Inconsistent Physician Visits in LTC Facility
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. Additionally, residents were not consistently seen by the attending physician or Nurse Practitioner (NP) every thirty days, with a physician visit at least every sixty days. This deficiency was observed for eight residents, who were not seen by their attending physician or NP as required by the facility's policy and applicable regulations. For instance, one resident, who had been at the facility for almost two years, reported seeing the doctor only two or three times. The resident's medical records revealed multiple diagnoses, including Type 2 Diabetes Mellitus, heart failure, and dependence on renal dialysis. Despite these conditions, there were significant gaps in the physician's visits, with no progress notes from the attending physician or NP for several months. Similar patterns of missed visits and lack of documentation were observed for other residents, who had various medical conditions such as metabolic encephalopathy, hemiplegia, paranoid schizophrenia, and end-stage renal disease. Interviews with facility staff, including the Registered Nurse/Unit Manager and the Licensed Nursing Home Administrator, confirmed the inconsistency in physician visits. The facility's policy required the attending physician to visit residents at least once every thirty days for the first ninety days following admission and at least every sixty days thereafter. However, the surveyor found that the facility did not adhere to this policy, resulting in a failure to provide adequate supervision and care for the residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis, who was cognitively intact and receiving dialysis, was not seen by a physician within the required initial 30-day period after admission. The first documented physician assessment occurred several months later, even though the resident had been seen by an NP and a PA during that time. Review of records and staff interview confirmed the absence of a timely physician visit, resulting in noncompliance with required physician visit frequency and timeliness.
A resident was not seen by a provider throughout their entire admission, as confirmed by the absence of physician progress notes in the medical record. The resident was cognitively intact, and facility policy stated that residents should receive care from medical practitioners as needed.
The facility did not ensure that the Medical Director conducted required face-to-face visits with several residents, all of whom had complex medical conditions such as dementia, diabetes, and Alzheimer's disease, within the mandated 60-day interval. The Medical Director was unaware of this requirement, resulting in missed visits for these individuals.
The facility did not ensure that required face-to-face physician visits were conducted at least every 60 days for four residents with various medical conditions, as confirmed by record review and DON interview. The most recent visits for these residents were completed several months prior, and no subsequent visits were documented within the regulatory timeframe.
A resident with multiple chronic conditions did not have any in-person examination notes documented by the attending physician since admission. Instead, the Medical Director only co-signed notes from a Physician Assistant or Nurse Practitioner, contrary to facility policy requiring a physician's own progress note during visits. The DON confirmed the absence of required physician documentation.
A resident with severe cognitive impairment and complex medical needs did not have documented physician visits as required. Only an admission visit and a physician order were found in the record, and facility leadership could not provide evidence of additional required visits, despite the physician stating that notes had been sent.
Failure to Provide Timely Initial Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician within the first 30 days after admission, as required by §483.30(c). The resident was admitted on 06/25/25 with diagnoses including end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis, and a quarterly MDS documented that the resident was cognitively intact and received dialysis. Review of the medical record showed that the first documented physician assessment did not occur until 12/10/25, well beyond the required initial 30-day timeframe. Although the resident was assessed by a nurse practitioner and a physician assistant prior to that date, there was no documentation of a timely physician visit. In an interview, the MDS nurse confirmed that the resident had not been assessed by a physician within the first 30 days after admission and that the first physician assessment at the facility occurred on 12/10/25. This deficiency affected one of three residents reviewed for physician visits, in a facility with a census of 47 residents.
