Delayed Therapy Evaluation Due to Missed Orders and Miscommunication
Summary
Facility staff failed to provide a timely specialized therapy evaluation for a resident who was admitted with significant neurological impairments, including cerebral infarction and hemiplegia. The resident was dependent in multiple activities of daily living and had a physician's order for Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) evaluations upon admission. Despite this standing order, the initial therapy evaluations were not initiated until several weeks after admission, contrary to facility policy which required evaluations to be completed within two days of a referral. Interviews with staff revealed confusion and miscommunication regarding the resident's therapy orders and insurance status. The Director of Rehabilitation stated that no therapy orders were present initially, and therapy evaluations did not begin until nearly a month after admission. The Business Office Manager clarified that the resident had Medicare Part B as a therapy payor source, but there was a misunderstanding at admission regarding insurance coverage, which contributed to the delay in therapy services. The resident and her spouse reported that therapy services were not provided as expected, with the spouse stating that the facility social worker informed them that therapy could not be initiated due to insurance issues. The resident experienced significant pain and required assistance with mobility, as observed during the survey. Facility policy and staff interviews confirmed that the therapy evaluation order was missed, resulting in delayed treatment and placing the resident at higher risk for decline.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to provide ordered PT and OT services for multiple residents who were admitted or readmitted for rehab and had therapy included in their care plans and physician orders. Residents with conditions such as stroke-related hemiplegia, chronic pain, kidney disease, diabetes, obesity, COPD, and arthritis reported that therapy was unavailable or had stopped. Staff and leadership stated the contracted therapy provider reduced services, then stopped them, and the MD was not included in discussions about the change or an interim plan.
Failure to Provide Ordered OT Services: A cognitively intact resident with quadriplegia, neurogenic bladder, and total dependence for ADLs did not receive ordered OT services. The resident said he had not been getting OT for ADLs, staff reported therapy had stopped because recertification was not completed, and the OT assistant said she could not continue until the OT completed the recertification.
Failure to Provide Ordered Lymphedema Care: A resident with severe chronic lymphedema, recent septic shock, and multiple comorbidities did not receive lymphedema treatment as ordered. The resident’s care plan lacked key lymphedema details, PT documented severe pain, stage 4 lymphedema, open and weeping skin, and recommended compression and pumps if allowed. Interviews showed the facility lacked trained lymphedema staff, delayed therapy assessment, and did not allow the resident to use compression pumps despite family and therapy stating she could operate them.
Failure to provide ordered Speech Therapy services for a resident with paraplegia, morbid obesity, a trach, and other complex diagnoses. The resident had an order for ST evaluation and treatment, but was never seen by ST during the stay. The ST reported not being informed of the order, and the Therapy Director confirmed the resident was not evaluated due to a communication error and that the resident was not added to the daily schedule.
Failure to provide ordered PT services after fall screenings. A resident with repeated falls, intact cognition, and wheelchair use had care plan interventions for therapy screening as indicated. After two post-fall therapy screens, PT was recommended, but therapy did not start. Interviews showed the DOR left a message about copay assistance and did not follow back up, while the resident, family, and PT EE all reported no therapy had begun.
A resident with generalized muscle weakness, mobility and ADL dysfunction had a care plan and physician/NP orders for PT/OT to improve function, but did not receive any therapy for an 11‑day period after services stopped despite an extended stay and an appeal of discharge. The resident, who required staff assistance with most ADLs and used a wheelchair, reported not receiving therapy after the appeal, while the PT confirmed the resident had not met goals and still needed to improve stair navigation before going home. The Rehab Director acknowledged awareness of the appeal, confirmed the absence of therapy during this period, and stated the resident would experience physical decline without those services, demonstrating a failure to provide rehabilitative services as care‑planned and ordered.
