Unlicensed Respiratory Therapist Provided Tracheostomy Care
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.
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 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.
A resident with multiple complex conditions and moderate cognitive impairment was admitted with physician orders for PT, OT, and ST to evaluate and treat as indicated, and the care plan identified ADL self-care deficits, fall risk, and an intervention for PT to evaluate and treat after any fall. Despite these orders and facility policies requiring therapy screening on all new admissions and PT evaluation after falls, the therapy department did not evaluate the resident at admission and did not complete a PT evaluation after a documented fall and a nursing therapy screen request. The DOR reported she did not perform the admission screening due to perceived lack of payer authorization and did not see the post-fall referral in the electronic system, while the BOM, Administrator, and Regional Nurse stated that all new admissions and post-fall events should be screened by therapy regardless of payer source.
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.
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.
Failure to Provide Ordered Therapy Evaluation at Admission and Post-Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized rehabilitative services were provided by qualified personnel as ordered by a physician and as outlined in the resident’s care plan. A male resident with multiple complex diagnoses, including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension was admitted with a physician order for PT, OT, and ST to evaluate and treat as indicated. The admission MDS showed moderate cognitive impairment with a BIMS score of 9 and documented that the resident required setup or clean-up assistance for some functional activities. Despite the standing physician order for therapy evaluation and treatment, the therapy department did not screen or evaluate the resident upon admission. The resident’s care plan, initiated on the date of admission, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls, and it documented a fall on a later date with an intervention specifying that PT was to evaluate and treat as needed after a fall. The resident experienced a fall next to the kitchen door, and nursing completed a Nursing to Therapy Screen Request in the electronic record, indicating a post-fall reason and requesting PT due to recent physical function changes. However, the Director of Rehabilitation (DOR) did not act on this request and did not perform a screening or evaluation following the fall, despite the care plan intervention and the facility’s process that a fall triggers a therapy evaluation request. Interviews revealed that the DOR chose not to screen or evaluate the resident upon admission because she believed there was no payer authorization from the hospital and stated that the therapy department usually did not treat residents without funding unless directed by the Administrator. The Business Office Manager (BOM) stated that all new admissions were to be screened or evaluated by therapy unless admitted only for nursing services and that treatment decisions were based on payer source, but also indicated that this resident was to be handled through an administrative authorization process. The Administrator and Regional Nurse both stated that all new admissions should be screened by therapy regardless of payment source and that PT should evaluate after every fall per facility standard, with payer source not preventing evaluation. The DOR later acknowledged that there was a communication in the electronic medical record regarding the resident’s fall that she did not see because she had not been checking the dashboard daily. Facility policies on fall risk assessment, falls clinical protocol, and resident screening guidelines required interdisciplinary assessment of fall risk factors and therapy screening on all new admissions and upon referral, but these processes were not followed for this resident at admission or after the fall. The facility’s fall risk assessment policy required nursing staff, the attending physician, therapy staff, and others to identify and document resident risk factors for falls and to establish a resident-centered fall prevention plan based on assessment data, including evaluation of ambulation, mobility, gait, balance, ADL capabilities, and cognition. The falls clinical protocol required assessment and recognition of fall risk, documentation of recent falls, and evaluation of musculoskeletal function and neurological status after a fall, with staff attempting to define possible causes within 24 hours. The resident screening guidelines policy required that screenings be completed by licensed therapy staff on all new admissions or upon referral to help identify functional loss and the need for rehabilitation services. Despite these written policies, the resident did not receive the ordered therapy evaluation at admission, and the post-fall therapy evaluation and treatment intervention in the care plan was not implemented after the documented fall and therapy referral. The Administrator stated that the therapy department should have assessed the resident when there was a request in the electronic system and that payer source was not a factor in determining the need for assessment. The Regional Nurse stated that once there is a fall, it triggers a form to be sent to therapy to evaluate the resident and that therapy should screen every resident, with further treatment decisions made after evaluation. The DOR stated she was new to the position, was still learning the process, and had only become aware of the nursing communication regarding the fall after the surveyor’s inquiry. These interviews and record reviews collectively showed that the facility failed to ensure that therapy services evaluated and treated a function impaired by illness or injury and failed to increase the resident’s functioning as ordered, by not conducting the required therapy evaluations at admission and after the fall, contrary to physician orders, the resident’s care plan, and facility policies.
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