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F0825
E

Failure to Provide Prescribed Rehabilitative Services

Pomona, California Survey Completed on 06-27-2025

Penalty

Fine: $64,875
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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 ongoing occupational and physical therapy services as required for a resident who had recently been admitted following a hospital stay for encephalopathy and hemiplegia/hemiparesis after a cerebral infarction. Upon admission, the resident had documented needs for aggressive rehabilitation, with both hospital and facility therapy evaluations recommending skilled therapy at a frequency of six times per week for four weeks. Despite these recommendations, the resident was discharged from physical therapy after only four days and from occupational therapy after five days, significantly short of the planned duration. Therapy records indicated that the resident was making some progress during the brief period of therapy, such as requiring less assistance with certain activities. Both the physical therapist and occupational therapist acknowledged that the resident would have benefited from continued therapy services, and the assistant director of nursing agreed that more therapy should have been provided. The facility's own policies emphasized the importance of providing therapy to improve patient outcomes and required thorough documentation to justify therapy decisions. Interviews with staff and the resident's family member confirmed that the resident did not receive the prescribed rehabilitative services after the initial days of therapy. The lack of continued therapy was attributed to a perceived lack of progress, despite evidence of improvement in the resident's functional abilities. This failure resulted in the resident not receiving the specialized rehabilitative services necessary for their condition, as required by their care plan and physician orders.

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