Failure to Provide Ordered PT and OT Services
Penalty
Summary
The facility failed to provide ordered PT and OT services for 5 of 5 residents reviewed for rehabilitation and restorative services. R2 had diagnoses including acute heart failure, chronic pain syndrome, and kidney disease, and his care plan and physician orders included PT and OT eval and treat. R8 had dysphagia and right-sided hemiplegia/hemiparesis following cerebral infarction, with care plan interventions calling for OT and PT eval and treat. R13 had end stage kidney disease, heart failure, and diabetes mellitus, with physician orders for PT and OT eval and treat. R25 had surgical aftercare following skin surgery, diabetes mellitus, kidney disease, and obesity, with physician orders for OT and PT eval and treat. R26 had polyarthritis, COPD, obesity, and a history of falling, and her hospital admission orders included OT and PT evaluation and treatment. Interviews with the residents showed they were aware therapy services were not available or were ending at the facility. R2 stated he was supposed to be doing therapy but there was no therapy available. R8 stated he was at the facility for therapy but was informed therapy was no longer available. R13 stated she had been readmitted from the hospital and was supposed to be getting therapy services, but the facility told her they did not have therapy right now. R25 stated he was supposed to be doing therapy but did not think he really needed it and planned to remain at the facility until new therapy services were available. R26 stated she was there for short term rehabilitation but was not getting walked in the hall and needed to get stronger so she could go home. Facility records and staff interviews showed therapy services stopped after communication problems and unpaid balances with the contracted therapy provider. Emails from the therapy contractor stated services would shift to telehealth and then were placed on hold, with no further telehealth or rescheduled appointments. The DON stated she learned therapy services were discontinuing and acknowledged she did not ask the MD to see or talk to affected residents and families or review therapy orders to determine an interim course of action. The MD stated he learned the facility no longer had therapy services during rounds and had not been brought into discussions about why services stopped or what the plan was going forward. Leadership staff stated they discussed the issue internally, but the MD was not included in those discussions, and the facility had not determined a plan to provide the ordered therapy services at the time of the survey.
Failure to Provide Ordered OT Services
Penalty
Summary
The facility failed to provide occupational therapy for Resident #8, who was cognitively intact with a BIMS score of 15 and had diagnoses of traumatic spinal cord dysfunction, quadriplegia, neurogenic bladder, and diabetes mellitus. The resident’s MDS identified him as totally dependent on staff for all activities of daily living and having an indwelling urinary catheter. A physician order dated 11/6/25 directed occupational therapy to evaluate and treat as ordered, but the last occupational therapy progress note was dated 4/2/26. The care plan, last revised 3/4/26, identified the resident as quadriplegic but did not address the occupational therapy order. On 5/20/26, the resident stated he had not received occupational therapy for activities of daily living. Staff later reported that the occupational therapy assistant had not worked with him for several weeks, and the assistant stated she had last worked with him about a month earlier because recertification had not been completed. The occupational therapist was behind on recertifications due to a family illness, and the administrator confirmed the therapist needed to complete recertification and that the facility did not have full-time in-house therapy staff.
Failure to Provide Ordered Lymphedema Care
Penalty
Summary
The facility failed to ensure lymphedema care was provided as ordered for a resident with kidney disease, hypertension, liver disease, severe obesity, chronic lymphedema with significant skin changes, and recent hospitalization for septic shock and acute kidney injury. The resident’s hospital discharge orders directed wound care with dressing changes before lymphedema PT wrap changes on Mondays, Wednesdays, and Fridays or as needed, along with PT evaluation and treatment for lymphedema. Additional provider orders included OT and PT evaluations, lymphedema treatment, and wrapping both lower extremities with Kerlix and ACE wraps daily for edema, on in the morning and off at bedtime. The resident’s care plan listed ACE wraps on in the morning and off at bedtime, but it lacked the indication for use and did not mention lymphedema treatment with compression and leg pumps. The April 2026 TAR showed Kerlix wraps were resumed on 4/24/26. PT notes documented that the resident would not allow touch to her legs due to pain, could not lift either leg from the bed surface, and later had severely progressed stage 4 lymphedema with significant pain, increased girth of the right lower extremity, open areas, and weeping skin. PT recommended compression at the doctor’s discretion and noted the resident would not tolerate wrapping in her current condition, but could benefit from lymphedema pumps if allowed. Interviews showed the resident and family were told the facility had a lymphedema specialist, but the position was unfilled and the facility did not allow outside training from a prior facility’s staff. The NP stated the resident was supposed to have lymphedema treatment and the facility could have sent her out for therapy but had not. Family members reported the resident was supposed to use compression pumps for a couple of hours a day, but staff said they did not have an order or did not want to do it. The PT stated the resident had used compression pumps at home and at another facility, demonstrated she could operate them, and therapy advocated for continued use, but the DON did not allow it initially and nursing staff were not trained. The DON stated therapy deferred care to nursing, the family member was managing the wraps and pumps, there was a six-to-seven-day delay for therapy assessment, and the delay in pump care could have contributed to increased leg swelling.
