Delayed PT Evaluation for Adaptive Equipment Use
Summary
The facility failed to timely provide a PT evaluation for a resident who had an order for specialized rehabilitative services. Resident #04 was admitted with diagnoses including metabolic encephalopathy, parkinsonism, schizoaffective disorder, bipolar disorder, and hypertension. The quarterly MDS showed intact cognition, delusions, verbal behavioral symptoms toward others, and significant assistance needs for mobility and self-care. After a self-reported incident on 05/27/25 in which the resident ran his power scooter into another resident's foot and walker, he was moved to a manual wheelchair and was to be reassessed by therapy for safe scooter use. A social services note on 05/28/25 stated he was being assessed for the electric scooter and was not authorized to use it at that time. A nursing note on 07/02/25 documented that therapy was contacted and the resident was re-educated on proper use of the walker and wheelchair, and a PT referral was made for non-compliance. Physician orders on 07/02/25 included a PT screen and/or evaluation or treatment for proper transfer/use of adaptive equipment due to non-compliance. Therapy records showed the resident had last been seen by PT and OT earlier in the year, but there was no evidence he was assessed by therapy after the 05/27/25 incident. The resident stated on 07/28/25 that he had not been able to use his electric scooter for several months and had not been assessed since it was taken away. The DOR confirmed there was no evidence of an evaluation after the incident and that the PT evaluation ordered on 07/02/25 was not completed until the morning of 07/28/25.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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 RT failed to perform trach care per physician orders and facility policy for a resident with trach and ventilator dependence. During observed care, the RT changed gloves multiple times without HH between changes, attempted double gloving, used NS instead of ordered H2O2 to clean the stoma, and inserted the sterile inner cannula before cleaning the stoma area. The RTM and DON stated the care did not follow the ordered procedure or infection control expectations.
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.
Tracheostomy Care Not Performed Per Order and Policy
Penalty
Summary
Respiratory Therapist 4 failed to provide tracheostomy care to a resident with chronic respiratory failure, tracheostomy dependence, ventilator dependence, intracranial brain injury, and a history of sepsis in accordance with the physician’s orders and the facility’s tracheostomy care and hand hygiene policies. The resident’s record showed orders for tracheostomy care every shift and as needed, including cleansing the stoma with hydrogen peroxide and rinsing with normal saline, along with daily and as-needed inner cannula changes. The resident was dependent on staff for bathing, toileting, dressing, oral and personal hygiene, and mobility, and was unable to reliably understand others or make himself understood. During observation of tracheostomy care, RT 4 performed hand hygiene on entering the room, then used clean gloves for suctioning and changed gloves multiple times during the procedure without performing hand hygiene between glove changes. RT 4 attempted to double glove, then removed the gloves and continued care, again without hand hygiene between glove changes. RT 4 suctioned the resident’s trach and inserted the sterile inner cannula while wearing sterile gloves, then later cleaned the neck around the stoma with normal saline and applied a new dressing. RT 4 did not clean the stoma with hydrogen peroxide as ordered and performed the insertion of the sterile inner cannula before cleaning the area around the stoma. In interviews, RT 4 stated she usually double gloves for suctioning and inner cannula placement, but stopped after being told not to double glove. RT 4 also stated she only performs hand hygiene before and after resident care, not between glove changes, and acknowledged she did not use hydrogen peroxide to cleanse the stoma. The RTM and DON reviewed the care and stated the resident’s order required hydrogen peroxide, hand hygiene should have been performed between glove changes, and the facility’s tracheostomy care procedure required cleaning around the stoma before inserting the sterile inner cannula. The DON stated RT 4 had a competency issue and did not demonstrate professional standards of practice for trach care.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.