Failure to Train Staff on CPAP Use and Maintenance
Summary
Staff failed to maintain and monitor CPAP settings for a resident diagnosed with COPD, insomnia, and renal insufficiency, who used a non-invasive mechanical ventilator. The resident's CPAP machine was observed on the bedside table, and a family member reported concerns that staff were not knowledgeable about the device, leading her to take the machine to the home supplier to verify its settings. The family member also stated that no staff assisted with the CPAP, and that the receptionist, rather than clinical staff, had to help with the device on two occasions because no one else knew how to operate it. Interviews confirmed that the receptionist assisted the resident with the CPAP due to a lack of trained staff, and the DON acknowledged that the facility did not have staff trained in CPAP use or a respiratory therapist available for consultation. The DON stated that only a respiratory therapist should monitor CPAP settings, but the facility did not have one accessible, resulting in unqualified personnel providing assistance with the resident's CPAP machine.
Penalty
Resources
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The facility allowed a respiratory therapist to provide respiratory care without verifying state licensure, despite a job description and a license verification policy requiring a valid, unrestricted state license. Human Resources hired the therapist and did not complete or document required license verification with the state regulatory agency, later confirming the therapist never held a state license during employment. This failure resulted in an unlicensed individual delivering respiratory services to residents and was cited as a deficiency.
A resident with bilateral knee osteoarthritis and intact cognition reported receiving only a few PT sessions over more than a month despite a physician order and PT plan of care for 2–3 sessions per week. The resident stated that a therapist came once and did not return that week and that staff told her she was not on the therapy schedule when she asked to get up for therapy. Record review confirmed only three PT encounters during the ordered treatment period, while the Therapy Director acknowledged that the ordered PT frequency was not met, contrary to the facility’s policy requiring therapists to follow physician-approved plans of care and ordered frequency and duration.
A respiratory therapist with an expired and non-renewed license continued to work in a respiratory therapist capacity, monitoring and providing care for an average of 14 residents with tracheostomies. The facility lacked a credentialing policy for respiratory therapists, and responsibility for tracking licenses had been assigned to a former HR manager. The NHA was unaware of the license lapse until shortly before the survey, while the SDD reported using tracking tools but confirmed that the departed HR manager had been responsible for monitoring this therapist’s license status.
A resident with multiple sclerosis was admitted with physician orders for PT and OT, but review of the clinical record showed no documentation that these therapies were ever provided. The resident reported not receiving any therapy since admission, and the Director of Rehabilitation confirmed that no therapy services had been delivered during this period despite active orders, resulting in a failure to provide ordered rehabilitative services.
Therapy services did not follow a physician order for a resident with a left femur fracture who was ordered NWB and no ROM to the left distal femur. PT was provided to both lower extremities, including stretches and active/passive ROM to the left leg, and the TD confirmed no new order had been received and that the therapy documentation showed movement performed despite the restriction.
A resident with respiratory failure, recent pulmonary emboli, muscle weakness, and impaired mobility had MD orders and a care plan for skilled PT five times per week for four weeks, including therapeutic exercises, activities, neuro re-ed, gait training, and training. During a transition from a contracted rehab provider to in-house rehab, the facility ended its external contract and had only an OT available, with no PT on staff and a PTA not yet started. The OT confirmed that only OT services could be provided and that the resident did not receive the ordered PT. The DON verified the active PT order, and RNA staff reported the resident was not on the restorative list. The resident reported not having PT appointments despite expressing a need to walk, while facility policy required therapy to be scheduled per the treatment plan.
Unlicensed Respiratory Therapist Allowed to Provide Care
Penalty
Summary
The facility failed to ensure a respiratory therapist was properly licensed by the state before hire and while providing care. Human Resources (HR) records showed the therapist was hired as a respiratory therapist on 7/14/25 and worked in that role until termination on 4/14/26. The termination form documented the reason for termination as failure to possess the licensure or certification required for the position. During interview, HR stated that respiratory therapist licenses were supposed to be verified with the Department of Consumer Affairs prior to employment, but HR could not provide evidence that this therapist’s state license had been verified at hire and confirmed the therapist did not have a state license at the time of hire or termination. The facility’s respiratory therapist job description required a valid, unrestricted state license, and the facility’s undated License Verification policy assigned the HR Director or designee responsibility for maintaining and ensuring the validity and current status of individual licensure, which was not carried out in this case. The report states that this failure resulted in the therapist providing respiratory care to residents without a state license and created the potential to put residents at risk for harm. No additional resident-specific clinical details or medical histories were provided in the report.
Failure to Provide Ordered Physical Therapy Services as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services, specifically physical therapy, as ordered by a physician for one cognitively intact resident with bilateral primary osteoarthritis of the knees. The resident reported that for over a month she had received very little rehabilitation therapy despite being told by her physician that she would be referred to therapy. She stated that one therapist came once and did not return that week, and that since March she had only two or three therapy sessions. On the day of interview, she asked a CNA if she was scheduled to get up for therapy, as she required assistance to get out of bed, and was told she was not on the therapy schedule. The resident expressed that she believed therapy would help with her arthritis and knee pain. Record review showed that the resident had a physician order and PT plan of care for physical therapy 2–3 times per week for 41 days beginning in mid-March, based on an evaluation documenting balance deficits, decreased functional capacity, pain, strength impairments, and a need for skilled PT to improve mobility and safety. PT encounter notes showed only three visits (evaluation and two treatment sessions) over this period. The Therapy Director confirmed that the resident was evaluated in mid-March and seen for treatment on two subsequent dates, and acknowledged that, based on the visits provided, the physician’s order for 2–3 sessions per week was not followed. The facility’s own policy required therapists to follow physician-approved plans of care and deliver services per the ordered frequency and duration, but this did not occur for this resident.
