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Clinical Case Study #4

Case Presentation

Resident moved into Morning Pointe on 12/12/25 following rehabilitation for a fractured left hip. At the time of admission, the resident was weak and required assistance with activities of daily living. Upon evaluation by the therapy team, the resident presented with a Berg Balance score of 20, a Timed Up and Go (TUG) of 54 seconds, and a CT SIB score of 21. Lower extremity strength was assessed at 2+, gait required contact guard assist, and transfers required moderate assist. The resident was deconditioned and needed structured support to regain strength, balance, and confidence.

The Approach

The resident’s individual plan of care focused on consistency and encouragement including support with activities of daily living from resident assistants, ongoing therapy services, nutritious meals to promote healing, and daily social engagement. Structured routines and consistent oversight were implemented to support recovery, reduce fall risk, and promote gradual independence.

The Progress

Through consistent in-house therapy and structured routines, the resident’s strength and mobility steadily improved. Berg Balance increased from 20 to 23, Timed Up and Go improved from 54 seconds to 45 seconds, and the CT SIB score improved from 21 to 30. Lower extremity strength increased from 2+ to 3. Gait status progressed from contact guard assist to supervision, and transfers improved from moderate assist to supervision, reflecting improved stability and reduced assistance needs.

Life Today

Status as of the most recent evaluation, the resident continues to participate in therapy and daily activities while enjoying consistent social interaction and routine schedules. Mobility is now performed with supervision rather than hands-on assistance, and overall strength and balance continue to improve. The resident remains engaged, active, and stronger than at admission.

Why This Matters

This case study reflects how assisted living services at Morning Pointe Senior Living support post-rehabilitation recovery, promote independence, and improve quality of life through structured care, therapy integration, and meaningful daily engagement.

Disclaimer: Care details shared in this case study are based on a Morning Pointe resident. In keeping with HIPAA guidelines, the resident’s name and identifying information are not disclosed.

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