Background <p>Cognitive impairment is common among older adults, particularly those residing in long-term care facilities (LTCFs), where limited resources and staffing constrain access to structured rehabilitation programs. This study aims to assess the clinical effectiveness of an exergame-based training program delivered via “WarioWare: Move It!” in improving physical and cognitive functions in elderly LTCF residents.</p> Methods <p>A randomized controlled trial was conducted across multiple rural LTCFs in Shanxi Province with participants aged 65 and older. The intervention group received a 12-week exergame-based program involving motion-sensing activities, while the control group received standard care. Physical and cognitive functions were assessed using validated clinical tests, and training effects were analyzed via mixed ANOVA.</p> Results <p>A total of 226 participants were recruited, including 30 with mild dementia, 18 with moderate dementia, and 178 with mild cognitive impairment. Significant group × time interactions were found for key outcomes, including improvements in flexibility, joint mobility, balance, hand dexterity, and cognitive performance (all <i>P</i> &lt; 0.05). Notable improvements were observed in sit and reach distance, shoulder and elbow range of motion, walking performance, and MoCA scores.</p> Conclusion <p>This low-cost, exergame-based intervention significantly enhanced both physical and cognitive functions in rural LTCF residents, demonstrating its feasibility and scalability for elderly rehabilitation in resource-limited settings.</p> Trial registration <p>ClinicalTrials.gov NCT06717971; December 10, 2024; (<a href="https://clinicaltrials.gov/study/NCT06717971">https://clinicaltrials.gov/study/NCT06717971</a>).</p>