Facility Lacks Medical Director and Updated Policies
Summary
The facility failed to designate a physician to serve as the medical director responsible for implementing resident care policies and coordinating medical care. This deficiency persisted for six months, affecting all 46 residents, including a resident who was readmitted with significant medical conditions such as aftercare following surgery on the digestive system and dysphagia following a cerebral infarction. The facility did not have a designated medical director since June 2023, which led to a lack of thorough evaluation of the resident's change in condition and subsequent death. The resident's clinical record showed no evidence of investigation into whether the facility's failure to provide healthcare interventions within professional standards contributed to the resident's death. Additionally, the facility's healthcare policies and procedures were outdated and had not been reviewed or approved by a medical director to ensure they met current professional standards. Policies such as 'Change in a Resident's Condition or Status' and 'Pain Assessment and Management' had not been updated since 2017 and 2015, respectively. The facility's administrator acknowledged the absence of a medical director and was in the process of hiring one, but no decision or contract had been finalized. The lack of a medical director and outdated policies had the potential to result in substandard care delivery and failure to provide necessary care and services to residents.
Penalty
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Surveyors found that the facility failed to ensure an active, on-site Medical Director and appropriate physician coverage. The DON reported that the sole Medical Director was only available by phone and did not come into the building, and that a second physician had retired and was never replaced. Weekly Medical Director rounds did not occur as scheduled, with no physician present for recent rounds. The Administrator acknowledged there was no Medical Director available to conduct weekly rounds and that efforts to secure additional physician coverage were limited. The facility lacked a current executed contract defining the Medical Director’s responsibilities and availability, had no documented contingency or alternate coverage plan, and could not produce a policy outlining the Medical Director’s roles and oversight expectations.
The medical director failed to provide adequate oversight of methadone medication management, including the development and implementation of procedures to safely reconcile and verify methadone received from external opioid treatment programs. Facility policy assigned the medical director responsibility for oversight of medical care practices and clinical standards, yet the medical director did not know how methadone was delivered, relied on methadone clinic reports entered by nursing staff into the EMR, and electronically signed orders without reviewing the source documentation. An attending physician reported having residents on methadone maintenance but was unsure of each resident’s correct dosage and stated that nurses administered the dose on the methadone bottle even when it did not match the physician’s order, demonstrating a lack of coordinated, standardized processes for methadone prescribing and administration.
The facility did not designate a physician to serve as Medical Director after the previous Medical Director retired, leaving the position vacant for an extended period and potentially affecting all 52 residents. The DON reported being solely responsible for reviewing clinical trends and participating in QAPI clinical review, with no physician-level oversight. The Administrator confirmed the ongoing vacancy, noted unsuccessful attempts to secure a contract with local medical groups, and relied on informal conversations with rounding physicians instead of formal Medical Director services. The Administrator also acknowledged uncertainty about how physician-level oversight, contractual obligations, and federal compliance were maintained, despite a written policy that assigns broad clinical and administrative responsibilities to the Medical Director.
Surveyors found that the medical director failed to provide effective oversight of infection prevention and control, informed consent for psychotropic medications, and diagnostic evaluation for serious mental illness. The Infection Prevention and Control Program, including antibiotic stewardship and monitoring for C. diff and Legionella, lacked active medical director oversight. Two residents receiving psychotropic medications had informed consent forms that were unsigned by their representatives and lacked documentation of verbal consent, while their representatives reported not being contacted about these medications. In addition, two residents were newly assigned diagnoses of schizophrenia or schizoaffective disorder based largely on medication use and behavior, without documentation of comprehensive, evidence-based assessments as required by facility policy, and without consistent confirmation of these diagnoses in behavioral health or psychology notes.
Surveyors identified that the facility did not have a written contract or agreement available to verify the designation and ongoing engagement of a physician as Medical Director responsible for resident care policies and coordination of medical care. During record review, no documentation of such an agreement could be produced, and the Administrator reported being unable to locate the contract after a recent evacuation in which key binders were moved. The facility also lacked a policy or procedure describing how the Medical Director contract is to be maintained, retained, or kept accessible.
A resident with multiple chronic conditions died, and the death certificate was not signed within the required timeframe due to a lack of timely communication between nursing staff and the Medical Director. The delay caused additional stress for the family and postponed funeral arrangements, as the funeral home could not proceed without the signed certificate.
