Failure to Ensure Resident Received Care Only from Approved Physicians
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.
Penalty
Resources
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Residents Not Offered Choice of Attending Physician: Four residents, including individuals who were alert and oriented or had capacity to make decisions, stated they were assigned an attending physician on admission and were not asked whether they wanted to retain a personal physician or choose one of their own. The AM, AD, and DON confirmed residents were assigned physicians from an approved panel and were not offered a choice upon admission, despite the facility's Resident Rights policy stating residents have the right to choose an attending physician.
Failure to Provide Physician Choice Form: A resident with stroke, dementia, dysphagia, DM2, and bipolar disorder was found to lack decision-making capacity and have severely impaired cognition. The RP emailed the administrator requesting that the resident’s PCP continue as the attending physician, but the ADON confirmed the RP was not given the facility’s Resident’s Right to Choose a Physician form. The ADON stated residents have the right to choose their physician and that staff should have helped contact the requested physician.
A resident’s right to choose an attending physician was not honored when the facility changed the resident’s PCP from Physician A to Physician B after discontinuing services with Physician A. The resident was cognitively intact and stated he/she wanted to stay with Physician A but did not have a choice. Social services documented the PCP change and later asked if the resident wanted to return to Physician A when that physician resumed practice at the facility.
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
The facility discontinued use of a long-time attending physician and did not allow that physician to continue providing care within the facility, despite residents’ stated wishes to keep this provider. According to the admission agreement, residents could select their own qualified healthcare professionals, but after the facility cited concerns about the physician’s failure to sign orders, complete Medicare certifications, and enter timely progress notes, residents were asked to transition to another physician. Cognitively intact residents reported being automatically reassigned to a new physician, described being upset about losing their long-standing physician and NP relationships, and said their questions about what happened to the prior physician were ignored or minimally addressed. A group of residents stated that a sheet was passed around informing them the physician had been dropped and a new doctor assigned, while leadership reported that residents could only continue seeing the former physician outside the facility, effectively preventing them from exercising their choice of attending physician for in-facility care.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Residents Not Offered Choice of Attending Physician
Penalty
Summary
The facility failed to ensure that four residents were informed of, and allowed to exercise, their right to choose an attending physician. Resident 1 was admitted with chronic osteomyelitis of the left thigh and osteonecrosis of the left femur and was alert and oriented x3; during interview, she stated she was assigned a facility physician on admission and was not asked whether she wished to retain her own physician or select one of her choice. Resident 2 was admitted for orthopedic aftercare following surgical amputation and was alert, oriented, able to follow commands, and had good safety awareness; she stated her physician was assigned by facility staff and she did not have a choice. Resident 3 was admitted with a fracture of the neck of the right femur and had the capacity to understand and make decisions; she stated she did not have a choice regarding her attending physician and was assigned one upon admission by facility staff. Resident 4 was admitted with difficulty walking and major depressive disorder and was alert, oriented x4 with cognitive status within normal limits; she stated the facility did not ask whether she wanted to choose her own physician or had a preference for an attending physician. Interviews with the Admissions Marketer, Admissions Director, and DON showed that attending physicians were assigned from a panel of approved physicians and rotated among the list. The Admissions Marketer stated residents were not asked whether they had a preferred physician or wished to retain their personal physician upon admission. The Admissions Director stated the attending physician's name was already listed in the admission packet before admission, residents were admitted with the assigned physician, and they were not offered a choice upon admission. The DON stated residents were informed who their assigned physician would be, but were not asked whether they had a preferred physician because the facility assigned physicians from a list of affiliated physicians. The facility's Resident Rights policy stated residents have the right to choose an attending physician and participate in decision-making regarding care.
