Medical Director Not Fully Involved in Facility Oversight
Summary
The facility did not ensure the Medical Director was responsible for coordinating the medical care of the Westminster Unit. Survey findings showed there was no documented evidence that the Medical Director reviewed the Facility Assessment dated [DATE], participated in the development of facility policies and procedures to prevent abuse, or attended the most recent quality assurance committee meeting held on 04/23/2026. The Medical Director stated they had been involved in prior quality assurance meetings and had reviewed resident care policies when they took the role, but they did not know what topics were discussed at the most recent meeting and provided no evidence of involvement in the Facility Assessment. Interviews also showed the Medical Director had been the attending physician for the Westminster Unit until about one month before the interview, while Nurse Practitioner #1, employed through the Medical Director’s third-party staffing agency, had been assigned full-time to cover three units including Westminster and answered directly to the Medical Director. The Medical Director stated they were responsible for reviewing incident investigations and had assessed Resident #1 after an abuse incident, but they could not provide documented evidence of that assessment and were unaware that Resident #1 was not assessed by a psychiatrist as required by the facility’s incident investigation. The Administrator stated the facility would be using an outside consulting agency to help address resident care and abuse prevention and reporting policies.
Penalty
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A resident with mild cognitive impairment and poor decision-making ability was documented as lacking capacity, yet the MD was listed as the surrogate decision-maker. Facility policy required help obtaining an unaffiliated RP when a resident could not make decisions, but the resident’s sister was not used and no documentation showed that the Department of Aging obtained a patient representative. The MD stated she knew the resident for years, did not know the RP policy, and agreed to act as the resident’s decision maker.
Medical Director Oversight of Resident Tube Feeding and Medication Care: The facility failed to ensure the MD provided appropriate oversight of care for a resident with a g-tube, moderate cognitive impairment, hyperparathyroidism with hypercalcemia, and multiple medications given via the tube. The resident’s care plan lacked key details for skin breakdown, refusal of care, fluid balance, HOB elevation timing, and monitoring for endocrine-related symptoms, while the physician orders lacked electrolyte monitoring, I&O tracking, medication interaction management, and guidance for symptoms or refusals. Interviews showed the PA was unsure about electrolyte monitoring and relied on consulting services and the pharmacist, while the DON stated the MD was new to the role and seeing outpatients.
Medical Director Not Active in QAPI and Policy Review. The facility failed to ensure the medical director was active in QAPI and in the review, development, and revision of facility policies and procedures. Staff reported the medical director was not always present at QAPI meetings, and the medical provider stated he was not the medical director, worked full-time at another healthcare entity, and saw residents about every other week. The facility did not provide documentation showing the medical director’s involvement, and a QAPI at Risk Meeting document did not list the medical director among the IDT members who attended.
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.
Medical Director Served as Resident’s Decision Maker Without Unaffiliated RP
Penalty
Summary
The facility did not ensure that the Medical Director effectively implemented resident care policies for one sampled resident when it failed to obtain a resident representative who was unaffiliated with the facility. Facility policy stated that the facility was responsible for assisting residents in obtaining a representative if they could no longer make their own decisions or had no family to fill that role, and the compliance manual stated employees should not place themselves in positions involving conflicts of interest. Resident 8 was admitted with mild cognitive impairment, and later assessment showed poor decision-making ability. The resident’s record also stated that he did not have capacity to make decisions and that the surrogate decision-maker was the MD. The MD documented that the social services director informed her that the resident refused to have his sister as decision maker, and the MD then asked the resident if she could be his decision maker if he was not able to decide for himself; he agreed. The DON stated the resident did not currently have an RP and that the MD was acting as an intermediary between the resident and his sister. The MD stated she knew the resident for 15 years, did not know the facility policy on responsible parties, and did not contact the Department of Aging for a patient representative because the resident would not be able to express what he wanted to someone he did not know. The SSD believed the DON had contacted the Department of Aging, but no documentation was produced showing that a patient representative had been obtained.
Medical Director Oversight of Resident Tube Feeding and Medication Care
Penalty
Summary
The facility failed to ensure the medical director provided appropriate oversight of resident care policies and coordination of medical care for a resident who had a gastrostomy tube and multiple ongoing medical issues. The resident had moderate cognitive impairment, used a walker, and required hydration and nutrition through a g-tube. Her care plan addressed urinary incontinence and potential pressure ulcer development, but it did not identify actual skin breakdown on the coccyx, did not include goals or interventions for the resident’s refusal of cares and treatments, did not address her risk for fluid-volume imbalance, and did not include specific time requirements for elevating the head of the bed during and after tube feedings. The care plan also lacked specific symptoms, side effects, and monitoring related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The resident’s physician orders included tube feedings, water flushes, and multiple medications administered through the g-tube, including levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol, senna, cinacalcet, omeprazole suspension, and ascorbic acid. The orders lacked monitoring of electrolytes, accurate intake and output, fluid balance management related to tube feedings and free water, medication interaction monitoring and interventions to prevent adverse effects, a process for monitoring ongoing symptoms such as nausea, vomiting, and abdominal pain, and guidance for when staff should alert the provider if the resident refused medications or treatments. During interviews, the PA stated the resident had a complicated GI tract and hyperparathyroidism causing hypercalcemia, and that electrolyte imbalances would remain an ongoing concern. The PA stated she did not have plans to order follow-up bloodwork because she thought consulting services would monitor electrolytes, and she was unsure of the electrolyte monitoring schedule and the nutrition team’s involvement. The DON stated the medical director was seeing patients at his outpatient clinic, had been in the role only a short time, and this was his first medical director position in LTC. Additional interviews showed the PA relied on the pharmacist for timing medications in relation to tube feedings and had not directly communicated the resident’s medication needs to the consultant pharmacist. The facility Medical Director Responsibilities policy stated the medical director was responsible for coordination of medical care, implementation of resident care policies, and ensuring the appropriateness and quality of medical care.
Medical Director Not Active in QAPI and Policy Review
Penalty
Summary
The facility failed to ensure the medical director was active in his role for QAPI and for the review, development, and revision of facility policies and procedures. During interview, staff member A stated the medical director was not always present at QAPI meetings and that staff member N did not always participate in reviewing and revising the facility’s policies and procedures, though he sometimes did. Staff member A also stated there was a new medical director expected to start in the near future. Staff member N stated he was not the medical director but was the medical provider, that he worked full-time at another healthcare entity, and that he came to see residents about every other week. He also stated he had just gained access to the facility’s EMR. When documentation was requested to show the medical director’s involvement in QAPI activities and policy review, the facility did not provide records before the end of the survey. Review of a QAPI at Risk Meeting document showed the medical director’s name was not listed among the IDT members who attended.
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.
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