Lack of On-Site Medical Director Oversight and Contractual Structure
Penalty
Summary
The deficiency involves the facility’s failure to ensure provision and oversight of a Medical Director in accordance with federal requirements. Interviews and document review with the Administrator and DON showed the facility had no current physicians coming to the facility. The DON reported that the facility had one physician designated as the Medical Director, but this physician was not available to come to the facility and was only available by phone. During the prior year there had been a second physician, but that physician retired on an unknown date and was not replaced. All residents were patients either of the Medical Director, who was not available to come to the facility, or of Optum, which provided APRN coverage. The DON stated that weekly Medical Director rounds were supposed to occur every Thursday, but no physician conducted rounds on the most recent scheduled date and none was scheduled for the following week; the last documented rounds occurred 12 days before the survey interview. The Administrator confirmed there was no Medical Director available to come into the facility for weekly rounds. After the second physician retired, the Administrator contacted two physicians about coverage and then waited for the Medical Director to locate a second physician, without advertising or using a staffing agency to secure coverage. The facility was unable to demonstrate that the designated Medical Director provided routine, ongoing oversight within the facility, including at least weekly on-site presence. Record review did not identify a current, executed contract defining the Medical Director’s responsibilities, availability, and coverage expectations. The facility also lacked documentation of a contingency agreement or alternate coverage plan for Medical Director services if the appointed Medical Director was unavailable or failed to provide required services, and could not provide a policy outlining the Medical Director’s roles, responsibilities, and expectations for facility involvement and oversight.
Failure of Medical Director Oversight for Methadone Medication Management
Penalty
Summary
The deficiency involves the failure of the medical director to collaborate with the facility to develop and implement procedures for the safe and accurate provision of methadone medications received from external opioid treatment programs. The facility’s policy on Physician Visits and Physician Delegation stated that the medical director’s role is to provide oversight of medical care practices, regulatory compliance programs, and clinical standards. Despite this, the medical director did not ensure that current standards of practice were followed for reconciling, verifying, and overseeing methadone medications from methadone clinics. Surveyor interviews revealed that an attending physician acknowledged having residents on methadone maintenance programs but stated they were unsure of the methadone dosage each resident was supposed to receive and that nurses were to administer the dosage indicated on the methadone bottle, even if it did not match the physician’s order. The medical director stated they did not know the process by which methadone was delivered to the facility and that the methadone dosage was determined by the methadone clinic, which sent a report to the facility. The medical director reported that nurses entered this information into the EMR as physician orders, which the medical director electronically signed without reviewing the clinic report, and that their only responsibility was to assess residents and renew orders. In a follow-up interview, the medical director characterized the lack of established processes and communication between the facility and the methadone clinic as a system failure.
Failure to Designate a Medical Director for Resident Care Oversight
Penalty
Summary
The facility failed to designate a physician to serve as Medical Director responsible for implementation of resident care policies and coordination of medical care, affecting all 52 residents in the facility. The DON reported that the former Medical Director retired in June or July and that the position had not been filled since that time. The Administrator confirmed that the Medical Director position had been vacant since July 2025 and that the local medical physician group would not contract with the facility. The facility had attempted to contract with two other medical groups and was in ongoing contract negotiations with a physician from one of those groups, but no formal appointment had been made. During interviews, the DON stated she was the only person reviewing clinical trends and participating in QAPI clinical review, indicating that physician-level oversight of these functions was not in place. The Administrator stated that, in the absence of a Medical Director, they had informal conversations with physicians when they rounded at the facility, but there was no formal notification to the Governing Body regarding the vacancy, although ownership was verbally informed in daily conversations. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements had been achieved since July 2025. This situation existed despite a written Medical Director policy, last reviewed on 3/2/25, that outlined extensive responsibilities for the Medical Director, including implementation of resident care policies, coordination of medical care, evaluation of staff adequacy, review of incidents and accidents, and participation in QAPI meetings.
Failure of Medical Director Oversight for Infection Control, Informed Consent, and Serious Mental Illness Diagnoses
Penalty
Summary
The deficiency involves the failure of the designated medical director, Physician R, to effectively participate in and oversee resident medical care, including infection prevention and control, informed consent for psychotropic medications, and appropriate diagnostic evaluation for serious mental illness. Surveyors determined that the Infection Prevention and Control Program for a census of 116 residents did not receive oversight by Physician R for antibiotic stewardship and monitoring of infectious diseases, including measures designed to slow and prevent the spread of C. difficile and to address waterborne illness risks related to positive Legionella results. This lack of medical director oversight was cross-referenced to F880. For informed consent, the facility’s own policy titled “Psychotropic: Medication Use,” revised 02/25, required that prior to initiating, increasing, or switching psychotropic medications, staff and the physician review non-pharmacological alternatives, indications and rationale, potential risks and benefits (including side effects, adverse consequences, and black box warnings), and the resident or representative’s right to accept or decline treatment. Record review showed that Resident 12 had an informed consent form dated 3/16/25 for Risperidone for visual hallucinations that was not signed by the resident’s representative and did not indicate verbal consent. A second informed consent form dated 9/11/25 for Mirtazapine