Failure to Provide Ordered RNA Services
Summary
The facility failed to ensure one of seven sampled residents received restorative nursing assistant (RNA) services as ordered by the physician. Resident 101 was admitted with diagnoses including spondylosis with myelopathy in the cervical region, disorder of bone density and structure, and osteoarthritis in both hands. The resident’s H&P indicated the resident had the capacity to understand and make medical decisions, and the MDS indicated the resident was cognitively intact. The MDS also showed the resident was dependent for shower transfer and chair/bed-to-chair transfer, required substantial assistance for lower body dressing, and needed help with personal hygiene. The order summary report showed orders for RNA active assistive range of motion to both lower extremities three times a week, RNA application of an abductor wedge with skin checks three times a week, and an RNA program for a right resting hand splint three times a week. During interview and record review, the DSD confirmed missing documentation for multiple scheduled RNA services, including no documentation for bilateral upper and lower extremity ROM on 2/14/2026, no documentation for the right hand splint on 2/21/2026, and no documentation for the abductor wedge on 2/28/2026. The DSD stated that if it was not documented, then it was not done, and said the RNAs were present every day and could provide the service the following day if needed. The DON stated the RNA services were important to prevent further decline and overall functional ability. The facility policy stated residents would receive restorative nursing care as needed to help promote optimal safety and independence.
Penalty
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The facility failed to provide ordered speech therapy services for two residents with dysphagia and post‑cerebral infarction speech and swallowing deficits. Both had physician orders to continue existing speech therapy plans of care under a new provider, with one to receive therapy twice weekly and the other three times weekly over a defined certification period, targeting improved swallow function, diet tolerance without aspiration signs, and better communication and speech intelligibility. Medical records for each resident showed only a single 23‑minute speech therapy session during that entire period. A therapy regional manager confirmed that services under the new contractor started after the prior contractor was terminated, that these two residents received speech therapy only once, and that available telehealth speech therapy was not utilized.
A resident with cancer, CHF, and COPD, who initially received PT, OT, and ST and was dependent for bed mobility and transfers, had therapy services discontinued when skilled insurance coverage ended, despite not meeting therapy goals and documented need for continued services for mobility, ADLs, transfers, cognition, communication, and dysphagia. The resident reported that therapy stopped after insurance ended, that she wanted to get strong enough to return home, and that she previously could stand and transfer with one staff but now was only transferred with a mechanical lift. Staff interviews confirmed the resident was removed from the therapy caseload due to payer changes, Part B coverage had not been verified, Medicaid was pending, nursing staff were not instructed that manual transfers were possible, and no restorative programs were in place, contrary to facility policy requiring collaboration and transition to restorative care.
Failure to provide specialized rehab services occurred when a resident with dysphagia, TBI, schizophrenia, MDD, type II DM, and cognitive impairment had significant wt loss and recent teeth extractions, prompting the RD to request an SLP eval to assess swallowing and diet appropriateness. No documentation showed the eval was completed, and the TM confirmed the speech therapist had not seen the resident since July 2025. The DON was unaware the SLP eval had not been completed.
A resident with multiple medical conditions did not receive physical and occupational therapy at the frequency specified in their care plan. Therapy sessions were missed over several periods due to delays in insurance authorizations, as confirmed by the Rehab Director. The facility lacked a formal policy for therapy services, though it was expected that therapies would be delivered as ordered.
A resident with multiple diagnoses and a recent fall was discharged from OT with a recommendation for a restorative program focused on ADLs, including personal hygiene, dressing, and grooming. While a restorative ambulation program was implemented following PT recommendations, the ADLs restorative program was not initiated, as confirmed by staff interviews and record review.
A resident with significant communication impairments did not receive speech therapy as frequently as prescribed in their treatment plan due to the lack of a full-time speech therapist. Documentation and interviews revealed inconsistent therapy sessions, unclear caregiver training, and absence of recommended communication tools, resulting in ongoing communication difficulties and frustration for the resident.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered speech therapy services for two residents requiring specialized rehabilitative care. One resident, admitted with diagnoses including dysphagia, dementia, and rheumatoid arthritis, had an MDS indicating severe cognitive impairment and a need for supervisory support with eating, positioning, and transferring, while remaining independently mobile in a manual wheelchair. Physician orders directed continuation of the resident’s existing speech therapy plan of care under a new provider effective 02/01/26, with a treatment plan calling for speech therapy twice weekly for four weeks during the certification period 02/01/26–02/28/26. The short-term goals included tolerating a mechanical soft diet without signs or symptoms of aspiration and performing oral-motor strength exercises to improve swallow function. Record review showed only one 23‑minute speech therapy session on 02/20/26, with no other speech therapy visits documented during the certification period. The second resident, admitted with a history of cerebral infarction, dysphagia following cerebral infarction, and other speech and language deficits following cerebral infarction, had an MDS showing moderately impaired cognition, a need for supervisory support with eating, and dependence on staff for positioning and transferring, while also being independently mobile in a manual wheelchair. Physician orders similarly required continuation of this resident’s speech therapy plan of care under a new provider effective 02/01/26, with a plan of treatment specifying speech therapy three times weekly for four weeks during the same certification period. Short-term goals included improving communication and speech intelligibility and tolerating a regular texture diet without signs or symptoms of aspiration. Documentation revealed only one 23‑minute speech therapy session on 02/20/26, with no additional visits recorded. In an interview, the Therapy Regional Manager stated that rehabilitative therapy services began on 02/02/26 after termination of the previous therapy contractor, confirmed that both residents received speech therapy only on 02/20/26, and acknowledged that although telehealth speech therapy was available, it was not used.