Plan Of Correction
Physician Visits-Frequency/Timeliness/Alt NPP The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 28 has been seen by the facility physician on 3-18-2026. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken A sweep of new admissions to the facility has been completed by 4-1-26 by the ADON and the physician has seen all new admissions within the first 30 days of admission. The sweep included the last 30 days audit of residents that they have been seen by the physician. all have been seen. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee has in-serviced nursing management and nurses that they must ensure residents are assessed by a physician within the first 30 days after admission. Inservice completed on 3-31-2026. Medical director was in serviced that he will need to see new admissions within 30 days of admission on 3-18-26 by the DON. How the corrective action will be monitored to ensure the deficient practice will not recur. DON/designee is auditing new admissions for compliance with physician visit within 30 days weekly x 2 months and submitted to the weekly QAPI committee. The audits began 3-31-26. If any concerns are noted, the MD will be alerted to come in to see the resident in a timely. The audits will alert the adon that the time limit is approaching.
Failure to Ensure Required Physician Visits During Admission
Penalty
Summary
A review of the medical record, staff interviews, and facility policy revealed that a resident was not seen by a provider during the entire admission period from 05/07/25 through discharge on 08/21/25. The medical record for this resident, who was cognitively intact according to the five-day Minimum Data Set (MDS) assessment, showed no physician progress notes for the duration of the stay. Facility assessment documentation indicated that residents should expect a standard of care from medical practitioners and other healthcare professionals necessary to provide the required support and care. This deficiency was identified during an investigation under Complaint Number 2572811.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the Medical Director conducted face-to-face visits with residents at least once every 60 days, as required. Medical record reviews and staff interviews revealed that four residents, each with significant medical diagnoses such as pneumonia meningitis, ulcerative colitis, viral hepatitis, non-traumatic brain dysfunction, dementia, diabetes, cancer, coronary artery disease, Alzheimer's disease, renal insufficiency, and psychotic disorder, had not been seen by the Medical Director within the mandated timeframe. The last documented visit for these residents was on the same date, and subsequent review confirmed that no follow-up visits occurred within 60 days. During an interview, the Administrator acknowledged that the Medical Director was unaware of the requirement to see residents every 60 days.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that required face-to-face physician visits were conducted at least every 60 days for four residents. Record reviews showed that the most recent regulatory visits and exams for these residents were completed in March 2025, with no subsequent visits documented within the required timeframe. The residents affected had various diagnoses, including Alzheimer's disease, diabetes mellitus, emphysema, dementia, major depressive disorder, cerebrovascular disease, hemiplegia, hemiparalysis, seizures, non-traumatic brain dysfunction, heart failure, and hypertension. Cognitive assessments ranged from intact to severely impaired cognition. An interview with the Director of Nursing (DON) confirmed that the facility did not currently have a physician available to conduct in-person regulatory visits, resulting in the lapse of required visits for the identified residents. This deficiency was identified during the investigation of a specific complaint and affected a facility census of 102 residents.
Lack of Physician In-Person Examination Documentation
Penalty
Summary
The facility failed to provide evidence that the attending physician conducted in-person examinations for all residents as required. Specifically, for one resident with multiple complex diagnoses including Type 2 Diabetes Mellitus with neuropathy, asthma, morbid obesity, bipolar disorder, atrial fibrillation, acute respiratory failure, hypertension, and hyperlipidemia, there were no physician progress notes documented in the medical record since admission. The medical record review showed that the Medical Director, who was the attending physician, only co-signed notes written by a Physician Assistant or Nurse Practitioner and did not write any direct physician notes for the resident. The facility's policy requires the physician to review the resident's plan of care during visits and to write and sign a progress note, but this was not followed in this case. The Director of Nursing confirmed the absence of physician notes for the resident.
Failure to Ensure Required Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that physician visits were provided as required for a resident with multiple complex medical diagnoses, including osteonecrosis, gastrostomy, a history of malignant neoplasm, and nicotine dependence. The resident, who had severe cognitive impairment and was dependent on a feeding tube for the majority of nutritional needs, had documentation of an admission physician visit and a subsequent physician order fax, but no other physician visits were found in the medical record. During interviews, the attending physician stated that a visit had been completed and notes sent to the facility, but facility leadership was unable to provide evidence of any required physician visits beyond the initial documentation. This lack of documentation and evidence of ongoing physician visits constituted the deficiency.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
