F0825

E

Failure to Provide Ordered PT/OT Services During Therapy Provider Transition

Turlock, California Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered Physical Therapy (PT) and Occupational Therapy (OT) services for five residents during a transition from contracted to in-house therapy services. Physician orders and therapy plans of care were in place for all five residents, but PT and OT services were not delivered as prescribed for multiple weeks. For Resident 1, who had a BIMS score of 15 indicating no cognitive impairment, PT and OT were ordered on 12/26/25 for muscle weakness, with a plan for services five times per week from 12/26/25 to 1/22/26. Resident 1 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in eight missed PT and eight missed OT treatments.

Resident 2, also with a BIMS score of 15 and no cognitive impairment, had PT and OT ordered on 1/20/26, and a PT plan dated 1/21/26 for muscle weakness with services five times per week from 1/21/25 to 2/4/26. Resident 2 did not receive PT during the weeks of 1/26/26 and 2/2/26, totaling seven missed PT treatments, and there was no OT evaluation or OT treatments documented. Resident 3, with a BIMS score of 7 indicating severe cognitive impairment, had PT and OT ordered on 12/26/25 and a PT/OT plan dated 12/28/25 for muscle weakness, with services five times per week from 12/28/25 to 1/24/26. Resident 3 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in thirteen missed PT treatments and fifteen missed OT treatments.

Resident 4, with a BIMS score of 4 indicating severe cognitive impairment, had PT and OT ordered on 12/21/25 and a PT/OT plan dated 12/23/25 for abnormalities of gait and mobility, with services five times per week from 12/23/25 to 1/19/26. Resident 4 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in thirteen missed PT and fifteen missed OT treatments. Resident 5, with a BIMS score of 13 indicating no cognitive impairment, had PT and OT ordered on 12/13/25 and a PT/OT plan dated 12/15/25 for pelvic issues and abnormalities of gait and mobility, with services five times per week from 12/15/25 to 1/11/26. Resident 5 did not receive PT or OT during the week of 1/5/26, resulting in five missed PT and five missed OT treatments.

Interviews with facility leadership and therapy staff confirmed that PT and OT services were not available from 1/5/26 to 1/22/26 due to the termination of contracted therapy services before in-house therapists were hired. The Consultant Administrator stated that PT and OT services should have continued without disruption after the contracted services ended on 1/5/26, but actual services did not restart until after 1/22/26. The DON confirmed that therapy services are expected to be evaluated and initiated within 72 hours of orders and that there was no PT or OT available during the identified period to conduct evaluations or continue treatment plans for the five residents. The PT, who was hired on 1/22/26 and had previously worked with the contracted provider, stated that residents did not receive therapy services from 1/5/26 to 1/22/26 because no one was hired to provide them and expressed concern about how the contract termination was handled.

The Administrator acknowledged that the plans of care and physician orders for the five residents were not followed according to the medical record and that therapy services policies were not followed. The Administrator also stated that the primary physicians should have been notified of the delays and orders clarified to readjust treatments, but this did not occur. The OT, hired on 1/20/26 and providing services via telehealth, stated she could not speak to what occurred before her hire date but described the current process of instructing staff during telehealth sessions. Facility policies reviewed by surveyors, including "Scheduling Therapy Services" and "Care Plans, Comprehensive Person-Centered," require that therapy be scheduled and provided in accordance with the resident’s treatment plan, coordinated with nursing, documented in the medical record, and incorporated into a comprehensive care plan with measurable objectives and timetables. These documented expectations contrasted with the period in which no PT or OT services were provided despite active orders and treatment plans for the five residents.

The DON and Administrator both described that from the time contracted services ended until in-house therapists were hired, there was no PT or OT available to evaluate residents or continue existing treatment plans. Nursing staff were responsible for notifying therapy of new orders, but there were no therapists available to receive or act on those notifications. As a result, the ordered rehabilitative services for muscle weakness, gait and mobility abnormalities, and pelvic issues were not delivered as planned for the five residents during the specified weeks, constituting the failure to provide specialized rehabilitative services as required by physician orders and facility policy.