Failure to Honor Residents' Right to Choose Attending Physician
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting all residents reviewed for this right. The issue arose when the facility terminated their Medical Director agreement and changed the attending physician without notifying the residents or their representatives. This change took effect on July 4, 2024, and was not communicated to the residents or their families, leaving them without the opportunity to select their preferred physician. Interviews with residents and their family members revealed that they were not informed of the change in attending physician. For instance, one resident's family member, who was the responsible party, stated that they were not notified of the change and were not given the option to choose another physician. Another family member expressed concern over the lack of notification and the inability to select a new attending physician, especially since the previous physician had an established relationship with the resident. Staff interviews further confirmed the lack of communication regarding the change. A medical assistant mentioned that the change was a surprise to both staff and residents, and the previous attending physician and nurse practitioner were not informed in advance, preventing a proper transfer of care. The Director of Nursing, although new to the role, stated that residents should have been informed of the change and had the right to choose their doctor. The facility's administration could not provide evidence of notification letters being sent to residents or their families, and the letter they claimed to have sent only mentioned a change in the medical director, not the attending physician.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and multiple diagnoses was admitted without a signed consent for treatment by facility providers, as the legal guardian insisted on exclusive care by VA providers. Despite this, staff obtained or attempted to obtain medical orders from facility providers on several occasions, contrary to the guardian's directives and without proper authorization.
Failure to Ensure Resident Received Care Only from Approved Physicians
Penalty
Summary
This facility failed to ensure that a resident received care and services only from approved physicians, as required. The resident in question was admitted with diagnoses including Alzheimer's disease, heart disease, and obstructive sleep apnea, and had a severely impaired cognitive status as indicated by a BIMS score of 3 out of 15. The resident's legal guardian, who was also the daughter, refused to sign the facility's consent for treatment and insisted that all medical care be provided exclusively by VA providers. The guardian also took responsibility for scheduling and notifying the VA for all appointments, declining involvement from the facility's medical director or related providers. Despite the lack of consent for treatment by facility providers, there were multiple instances where facility staff either attempted to obtain or did obtain medical orders for the resident. These included a new order for Depakote from a CNP for increased agitation, notification of a provider regarding leg swelling, and a treatment order for a skin injury after the medical director's group was contacted. Interviews with the Administrator and DON confirmed that the facility did not have a signed consent on file and that staff actions were taken without the required authorization from the resident's legal guardian.
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.
