"She's just declining"
Three months ago your mother walked to the dining room with a walker. Now she is wheeled. When you ask, you get some version of: "That's the progression at her age." Sometimes that is true. Very often it is not, and the reason is duller and more fixable: her therapy stopped, and nobody told you it could continue.
The two things families are told that are not right
"Her Medicare ran out." What ran out was almost certainly the Part A skilled nursing benefit — the post-hospital stay with its 100-day maximum. That is not the end of therapy coverage. Medicare Part B covers outpatient therapy services — physical, occupational, and speech-language — for long-stay nursing home residents, and it does not have a 100-day clock. Many residents are entitled to ongoing therapy under Part B while living in the facility, and never receive it because nobody initiated it.
"She has to be improving to qualify." This is the big one, and it is simply not the standard. Under the Jimmo settlement, Medicare confirmed that coverage of skilled therapy does not turn on whether the patient is improving. Skilled care to maintain function, or to slow or prevent deterioration, is covered when the skills of a therapist are required. The so-called improvement standard was never the law, and CMS was required to correct the record.
That single fact is worth more to your mother than anything else on this page. If a therapist or a business office tells you she is being discharged from therapy because she has "plateaued", that is the moment to say the word Jimmo out loud and ask for the decision in writing.
What to ask for, and of whom
Do not raise this with an aide in the hallway. Ask for a care plan meeting — you can request one, and you and your parent are entitled to participate — and put these in writing to the director of nursing and the therapy department:
- "Please arrange a physician order for a physical therapy and occupational therapy evaluation under Part B." An order and an evaluation are what start the process.
- "If therapy is being discontinued, please provide the written notice and the reason." If the reason given is lack of improvement, appeal.
- "Has a falls risk assessment been done since the change, and what did it recommend?"
- "What is in the care plan for daily mobility, and who performs it?"
- "Is a restorative nursing program in place?" This is the piece families never ask about — a nursing-run maintenance program for walking, range of motion and transfers, delivered by staff between or after formal therapy.
The part that matters more than the therapy sessions
Two or three therapy sessions a week will not keep anyone walking if the other days are spent in a chair. What decides the outcome is the daily routine, and that is squarely the facility's responsibility: federal requirements are explicit that a resident's abilities must not decline unless it is clinically unavoidable, and that residents receive the care needed to maintain function.
Ask for these in the care plan, in writing:
- Walking to meals rather than being wheeled, where it is safe.
- A daily walk with staff, documented.
- Up and dressed rather than left in a gown.
- Sitting out of bed for meals.
- Her walker parked within reach on her stronger side. The most common invisible reason a resident stops walking is that the device is across the room.
What immobility actually costs
This is why the argument is worth having:
- Contractures — joints that shorten and fix permanently, making washing and dressing painful.
- Pressure ulcers, because someone who does not move stays on the same points.
- Falls and fractures, driven by muscle loss and balance rather than by age.
- Pneumonia from prolonged immobility.
All four are things surveyors look at, and all four are things a facility would rather avoid — which is useful leverage when you are asking politely and getting nowhere.
Also worth checking
- Occupational therapy for seating and wheelchair fit. A poorly fitted chair causes more decline than families realize.
- Speech-language therapy if there is coughing at meals or a swallowing change after a stroke. Untreated dysphagia ends in aspiration pneumonia.
- A drug regimen review. Sedatives, antipsychotics and blood pressure medications cause unsteadiness. A resident who stopped walking sometimes has a prescribing problem, not a muscle problem. The consultant pharmacist reviews each resident's regimen monthly — ask what the last review said.
- If she is in a Medicare Advantage plan, coverage rules and appeals run through the plan. Ask for the denial in writing and appeal it; plans overturn a meaningful share of their own denials on appeal.
If nothing happens
- Written request to the administrator and director of nursing, with a care plan meeting date.
- Appeal any therapy denial in writing, citing maintenance coverage. Do not accept a verbal "Medicare won't pay."
- The Long-Term Care Ombudsman — free, in every state, and effective on exactly this kind of issue.
- The state survey agency, since avoidable decline in function is a compliance matter, not just a disappointment.
The question to ask before choosing a facility
If you are still looking, do not ask whether they "have therapy" — every facility does. Ask: "How many of your long-stay residents currently receive Part B therapy, and do you run a restorative nursing program?" The second half of that question separates facilities that keep people walking from those that do not.
And if you would rather not make the calls yourself, that is the part we do. Tell us the area, your parent's needs and your timeframe, and you get a shortlist worth calling, for $89. If you don't receive at least 3 homes matching the area and criteria you gave us, we refund you in full. Start here
This article is general information for families, not medical, legal or insurance advice. Whether therapy is clinically appropriate is a decision for the treating clinicians, and coverage details vary between Original Medicare, Medicare Advantage plans and state Medicaid programs. Curalune does not allocate beds and does not guarantee availability.