Resident 60 was supposed to get intensive rehabilitation — physical therapy three days per week, occupational therapy five days per week, and speech therapy three days per week. That's 11 sessions weekly, according to evaluations by the facility's therapy team.
Instead, the resident received five sessions the first week, one the second week, and two the third week.
During the week of February 25 through March 2, 2024, Resident 60 received two of three scheduled physical therapy sessions, one of five occupational therapy sessions, and two of three speech therapy sessions. The following week brought even less care — just one physical therapy session out of three scheduled, with no occupational or speech therapy documented.
The third week showed minimal improvement. Resident 60 received two physical therapy sessions but again missed occupational and speech therapy entirely.
Federal inspectors discovered the pattern during a complaint investigation in August 2025, more than a year after the missed sessions occurred.
Staff 13, who serves as both administrative assistant and director of rehabilitation, acknowledged the missed appointments when questioned by inspectors on August 20. She explained that the physical therapist was out sick during the first and third weeks, preventing completion of those scheduled sessions.
But Staff 13 couldn't explain why the resident missed most occupational therapy sessions or any speech therapy sessions during those weeks. She was "unaware of the reason for the other missed therapy sessions," according to the inspection report.
The documentation problems ran deeper than missed appointments. Staff 25, the regional director of rehabilitation, admitted to inspectors that therapists "sometimes documented in the electronic record and sometimes they did not." This inconsistent record-keeping made it impossible to track whether residents received ordered care.
The facility had promised more to the family. Witness 6, identified as a family member, told inspectors that "Resident 60 was supposed to receive therapy every day and the staff guaranteed Resident 60 would receive therapy three to four days a week."
Even the lower promise of three to four days weekly wasn't met. During the documented period, the resident received therapy on only two or three days per week, falling short of both the clinical recommendations and the facility's own commitments to family.
The resident's care plan, dated February 23, 2024, included a specific goal "to work with therapies to increase strength and reinforce cognitive strategies." Missing more than half the scheduled sessions directly undermined this therapeutic objective.
Administrator Staff 1 acknowledged the failures when confronted by inspectors on August 22. He stated that "he expected all residents to receive skilled therapy as ordered," but offered no explanation for why his facility had fallen so far short of that expectation.
The inspection revealed a facility where therapy schedules existed on paper but weren't consistently followed in practice. Residents and families were told one thing while receiving something entirely different, with staff unable to account for the gaps in care.
Federal regulations require nursing homes to provide rehabilitation services as ordered by physicians and documented in care plans. When facilities fail to deliver prescribed therapy, residents may experience slower recovery, decreased function, or setbacks in their rehabilitation goals.
The timing of the missed sessions was particularly concerning. February and March typically represent crucial early weeks of rehabilitation when consistent therapy can determine long-term outcomes for residents recovering from illness or injury.
Willowbrook Post Acute's therapy department appeared to operate without adequate oversight or backup plans for staff absences. When one physical therapist called in sick, the entire schedule collapsed with no alternative arrangements made for continuing care.
The facility's inability to explain missed occupational and speech therapy sessions suggested deeper organizational problems beyond individual staff illness. These gaps pointed to systemic failures in scheduling, documentation, and accountability within the rehabilitation department.
For Resident 60's family, the broken promises represented more than administrative failures. They had entrusted their loved one's recovery to a facility that guaranteed daily therapy but delivered inconsistent care with no explanation for the shortfalls.
The inspection found that few residents were affected by these specific therapy failures, but the documentation problems identified by the regional director suggested the issues could be more widespread than initially apparent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willowbrook Post Acute from 2025-08-22 including all violations, facility responses, and corrective action plans.