for depression and Risperidone for visual hallucinations was also not signed by the representative and did not indicate verbal consent. Resident 10’s representative reported never hearing from the medical doctor and not signing any forms concerning psychotropic medications, stating she felt she was not kept informed. Resident 12’s representative stated she had not spoken to anyone about psychotropic medications and would have declined them because she felt they made Resident 12 less functional. The DON stated her expectation was that Physician R would contact representatives for education and treatment planning before nurses obtained confirmation and signatures, and she was surprised the representatives had not heard from him. In contrast, Physician R stated he could not do all the education and depended on nurses to teach and notify him if representatives had concerns. The deficiency also included inadequate diagnostic evaluation for new diagnoses of serious mental illness, specifically schizophrenia and schizoaffective disorder, for two residents. Resident 10 was admitted with dementia, major depressive disorder (MDD), and unspecified psychosis, and had severe cognitive impairment per an MDS dated 12/22/25. Her physician order summary listed Seroquel for schizoaffective disorder manifested by visual hallucinations. However, a CHE Behavioral Health psychiatry note dated 9/13/23 listed active diagnoses of dementia and MDD with no auditory hallucinations, and a SOAP note by Physician R dated 10/12/23 listed no new diagnosis of schizoaffective disorder. On 10/16/23, facility staff faxed Physician R noting Resident 10 was taking Seroquel without an assigned diagnosis and requested an updated diagnosis list; schizoaffective disorder was added that same day by Physician R. Subsequent CHE psychiatry notes, including 12/27/23 and 12/24/25, continued to list dementia and MDD, recommended a Seroquel dose decrease, and did not mention schizoaffective disorder. The DON stated a serious mental illness diagnosis should not be added solely for medication and should be properly diagnosed by behavioral health, and that mislabeling could inappropriately label residents. Resident 10’s representative stated the resident had no history of schizoaffective disorder and she had never spoken to a medical doctor about this diagnosis. Physician R stated residents with schizoaffective disorder are referred to psychiatry and, if psychiatry did not confirm the diagnosis, it should have been removed; he further stated he may have added the diagnosis based on evolving symptoms. Resident 2’s record showed admission with cerebral infarction with right-sided weakness, epilepsy, diabetes, anxiety, and psychotic disorder with delusions. On 2/6/24, a schizophrenia diagnosis was entered. A behavioral health note dated 11/29/23 by NP LL recommended starting Risperdal 0.25 mg daily for delusions and paranoia but did not list schizophrenia. Review of physician and behavioral health notes from November 2023 through May 2024 revealed no mention of schizophrenia. NP KK, from the behavioral health group, confirmed that NP LL’s notes did not mention schizophrenia at the time Risperdal was prescribed and that her own December 2024 note was the first documentation of schizophrenia as a diagnosis. A fax dated 2/6/24 from MDS Nurse NN to Physician R asked if the diagnosis list could be updated to include schizophrenia for a resident on Risperdal; Physician R responded “Yes” with his signature. NP KK stated the schizophrenia diagnosis was based on delusions, a BIMS score of 3, and symptom improvement on Risperdal. Psychologist MM, Resident 2’s psychologist, stated his notes documented a delusional disorder, not schizophrenia, and that the two diagnoses are not interchangeable; his progress notes did not mention schizophrenia. MDS Nurse NN stated she sent the fax because the MDS system required a matching diagnosis for the antipsychotic and that she was not aware of any clinician documentation diagnosing schizophrenia at that time. MDS Nurse OO similarly stated there was no documentation that a clinician had diagnosed schizophrenia when the diagnosis was entered in February 2024. The facility’s “Schizophrenia and Related Disorders – Clinical Protocol,” revised 3/2025, required that practitioners not newly diagnose serious mental illness without evidence-based criteria documented in the record, including comprehensive assessment findings, DSM-consistent symptoms and duration, exclusion of other causes, and documentation of the effect on function. These requirements were not met in the documentation surrounding the new schizophrenia diagnoses for Residents 2 and 10.
Lack of Written Medical Director Agreement and Contract Management Process
Penalty
Summary
The facility failed to maintain and provide evidence of a written agreement designating a physician as Medical Director responsible for implementation of resident care policies and coordination of medical care. During document and policy review, surveyors were unable to obtain any written contract or agreement verifying the appointment and ongoing contractual relationship between the facility and a Medical Director. An interview with the Administrator revealed that she could not locate the Medical Director contract at the time of survey, explaining that a recent facility-wide evacuation had led to relocation of important binders, but the requested contract still could not be produced. The facility also could not provide any policy or procedure describing how the Medical Director contract is to be maintained, retained, or made accessible. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Delay in Death Certificate Signature Due to Communication Breakdown
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled their responsibility for timely implementation of resident care policies following the death of a resident. Specifically, after a resident with diagnoses including dementia, repeated falls, chronic kidney disease stage 3, and basal cell carcinoma died, the death certificate was not signed within the required 72-hour timeframe as mandated by State Public Health Law 4041. Documentation showed that the resident was found without respirations and an apical pulse, and post-mortem care was provided. The family and funeral home were notified, but the funeral home was unable to proceed with arrangements due to the unsigned death certificate, resulting in a delay of services. Interviews with the resident's representative and the funeral director confirmed that the delay in signing the death certificate caused additional stress and postponed the resident's services. The Medical Director stated that they were not informed in a timely manner to sign the certificate, as the nurse who documented the resident's expiration did not follow up with a phone call. The facility's investigation found no documentation that the Medical Director was contacted to sign the certificate, leading to the late signature. This breakdown in communication between nursing staff and the Medical Director resulted in the deficiency.
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