Failure to Continue Therapy Services After Insurance Denial
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing specialized rehabilitative services to ensure a resident maintained the highest practicable level of physical and functional mobility. The resident was admitted with malignant neoplasm of the cerebellum and right lung, congestive heart failure, and COPD, and the admission MDS showed modified independence in decision making, substantial/maximal assistance needed for toilet hygiene, and dependence for bed mobility and transfers. The resident initially received PT, OT, and ST per physician orders, and the care plan included PT/OT evaluation and treatment. OT, PT, and ST evaluations were completed, and subsequent OT and PT discharge summaries documented that the resident had not met therapy goals and would benefit from continued therapy for functional mobility, ADLs, transfers, safety, and for ongoing cognitive/communication and dysphagia needs. However, PT and ST services were discharged due to insurance exhaustion and loss of appeal, and the resident remained in the facility without further therapy. Interviews confirmed that after skilled insurance coverage ended, the resident was removed from the therapy caseload and had not received therapy services since the discharge date, while Medicaid status was still pending and Part B coverage had not yet been verified. The resident reported that therapy had stopped a few weeks earlier when insurance ended, that she had applied for Medicaid, and that her goal was to return home once she became stronger and more independent. She stated that when she was in therapy she could stand and transfer with one staff member, but currently nursing staff only used a mechanical lift and did not assist her to stand. An STNA corroborated that when the resident was on therapy she could transfer with one staff assist, but nursing staff now used a mechanical lift for all transfers and had not been informed by therapy that manual assistance was possible. The PT and Director of Rehab acknowledged that the resident would benefit from therapy, that services had been discontinued due to insurance denial, that Part B coverage had not been verified, and that the facility did not have restorative programs, despite a facility policy stating that therapy services are to help residents reach maximum functional performance and transition to restorative nursing when appropriate.
Failure to Complete SLP Evaluation for Resident With Dysphagia
Penalty
Summary
Provide or get specialized rehabilitative services as required for a resident was not met when the facility failed to provide a required SLP evaluation for Resident #17, who had diagnoses including dysphagia, traumatic brain injury, schizophrenia, major depressive disorder, type II diabetes mellitus, and other chronic medical conditions. The resident’s comprehensive MDS reflected cognitive impairment. The RD’s weight review documented significant weight loss and noted the resident had recently had teeth extracted, then requested an SLP evaluation to assess swallowing function and determine whether the current diet order remained appropriate. Review of physician orders and therapy documentation showed no evidence that the SLP evaluation was completed after the RD’s recommendation. During interview, the TM stated therapy typically received referrals verbally from nursing staff and confirmed the speech therapist had not seen the resident since July 2025, adding that documentation would be present if an evaluation had been completed. The DON and Regional DON stated staff enter therapy orders and verbally notify therapy when referrals are made, and the DON acknowledged being unaware that the SLP evaluation had not been completed for Resident #17.
Failure to Provide Prescribed Therapy Services Due to Authorization Delays
Penalty
Summary
The facility failed to ensure that a resident received specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), as outlined in the resident's plan of care. The resident was admitted with multiple diagnoses, including a lumbar vertebra fracture, dementia, muscle weakness, and difficulty walking. The care plans for both PT and OT specified therapy services to be provided three to five times per week for various therapeutic interventions. However, medical record and therapy service log reviews revealed multiple periods in October and November during which the resident did not receive the prescribed therapy sessions. Interviews with the Rehab Director confirmed that the therapy frequencies were not met as written in the plan of care. The Rehab Director attributed the missed therapy sessions to delays in obtaining insurance authorizations from the corporate office, which resulted in interruptions in therapy services. Additionally, it was noted that the facility did not have a formal policy regarding therapy services, though it was expected that therapies would be provided according to the care plan.
Failure to Implement Recommended ADLs Restorative Program After OT Discharge
Penalty
Summary
The facility failed to implement a recommended restorative program for activities of daily living (ADLs) for a resident following discharge from occupational therapy (OT) services. The resident, who had diagnoses including orthopedic care, left femur fracture, high blood pressure, spinal stenosis, and dementia, was readmitted after a fall incident. Upon readmission, therapy evaluations were recommended, and both physical therapy (PT) and OT assessments were completed. The PT evaluation resulted in a restorative program for ambulation, which was implemented and documented as being followed daily. However, although the OT evaluation recommended a restorative program for ADLs such as personal hygiene, dressing, and grooming, this program was not implemented. Staff interviews confirmed that the resident never participated in an ADLs restorative program, and the Assistant Director of Nursing acknowledged that the evaluation for the ADLs program was not reviewed or acted upon after it was completed and locked by OT. This omission resulted in the resident not receiving the specialized rehabilitative services as required.
Failure to Provide Prescribed Speech Therapy Services
Penalty
Summary
The facility failed to provide a resident with the specialized rehabilitative services of speech therapy as required by the resident’s plan of treatment. The resident, who had a history of encephalopathy, aphasia, dysarthria, cerebral infarction, dysphagia, hemiplegia, and cognitive impairment, was admitted with significant communication challenges. The speech therapy plan called for treatment five times a week for six weeks, but documentation showed inconsistent delivery of services, with the resident receiving therapy fewer times than prescribed in several weeks. The speech therapy discharge summary included recommendations for ongoing strategies and caregiver training to support the resident’s communication needs. However, interviews with the Rehabilitation Director revealed uncertainty about what specific training was provided to caregivers, which caregivers received it, and whether any visual aids or communication tools were supplied to the resident. The Rehabilitation Director also confirmed that the lack of a full-time speech therapist led to irregular therapy sessions, as services were only provided when a therapist was available. The resident expressed ongoing frustration and difficulty with communication, both with family and caregivers, and indicated a need for additional speech therapy. Observations during interviews confirmed the resident’s communication struggles and emotional distress related to these challenges. The deficiency was identified during a complaint investigation and affected one resident reviewed for therapy services.
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