Unqualified Personnel Conduct Joint Mobility Assessments
Summary
The facility failed to ensure that Joint Mobility Assessments (JMA) for three residents were completed by qualified personnel, specifically a Physical Therapist (PT) or Occupational Therapist (OT). Instead, an Occupational Therapy Assistant (OTA), who was also the Director of Rehabilitation (DOR), performed these assessments independently. This practice was not in compliance with the Occupational Therapy Practice Act and the California Code of Regulations, which require that such assessments be conducted by licensed therapists and not by OTAs independently. For Resident 15, who was admitted with diagnoses including quadriplegia, muscle weakness, and muscle spasms, the OTA performed the JMA independently, noting a decline in range of motion (ROM) in both knees and ankles. The OTA admitted to possibly collaborating with an OT but had no documented evidence of such collaboration. Similarly, for Resident 29, who had a left-hand contracture and muscle weakness, the OTA conducted the JMA without supervision, despite the resident's severe cognitive impairment and functional ROM limitations. The OTA confirmed that she was not qualified to perform these assessments independently. Resident 34, who had left-sided hemiplegia and hemiparesis following a cerebral infarction, also had their JMA conducted by the OTA without proper supervision. The OTA noted changes in the resident's ROM but again lacked documentation of OT involvement. Interviews with the OT and the Director of Nursing (DON) confirmed that the OTA's actions were outside the scope of practice, potentially leading to inaccurate assessments and inappropriate care recommendations. The facility's policies and procedures, as well as state regulations, clearly outlined that JMAs should be performed by licensed therapists, highlighting the deficiency in the facility's adherence to these guidelines.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
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.
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 hemiplegia and muscle atrophy did not receive physical therapy as frequently as ordered by the physician, with two scheduled sessions missed in one week and no documentation provided to explain the absences. Interviews with the DOR and PTA confirmed the lack of documentation and communication regarding the missed therapy, which was not in accordance with facility policy or physician orders.
A resident with muscle weakness and intact cognition did not receive occupational therapy (OT) services as ordered by a physician, with therapy sessions frequently missed or reduced due to staffing shortages. Therapy records confirmed that the resident received OT less often than prescribed, and facility staff acknowledged the failure to follow the physician's order.
A resident with acute pulmonary edema and muscle weakness received PT and OT services for 25 days without a physician's order. Therapy assistants conducted sessions, but clinical records lacked documentation of physician authorization or notification. The DON was unaware of the requirement for a physician's order, and the facility had no formal policy to ensure compliance.
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.
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.
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 Therapy Services as Ordered and Document Reasons for Missed Sessions
Penalty
Summary
The facility failed to provide physical therapy (PT) services in accordance with physician orders for one resident who had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as muscle wasting and atrophy. The resident was admitted with significant deficits in activities of daily living (ADLs) and had orders for PT evaluation and treatment five times a week for 30 days, with subsequent recertifications to continue therapy at the same frequency. Documentation showed that during one week, the resident received PT only three times instead of the five times ordered, with no explanation documented for the missed sessions. Interviews with the Director of Rehabilitation and the Physical Therapy Assistant confirmed that the resident was scheduled for therapy on the missed days, but there was no documentation as to why therapy was not provided. The facility's policy required care and services to be provided and documented in accordance with physician orders and professional standards. The lack of documentation for the missed therapy sessions and absence of communication regarding the reasons for not providing therapy constituted a failure to follow physician orders and facility policy.
Failure to Provide Physician-Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to provide occupational therapy (OT) services as ordered by a physician for one resident. The physician's order specified that the resident should receive skilled OT five times per week for eight weeks, including specific therapy modalities. However, therapy records and interviews revealed that the resident received OT only three or four times per week on several occasions, with multiple therapy sessions missing and no documented reasons for the absences. The Director of Rehab and the Assistant Director of Rehab both confirmed that the resident did not consistently receive therapy according to the physician's order. The resident, who was admitted with a diagnosis of muscle weakness and was cognitively intact, reported that therapy sessions were skipped due to insufficient therapy staff. The resident expressed that therapy was beneficial for self-care and that he needed more therapy, but sessions were reduced due to staffing shortages. Facility policy required therapy services to be scheduled in accordance with the resident's treatment plan, but this was not followed in the resident's case.
Rehabilitative Services Provided Without Physician Order
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided in accordance with federal regulations for one of two sampled residents. A resident who was readmitted with acute pulmonary edema and muscle weakness received both physical therapy (PT) and occupational therapy (OT) services for 25 days without a physician's order. Observations confirmed that the resident participated in PT and OT sessions, including sitting to standing transfers and arm exercises, under the guidance of therapy assistants. A review of the resident's clinical records revealed no documented physician's order for PT or OT treatment, nor any evidence that a physician had been notified about these services. During interviews, the Director of Rehab confirmed the ongoing therapy services, and the Director of Nurses stated unawareness of the regulatory requirement for a physician's order for such services. The facility did not have a formal policy or procedure to ensure physician oversight for rehabilitative treatments.
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