The resident, who uses a prosthetic leg, was admitted on August 4 with physician's orders for both physical therapy and occupational therapy. Staff didn't notice the orders until August 27, when the resident's primary care physician placed new orders for therapy evaluation.
Therapy finally began September 3.
"The order was missed," the Director of Nursing told inspectors during the October complaint investigation.
The resident's mental status assessment scored a 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Medical records show the resident had undergone a right below-knee amputation and relied on a prosthetic device for mobility.
When therapy eventually started in early September, the occupational therapist assistant explained the resident needed help with standing, strengthening, and applying the prosthetic leg. The therapy department had received orders on August 27 to evaluate the resident, nearly a month after the original admission orders.
The facility administrator acknowledged the breakdown. "The facility should have followed up better with the order for PT / OT," the administrator told inspectors.
The Director of Nursing confirmed that therapy orders dated August 4 documented admission orders for both physical and occupational therapy. She acknowledged the orders weren't followed and that the resident should have been seen immediately when the original orders were placed.
Federal inspectors found that Good Samaritan - Villisca failed to provide services according to professional standards by not acting on physician's orders for therapy services.
The facility's own policy, revised in April, requires staff to provide individualized care by obtaining "appropriate accurate and timely" physician orders. The policy specifically states that required admission orders include "rehabilitation potential and therapy orders when appropriate."
The resident's therapy evaluation documents show a certification period running from September 3 through November 25. Both physical therapy and occupational therapy began the same day, September 3, after the month-long delay.
For a resident with severe cognitive impairment and mobility challenges from amputation, the delay meant nearly four weeks without professional rehabilitation services that doctors had deemed necessary from the day of admission.
The occupational therapist assistant described the resident's needs as focusing on fundamental skills: standing, strengthening, and proper application of the prosthetic leg. These basic mobility functions had gone without professional therapeutic intervention during the entire month of August.
The facility reported a census of 37 residents at the time of the inspection. Federal investigators classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Good Samaritan Society - Villisca operates under policies that emphasize the importance of following physician orders promptly, particularly for rehabilitation services. The policy states that admitting orders provide guidance on appropriate resident care until comprehensive assessments are conducted and interdisciplinary care plans developed.
The missed orders represented a failure in the facility's system for tracking and implementing physician directives, leaving a vulnerable resident without ordered therapeutic services during a critical period following admission.
The resident's condition required specialized attention due to both the cognitive impairment and the physical challenges of adapting to life with a prosthetic limb. Professional therapy services are designed to help residents maintain or improve functional abilities, particularly important for someone learning to navigate mobility with an artificial limb.
When the therapy department finally received the August 27 orders, staff quickly arranged for evaluation and treatment to begin. The resident was "picked up for therapy in the beginning of September," according to the occupational therapist assistant.
The delay highlighted gaps in the facility's order management system, despite having written policies requiring timely implementation of physician directives for rehabilitation services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Villisca from 2025-10-16 including all violations, facility responses, and corrective action plans.