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F0825
E

Failure to Provide Timely Occupational Therapy Services as Ordered

Bremerton, Washington Survey Completed on 11-18-2025

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 occupational therapy (OT) services as ordered for two residents who were admitted with fractures. Both residents had physician orders for OT evaluation and treatment upon admission, and their medical provider notes indicated ongoing need for OT. However, the OT evaluations and initiation of therapy were delayed for both residents due to the unavailability of an occupational therapist at the facility. The Director of Rehabilitation confirmed that OT services were not started until several days after admission for both residents, and was unable to confirm whether the medical providers were notified of these delays. Staff interviews revealed that the occupational therapist was not available at the time of the residents' admissions, resulting in a gap between the physician's order and the actual provision of therapy services. The facility administrator stated an expectation that therapy would be provided when ordered and indicated that resources were available to obtain OT services, but was unaware that the residents did not receive timely OT evaluations and treatment as required.

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