Unlicensed Respiratory Therapist Provided Tracheostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized respiratory therapy services were provided by qualified, licensed personnel. The facility had an average of 10–18 residents receiving tracheostomy care, with an average census of 14 residents with tracheostomies while Respiratory Therapist (RT)-L was employed. RT-L was hired with a respiratory therapist license that later expired, and RT-L continued to work in a respiratory therapist capacity in the facility after the license expiration date. Review of the Department of Human Services (DHS) online license look-up confirmed that RT-L’s license had expired and that renewal had been denied. Time clock records verified that RT-L continued to work in the role of a respiratory therapist after the license expiration and up until the last recorded work date. The facility did not have a policy for credentialing respiratory therapists, and responsibility for monitoring licenses had been assigned to a human resources manager who was no longer employed at the facility. The Nursing Home Administrator (NHA) reported being unaware that RT-L’s license had lapsed until informed shortly before the survey and acknowledged concern about the situation. The Staff Development Director (SDD) described using a checklist and spreadsheet to track employee licenses and certifications but indicated that the former human resources manager was responsible for monitoring RT-L’s license status. Another respiratory therapist (RT-N) stated that respiratory therapists in the facility are primarily responsible for monitoring all residents with tracheostomies, confirming that RT-L was functioning in this capacity while unlicensed.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide ordered rehabilitative services to a resident with multiple sclerosis. The resident was admitted in February 2026 with admission orders dated 2/24/26 for both physical therapy and occupational therapy. Review of the resident’s clinical record showed no documented evidence that any therapy services were provided as ordered. In an interview on 3/11/26 at 10:58 AM, the resident reported not having received any therapy since admission. During a separate interview on 3/11/26 at 10:40 AM, the Director of Rehabilitation confirmed that the resident had not received any therapy services from the date of admission through 3/11/26, despite the existing orders for physical and occupational therapy. This failure to implement the physician’s orders for rehabilitative services for this resident placed the resident at risk for a decline in range of motion.
Therapy Did Not Follow Physician ROM Restrictions
Penalty
Summary
Therapy services failed to follow a physician-ordered restriction for a resident with an unspecified fracture of the left femur managed non-operatively. The resident re-entered the facility from the hospital with an order dated 02/26/25 for non-weight bearing (NWB) and no range of motion (ROM) for the left distal femur fracture. Record review and interviews showed that physical therapy was provided from 04/29/25 through 06/27/25, and ROM was performed to the resident’s bilateral lower extremities, including the ankle, knee, and hip. The Therapy Director confirmed that no new order had been received during that therapy period and that the physician orders should have been checked for restrictions before therapy began. She also confirmed that the therapy notes documented movement to the resident’s left leg in the form of stretches and active and passive ROM. After therapy ended, a Therapy to Restorative Nursing Communication dated 06/27/25 recommended everyday ROM, and the Therapy Director stated that the recommendation should have been more specific about which extremities were to receive ROM.
Failure to Provide Ordered Physical Therapy During Rehab Service Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered rehabilitative services, specifically PT, to a resident in accordance with physician orders and the care plan. Resident 1 was admitted with acute and chronic respiratory failure, recent pulmonary emboli, muscle weakness, and a need for assistance with personal care. The MDS dated 1/6/26 indicated no memory impairment. Physician orders dated 12/30/25 directed skilled PT services five times per week for four weeks, including therapeutic exercises, therapeutic activities, neuro re-education, gait training, and patient/caregiver training. The resident’s care plan, initiated the same day, identified generalized weakness, impaired functional mobility, balance deficits, and increased need for caregiver assistance, with interventions that included the same ordered PT services. During interviews and record review, surveyors found that these PT services were not provided. The Administrator reported that the facility ended its contract with the outside rehab provider at the start of the year and was transitioning to in-house rehab staff, with only one OT hired from the former contractor and a PTA scheduled to start later. The OT confirmed that since the contract ended, no PT, OT, or SLT staff from the outside provider had come to the facility and that, at the time of the survey, the facility could only provide OT services. The OT stated the facility did not have a PT, so the resident did not receive the ordered PT. The DON acknowledged the PT order in the electronic record and stated most of the resident’s PT was due during the transition period. The RNA staff reported the resident was not on the restorative list and had not been discharged from PT to restorative services. The resident reported needing PT to be able to walk, stated she had not had any PT appointments, and recalled only possibly seeing a therapist once with a promise that therapy would start soon. The facility’s policy on scheduling therapy services required that therapy be scheduled in accordance with the resident’s treatment plan, which did not occur for PT in this case.
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