F0825

D

Failure to Provide Ordered Therapy, Offer ST, and Maintain a Restorative Program

Kirkwood, Missouri Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide specialized rehabilitative services as ordered, failure to offer speech therapy (ST) over several months, and failure to maintain an active restorative program in accordance with resident needs. Facility policy required that therapy services be provided under physician orders, coordinated with the interdisciplinary team, and accurately documented in the medical record, with periodic evaluation of effectiveness. Review of therapy minutes showed no ST evaluations or services offered during the review period, and interviews confirmed there was no restorative nursing program in place following a change in ownership and therapy staffing transitions.

One resident, identified as having moderate cognitive impairment and multiple diagnoses including heart failure, coronary artery disease, hypertension, MDRO, anxiety, and depression, required extensive assistance with mobility and transfers and used a wheelchair/scooter. The resident’s MDS dated 10/24/25 showed no therapy minutes and no days in a restorative nursing program, despite physician orders for PT/OT/ST to evaluate and treat for transfer status, functional decline, and confusion. Orders for PT/OT/ST were initiated and then discontinued on two separate occasions, and the resident’s care plan did not document the outside therapy services the resident was receiving. Progress notes documented that the resident left the facility for outside therapy appointments and that the physician noted the resident was receiving outside PT five times per week, but this outside therapy was not reflected in the care plan or therapy documentation as required by facility policy.

Interviews with the resident and family member revealed that the resident did not receive consistent PT or ST in the facility and had a three‑month period without therapy after an ownership change and staff turnover. The family arranged for the resident to attend an outside day program providing PT five days per week, with the family providing transportation after the facility stated it could not provide daily transport. The Director of Rehab stated the resident had not received in‑house therapy since the director’s start date, that there was no ST available during the period in question, and that there was no restorative program in place. The DON acknowledged awareness that the resident received outside therapy and stated expectations that such services should be scheduled, coordinated, documented, and care planned, but confirmed there was no restorative therapy program operating at the facility during this time.

Additional staff interviews corroborated that there was a gap in PT/OT services during the transition to new ownership and that the restorative aides were removed without replacement, leaving the facility without a restorative program. The Plant Operations Manager reported that therapy under the prior contract became “light” during the transition and that nursing management handled therapy after the therapy company left. The Dietary Manager and Director of Rehab confirmed that ST had not been provided during the review period, with only a plan for telehealth ST and a new ST hire pending. Collectively, these findings show that the facility did not provide therapy services as ordered, did not offer ST for an extended period, and did not maintain an active restorative program, and failed to update the medical record and care plan to reflect and coordinate the resident’s outside therapy services.