F0656

E

Failure to Develop Person-Centered Therapy Care Plans for Multiple Residents

Milpitas, California Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop person-centered care plans that included target symptoms, measurable objectives, and specific interventions for residents receiving PT, OT, and ST services. For five sampled residents, the surveyor’s record review showed active therapy orders without corresponding individualized care plans for those services. One resident admitted with muscle weakness had orders for PT five times per week for 12 weeks and OT twice per week for 12 weeks, but there was no documented care plan addressing these therapies. Another resident with muscle weakness and abnormalities of gait and mobility had orders for PT, OT, and ST over several weeks, yet there was no individualized care plan for any of these treatments.

A third resident with abnormalities of gait and mobility had PT and OT ordered, a fourth resident with abnormalities of gait, mobility, and dysphagia had PT and ST ordered, and a fifth resident with abnormalities of gait and mobility had PT ordered; none of these residents had documented care plans for the ordered therapy services. During concurrent record review and interviews, the MDS coordinator confirmed that there were no therapy care plans for any of the five residents and stated that therapy staff were responsible for initiating and implementing these care plans when residents received therapy. The DON also confirmed that therapy treatments were provided as ordered but that therapy staff had not initiated the required care plans. The director of rehabilitation similarly stated that therapy staff should have initiated separate care plans for therapy. The facility’s policy on care planning indicated that care plans are to be based on the comprehensive assessment and developed by an interdisciplinary team, including therapists as applicable.