percentile for the state in the domain ‘Residents whose ability to move in and around their room’ got worse.”

That ranking meant that 95% of facilities in the state were outperforming us. To make matters worse we were in the 97th percentile in the domain “Residents whose need for help with daily activities has increased.” It was time for a “gut check.”

I had been the rehab manager for more than four years and I prided myself on not only providing excellent rehab care to our short-term residents, but also to the residents who called our facility home.


However, this was not just a rehab issue; this was not just a nursing issue. It was a Renaissance Gardens at Riderwood issue. We succeed or we fail as a team. So after much discussion with the team, an interdisciplinary approach was established.

Were we successful? Six months later, our FQIP report scored us in the 13th percentile in “Residents whose ability to move in and around their room got worse” and in the 17thpercentile in “Residents whose need for help with daily activities has increased.” 

Our plan called for all LTC residents to have an appropriate five-day restorative nursing program each week. Rehab staff evaluated all LTC residents with two goals in mind. First, the therapist would determine if the resident experienced a decline in function and, if so, a treatment plan would be developed. The second goal focused on evaluating the resident’s current restorative nursing program to determine if it was still appropriate. 

If the plan was not appropriate or if the resident currently did not have a plan, one was developed and reviewed with our restorative nursing assistants (RNAs) and the resident. Specific communication pathways for our RNAs were established so they could communicate with the therapists in real time. As a result, the therapist was aware that a resident was beginning to decline, which enabled him or her to intervene before the decline became significantly detrimental to the resident.


Restorative nursing often doesn’t happen the way it should. Perhaps the facility has a number of staff call-outs and needs to pulls its RNAs to work as nursing assistants on the floor. The RNA gets bogged down with nonrestorative duties (stocking supplies, etc). This can happen even in the most committed facilities, but I believe it often occurs because the staff has not fully bought into the benefits of restorative nursing.

Remsburg et al found that “a progressive mobility restorative program implemented by a certified nursing assistant specially trained in restorative techniques resulted in most residents maintaining their baseline ADL self-performance abilities and the level of assistance provided by staff.”1 I believe that a restorative nursing program can do much more.

The benefits of exercise for the elderly has been well studied and has been shown to improve cardiovascular functioning and endurance, increase strength, improve balance, decrease joint pain and even to improve mood.2 To realize these benefits, the intensity of the restorative program needs to be high enough as to challenge the residents. This is where most programs fall short and why I advocate that an “appropriate” physical or occupational therapist develop the program.

The reason I use the word “appropriate” because the therapist designing the program needs to have both experience and knowledge in working with LTC residents. He or she also must understand recent research that shows that elderly residents can benefit from an “aggressive” exercise program. If the program challenges the resident, then he or she likely will require less physical staff assistance, will be more likely to be able fight off disease such as pneumonia, will have a lower risk of skin breakdown and a lower risk of falls. Basically, you get a healthier, happier resident who has a better quality of life and, perhaps, requires less assistance.

Restorative care also allows a facility to comply with the Code of Federal Regulations 42 Subpart B, Section 483.25 Quality of Care, which states: “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”

In addition Section 483.25(a)(1) states: “A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to (i) bathe, dress and groom; (ii) transfer and ambulate; (iii) toilet; (iv) eat; and (v) use speech, language, or other functional communication systems. 


Our SNF has a great restorative nursing program with well-trained RNAs and a commitment from the administration to protect their time for restorative nursing. Generally, there are two “approaches” to restorative nursing: the designated model and the integrated model. The designated model relies on a specially trained nursing assistant to perform restorative activities. The integrated model relies on regular staff nursing assistants trained to incorporate restorative activities into their daily routines. 

Research has shown that the designated model may be more beneficial. Remsburg et al found that “the designated model resulted in higher rates of enrollment, compliance, and staff satisfaction compared with the integrated model.”3

A study by Bonnani et al found that “dedicated restorative nursing staff was able to complete assignments in an efficient, timely manner and document results. The program led to more consistent care delivery and a higher quality of care.4

Having worked in a number of SNFs, I have seen successful and unsuccessful programs. The successful ones have three components: (1) there is a facility wide commitment to the program, (2) the right people (those that have the right attitude, intelligence, and work ethic) are in the right positions and (3) they are creative and resourceful.

Our program incorporated all three components, but it took time. The first two components are fairly self-explanatory but the third one can challenge teams. Here are some suggestions:

  • Most residents enjoy exercising together, why can’t restorative nursing like therapy use groups?
  • Can exercise equipment be purchased to help assistants provide good restorative care to more than one resident at a time?
  • Can the other departments, such as activities, partner with nursing to assist in providing restorative care?


Aside from the improvement in the FQIP score, several other benefits were observed. The residents really seemed to enjoy the increase in activities—both the physical activity and group atmosphere. This in conjunction with maintaining or even improving physical functioning resulted in a better quality of life for our residents. In addition, the activity may have a played a role in our low rates of hospital transfers, pressure ulcers and depression.

The restorative plan also led to higher utilization of therapy services for our LTC residents, which translated into higher functioning residents and a 50 percent increase in nonskilled therapy revenue. 


Quality measures have changed. Now the only physical functioning domain that will be measured is “percent of residents whose need for help with daily activities has increased,” but a great program can significantly impact other measures. With these new measures having recently gone into effect, this may be a good time for you and your team to do a “gut check” and evaluate your commitment to providing great restorative care. 

If you believe that you are fully committed, ask yourself several questions: Do you have an RNA who is up to the task? Is your rehab department willing and able to partner with an interdisciplinary team? Are the therapists knowledgeable enough to evaluate, treat and design an “appropriate” restorative program for your LTC residents? Is the entire facility fully committed to the project? Are you ready to succeed as a team? 

Joe Graham is a physical therapist with 13 years of experience working with the elderly. For more than eight years he has managed rehab departments in SNFs. He is currently an administrator-in-training at Riderwood, which an Erickson Living community. He can be reached at


  1. Remsburg RE, Armacost KA, Radu C, Bennett RG.Two Models of Restorative Nursing Care in the Nursing Home: Designated Versus Integrated Restorative Nursing Assistants. Geriatric Nursing 1999;20:321-6.
  2. Heyn P, Abreu BC, Ottenbacher KJ. The effects of exercise training on elderly persons with cognitive impairment and dementia: A meta-analysis. Archives of Physical Medicine and Rehabilitation 2004;85:1694–704.
  3. Remsburg RE, Armacost KA, Radu C, Bennett RG. Impact of a restorative care program in the nursing home. Educational Gerontology 2001;27:261-80.
  4. Bonanni DR, Devers G, Dezzi K, et al. A dedicated approach to restorative nursing. Journal of Gerontological Nursing 2009;35(1):37-44.

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