Health inspection·November 13, 2024

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide physical therapy services to a resident as ordered for 1 of 3 residents reviewed for specialized rehabilitation services in the sample of 5. Residents Affected - Few The findings include: R1's admission Record dated 11/6/24 showed R1 was a [AGE] year old female admitted to the facility with diagnoses of lung cancer and pneumonia. R1's hospital discharge instructions dated 11/6/24 showed R1 was to receive physical therapy services, 1-2 times per day, Monday-Friday, while in the facility. A physician order for R1, dated 11/6/24, showed, Eval and treat-PT (physical therapy). On 11/13/24 at 8:23 AM, R1 was in bed. R1 stated, I came here to get stronger so I could go home to my kids. I am not getting any physical therapy. I have gotten OT (occupational therapy) but I need to get stronger so I can get out of bed . R1's therapy records dated 11/6/24-11/13/24 were reviewed. The records showed she was evaluated by occupational therapy on 11/7/24. R1 received occupational therapy services on 11/8/24 and 11/11/24. The records showed no physical therapy evaluation was completed on R1. R1 had not received any physical therapy services in the facility. On 11/13/24 at 10:26 AM, V7 Director of Rehab stated, Our goal is to have any newly admitted resident assessed by therapy within 24 hours of admission. V7 stated R1 had been assessed by the occupational therapist upon admission but had yet to be assessed by a physical therapist. When V7 was asked why R1 had not been assessed by a physical therapist, V7 stated, It was a scheduling thing. Our therapists come PRN (as needed) and our therapy assistants do the daily treatments. Our occupational therapist was here last week and could see (R1) right away. Our occupational therapist thought (R1) would be tired from the OT so we didn't have our physical therapist see (R1) . V7 stated she was unaware of R1's hospital discharge (therapy) instructions. On 11/13/24 at 12:50 PM, V2 Director of Nursing stated, We dropped the ball. We should have had the physical therapist evaluate (R1). The facility's Functional Impairment-Clinical Protocol policy dated March 2019 showed, The physician will identify and document the impact of medical conditions on function and identify a resident's/patient's potential to benefit from rehabilitation services such as physical and occupational Page 1 of 2 145278 145278 11/13/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

F 0825 therapy . The physician will order any therapy services based on above considerations . Level of Harm - Minimal harm or potential for actual harm The facility's Scheduling Therapy Services policy dated July 2019 showed, Therapy Services shall be scheduled in accordance with the resident's treatment plan . The therapist shall interview the resident and consult with the Attending Physician as to the type of treatment to be administered . Residents Affected - Few 145278 Page 2 of 2