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F0825
D

Failure to Provide Prescribed PT and OT Services as Ordered

Lake Forest, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide specialized rehabilitative services as required for a resident diagnosed with spinal stenosis and neurogenic claudication. According to the physician's orders and the initial physical therapy (PT) and occupational therapy (OT) evaluations, the resident was to receive PT and OT services five times a week for two weeks. However, medical record reviews and service logs revealed that the resident did not receive the prescribed frequency and duration of PT and OT sessions. Specifically, there were multiple dates within the planned treatment period where the resident did not receive either PT or OT services as scheduled. The facility's policies required therapists to develop and follow individualized plans of care, including specified treatment frequencies and durations. Despite these requirements, the Director of Rehabilitation (DOR) confirmed that the resident's therapy sessions were not provided as planned, due to an incorrect assumption about the scheduling of services. The interim Administrator and Director of Nursing (DON) acknowledged these findings during interviews, confirming that the resident did not receive the rehabilitative services as ordered and documented in the care plan.

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