Failure to Complete Ordered SLP Evaluation for Resident With Dysphagia
Summary
The facility failed to ensure that one of three sampled residents, Resident 42, received a speech language pathology evaluation after a physician ordered it on 12/10/2025 because the resident was coughing during meals. During observation on 1/5/2026, Resident 42 was seen lying in bed with the head of the bed elevated to 30 degrees and drinking water; after a few sips, the resident coughed and took several seconds to clear the airway. Record review showed the resident had been admitted and readmitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and dysphagia following cerebral infarction. The resident’s MDS dated 10/2/2025 indicated intact cognition and set-up or clean-up assistance with eating. The care plan initiated on 12/10/2025 identified risks for altered nutritional and hydration status and aspiration related to dysphagia and CVA, with interventions including supervising and assisting with meals as needed. The physician order dated 12/10/2025 at 10:13 p.m. directed an SLP evaluation due to coughing during meals, but interviews with the RN Supervisor, Speech Therapist, Director of Rehabilitation, and DON confirmed the evaluation was not completed because licensed nurses did not communicate the order to the rehab department.
Penalty
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Failure to Refer Resident Request for Drop Arm Commode to OT: A resident who became non weight bearing and had intact cognition requested a drop arm commode after she could no longer safely use a standard commode. The DOR, a COTA, told her she did not need the device and suggested using the existing commode or a bedpan instead, without notifying the supervising OT for an evaluation. The resident then used adult diapers for toileting and reported feeling humiliated, angry, and frustrated.
Failure to Provide Ordered PT/OT Services: A resident with paraplegia, intact cognition, and an active PT/OT eval and treat order did not receive the ordered rehab services. The resident said he wanted therapy to help him discharge, but the LPN's follow-up was not documented, and the rehab dept confirmed the resident had not been screened or evaluated for PT/OT.
A DOR who was a COTA transcribed PT findings into JMAs for two residents instead of the JMAs being independently assessed by a qualified PT. One resident had Parkinson's Disease, hemiplegia/hemiparesis, and contractures, yet the JMA understated severe ROM limits documented in the PT eval and observed during PROM. Another resident with dementia and lower-extremity limitations had a JMA showing WFL despite PT and bedside observations showing impaired positioning and mobility. The DOR stated she transposed the PT assessment into the JMA and did not know what the impairment levels meant in degrees.
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.
Failure to Refer Resident Request for Drop Arm Commode to OT
Penalty
Summary
The facility failed to ensure the Director of Rehabilitation, who was a COTA working under the supervision of a licensed OT, referred a resident to OT when the resident requested a drop arm commode after becoming non weight bearing on both legs. The resident had diagnoses including anorexia nervosa, polyneuropathy, and abnormalities of gait and mobility, and records showed she had the capacity to understand and make medical decisions and was cognitively intact. After the resident was ordered to be non weight bearing until seen by orthopedics, she told the DOR that she could no longer use a standard commode because she previously pivoted onto it but now had significant wrist pain that made scooting difficult. The DOR told her she did not need a drop arm commode, suggested she continue using the existing commode by scooting, and later suggested she use a bedpan. The DOR stated she should have informed the supervising OT because she could not screen or evaluate residents, but the OT stated she had not been informed of the request and had not completed an evaluation. The resident stated that because she could not obtain the drop arm commode, she began wearing adult diapers to urinate and defecate and felt humiliated, angry, and frustrated. She also stated she cleaned herself independently after toileting in the diaper because she was embarrassed to have anyone else clean her. The DON stated she was not aware of the request or that the DOR had attempted to address the resident's toileting needs without notifying the supervising OT or nursing, and stated that requests for specialized equipment must be promptly communicated to the licensed OT for proper evaluation.
Failure to Provide Ordered PT/OT Services
Penalty
Summary
Specialized rehabilitative services were not provided for a resident with an active physician order for PT/OT evaluation and treatment. The resident had diagnoses including paraplegia, need for assistance with personal care, muscle wasting and atrophy, weakness, and lack of coordination, and the MDS documented a BIMS score of 15 out of 15. The resident stated he had not received physical therapy, had previously been seen by therapy when first admitted, and wanted therapy again so he could discharge from the nursing home. He also stated he told an LPN he wanted therapy, but did not receive a response. The LPN stated she was aware the resident had expressed interest in physical therapy and said she followed up with the doctor, but the matter was not documented in the chart. The Director of Rehabilitation stated the rehab department had not seen the resident since prior therapy services ended and that the resident had not been screened or evaluated for PT/OT. The Director of Rehabilitation reviewed the physician orders and confirmed an active PT/OT eval and treat order was present, and the DON stated she was not aware the resident had an active order and had not been evaluated by PT/OT. The resident's psychiatry note also documented motivation to regain strength and interest in physical therapy.
Inaccurate JMA Documentation by Unqualified Staff
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided by qualified personnel when the Director of Rehabilitation, who was a Certified Occupational Therapist Assistant, transcribed Physical Therapist evaluation findings into the Joint Mobility Assessment for two residents. The Joint Mobility Assessment was supposed to be completed by rehabilitative staff, and the report states that the DOR completed and documented the JMA based on the PT's assessment rather than independently assessing the residents. The facility's policy stated that rehabilitative staff would complete the JMA upon admission, annual assessment, and change in condition. For one resident, the record showed diagnoses including Parkinson's Disease, hemiplegia/hemiparesis after cerebral infarction, and a left knee contracture. The PT evaluation documented severe limitations, including the right knee fixed in neutral with no flexion or extension, the left knee bent at 40 degrees and unable to straighten fully, and both ankles fixed in 50-degree plantar flexion with no dorsiflexion. However, the JMA completed by the DOR described the left knee flexion as within functional limits, the right knee extension as minimally impaired, and the bilateral knees and ankles as moderately impaired. During observation, the resident's legs and feet were positioned in a way consistent with contractures, and the restorative aide stated the resident's legs and ankles were stiff and could not move normally during PROM exercises. For the second resident, the record showed diagnoses including lumbar spinal stenosis, lumbar spondylolysis, and dementia, with severe cognitive impairment and need for moderate assistance with ADLs and transfers. The PT evaluation documented bilateral lower extremity ROM as within functional limits, while the JMA completed by the DOR also stated the bilateral knees and ankles were within functional limits. Yet the resident was observed sitting and later lying with both ankles and toes pointed downward and away from the body. The PT stated that a resident who does not ambulate would not be considered within functional limits on the JMA, and the DOR stated that she transposed the PT's assessment into the JMA and did not know what the impairment levels meant in degrees.
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.
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