Failure to Provide Ordered Speech Therapy
Penalty
Summary
The facility did not ensure specialized rehabilitative services were provided for a resident with an order for Speech Therapy evaluation and treatment. R10 was admitted with diagnoses including complete paraplegia, morbid obesity, neuromuscular dysfunction of the bladder, tracheostomy, anxiety, and an unspecified T7-T10 spinal cord injury. R10’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. R10 had a Speech Therapy order, along with orders for a Shiley uncuffed size 4 trach, head of bed elevation, trach care every shift, and for the trach to remain capped with removal if needed. R10 was not seen by Speech Therapy during the stay from the time the order was written until discharge. A progress note documented that R10 refused to use a trach inner cannula because of the capped trach and stated it was not needed. A provider note indicated R10 should continue Physical, Occupational, and Speech Therapy to optimize functional recovery. During interview, the Speech Therapist stated R10 was not evaluated, was not informed of the order, and that the communication issue prevented services from being provided. The Therapy Director confirmed the resident was not seen for Speech Therapy and stated it was the Therapy Director’s responsibility to ensure new therapy orders were followed and residents were added to the daily schedule. The DON stated R10 should have been seen by Speech Therapy within days of the order.
Failure to Provide Ordered PT Services After Fall Screenings
Penalty
Summary
The facility failed to provide specialized rehabilitative services for Resident #67, a male resident with a diagnosis of repeated falls. His significant change of status MDS, dated 02/27/26, reflected that he made himself understood and understood others, had a BIMS score of 13, used a wheelchair, and was independent with self-care abilities and mobility. His comprehensive care plan identified him as at risk for injury related to falls and at risk for impaired mobility related to bone density and structure, with interventions that included therapy screening as indicated. Record review showed Resident #67 had a therapy post-fall screen after a fall on 03/10/26, and PT was recommended. A second therapy post-fall screen after another fall on 03/20/26 also recommended PT. The order summary report reflected an active physician order for PT/OT/ST screen as needed with a start date of 01/30/26. During interview, Resident #67 stated therapy had not started. The DOR stated she called and left a message regarding copay assistance, but did not follow back up, and stated she was not informed by nursing staff that Resident #67 had declined after the later fall. Additional interviews reflected that the family member had asked about therapy when Resident #67 was first admitted and later stated she would pay the copay, but she did not hear anything back. The Director of admission stated she had discussed therapy with the PT EE, while the PT EE stated he was waiting on approval from the DOR to start services. The DON and Administrator stated they expected therapy services to be available as requested and that follow-up should occur to confirm family approval. The facility policy stated therapy services would be available to assist residents in maintaining maximum independence, that residents would be screened upon admission and as needed, and that residents and/or representatives would be involved in the therapy plan.
Failure to Provide Ordered Rehabilitation Services During Extended Stay
Penalty
Summary
The facility failed to provide specialized rehabilitative services according to the resident’s care plan and clinical assessments. The care plan initiated on 3/25/26 identified a focus for rehabilitation services with a goal to improve the resident’s current level of function, and included an intervention to provide therapy services per physician orders. The admission MDS documented that the resident had no cognitive or communication impairment but required staff assistance with most ADLs and was wheelchair bound. On 4/16/26, an NP documented that the resident had generalized muscle weakness, mobility and ADL dysfunction, and was at risk for functional impairment without pain control and PT/OT services. The attending physician also documented on 4/16/26 that the resident was in extensive need of therapy and not ready for discharge home. Despite these assessments and the active care plan for rehabilitation, therapy notes showed that the resident did not receive any therapy services after 4/16/26. The record and interviews showed that the resident’s insurance coverage was initially ending, the resident agreed to go home, then appealed the decision and was granted additional days of coverage and an extended stay. The Social Services Director confirmed that the resident’s stay was extended and that the resident appealed and was granted to remain until 4/22/26. The resident reported being granted an extended stay and stated they had not received therapy since 4/16/26, despite feeling they needed more therapy to be safe at home. The PT stated the resident had not met therapy goals and needed to improve stair navigation before going home, and acknowledged that although services were approved until 4/23/26, insurance sometimes stopped services. The Rehab Director confirmed that the resident had not received therapy since 4/16/26, was aware of the appeal, and stated that the resident would experience physical decline without therapy services for 11 days, confirming a gap in providing ordered and care-planned rehabilitative services during the appeal and extended-stay period.
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