Failure to Provide Physician Choice Form
Penalty
Summary
The facility failed to ensure that one of three sampled residents had the opportunity to choose his or her attending physician. Resident 1 was admitted with diagnoses including cerebral infarction, dementia, dysphagia, type 2 DM, and bipolar disorder. The H&P dated 3/2/2026 indicated Resident 1 did not have the capacity to understand and make decisions, and the MDS dated 5/28/2026 indicated Resident 1’s cognition was severely impaired and that the resident required extensive assistance with eating, oral hygiene, toileting hygiene, dressing, showering, and personal hygiene. During interview, the ADON confirmed that RP 1 emailed the facility administrator requesting that Resident 1’s primary care physician continue as the resident’s physician while residing at the facility. The ADON stated RP 1 was not provided the facility’s Resident’s Right to Choose a Physician form. The ADON also confirmed that residents have the right to choose their physician and stated that RP 1 should have been provided the form, with social work and nursing staff assisting in contacting the requested physician to determine whether the physician would continue providing care to Resident 1 while admitted to the facility. The facility policy titled Resident Rights stated that residents have the right to choose a personal attending physician and be informed how to contact him or her.
Resident Physician Choice Not Honored
Penalty
Summary
The facility failed to honor residents’ right to choose their attending physician when it discontinued services with Physician A, who had been providing care to 30 residents. Three residents from the sample were reviewed, and one resident who was cognitively intact stated a desire to continue care with Physician A. Instead, on 03/25/26, social services informed the resident that the primary care physician would be changed from Physician A to Physician B, and the change-of-PCP paperwork was signed. The resident’s annual MDS dated 03/04/26 showed the resident was cognitively intact. Social service documentation later noted that the resident was told Physician A would be returning to practice in the facility and was asked whether the resident wanted to go back under that physician as PCP; the resident agreed. During interview, the resident stated he/she did not want to change to Physician B and wanted to stay with Physician A, but did not have a choice. The Administrator stated she expected resident rights to be honored and the resident rights policy to be followed as written.
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Failure to Honor Residents’ Choice of Attending Physician After Discontinuing a Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when it discontinued services with Physician RR and did not permit this physician to continue providing care within the facility. The admission agreement stated that residents may select qualified healthcare professionals who conform to facility policies and applicable laws and that the facility may require credentialing. It also stated the facility may assist residents in selecting another physician if a physician fails or refuses to meet statutory or regulatory requirements. The facility issued a letter, dated 4/10/26 and signed by the administrator, stating that Physician RR continued to fail to sign orders, complete Medicare certifications, and timely enter progress notes, and that residents under this physician’s care were being asked to transition to alternative physicians. Resident #133, cognitively intact with diagnoses including anemia, heart failure, hypertension, stroke, anxiety, depression, and a psychotic disorder, had been under the care of Physician DD as primary physician and Nurse Practitioner SS as alternate, and was his/her own responsible party. The resident reported receiving the letter about Physician RR and stated that residents were upset because they had been with Physician RR for many years. The resident said that when he/she asked staff what happened to Physician RR, staff ignored the question, and when he/she asked social services, he/she was simply told that the new physician was Physician DD. An LPN reported that Resident #133 wanted to keep Physician RR and had a rapport with this physician, but the resident was transitioned to the new physician instead of being allowed to continue with Physician RR in the facility. Resident #139, also cognitively intact with diagnoses including hypertension, anxiety, depression, schizophrenia, PTSD, and asthma, was his/her own responsible party and had Physician DD documented as primary physician. This resident stated that many residents wanted to keep Physician RR, but they were automatically enrolled with Physician DD whether they wanted to or not, and the resident chose not to contest the change despite a long-standing rapport with Nurse Practitioner SS. In a group interview, nine residents reported that the facility “dropped” Physician RR about a month earlier and passed around a sheet stating they were not using Physician RR and had a new doctor. The DON stated that Physician RR was difficult to reach, did not sign orders or return calls, and was no longer the facility’s primary physician as of the prior month, while also stating there were no residents who expressed feelings about losing Physician RR. The administrator reported that residents received 30 days’ notice of the primary physician change and that residents could continue to see Physician RR only outside the facility, indicating that residents who wished to retain Physician RR for in-facility care were not allowed to do so.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
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