F712

Based on observation, interview, and record review, the facility failed to ensure the medical care of each resident was supervised by a physician for one (Resident #15) of five residents reviewed for supervision of medical care by a physician. The facility did not ensure Resident #15's physician examined and assessed Resident #15 upon a significant change in condition following Resident #15 having intermittent high blood pressures, shortness of breath, chest pain, and a 41.9-pound weight gain in 36 days. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. …

Fortress Nursing and Rehabilitation · Texas

Based on interview and record review, the facility failed to ensure periodic routine visits at least every 60 days by the physician and/or Nurse Practitioner (NP) for one of two sampled residents (Resident 1). This failure for Resident 1 not being assessed by his physician and/or NP for three months (between 6/22/20 to 9/29/20), resulted in Resident 1's Activities of Daily Living (ADLs), fundamental skills which are required to independently care for oneself such as eating, bathing, and mobility, declining, and resulted in Resident 1 developing a facility-acquired pressure ulcer (PU): Sore on the skin) located at the coccyx (tailbone). …

Vacaville Ranch Post Acute · California

Based on interview and document review, the facility failed to ensure medically required, timely, and/or required face-to-face physician visits occurred for 3 of 3 sampled residents (R56, R60, and R61).Findings include: Interview on 8/19/26 at 9:25 a.m., with the Ombudsman identified she had received numerous complaints from residents not receiving required face-to-face visits from providers. Review of the facility's State Waiver for MN Rule 4658.0710 Subp. 3. indicated, A resident must be evaluated by a physician every 30 days for the first 90 days after admission, and then whenever medically necessary. A physician visit is considered timely if it occurs within ten days after the date the visit was required. …

Olivia Restorative Care Center · Minnesota

Based on record review and staff and physician interviews, the facility failed to ensure physician visits were performed at least once every sixty days for 3 of 3 sampled residents reviewed for physician visits (Residents #62, #44 and #9). 1. Resident #62 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, dementia and diabetes.Resident #62's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired and was dependent on staff for most activities of daily living. A review of Resident #62's electronic health record revealed a Nurse Practitioner (NP) progress note dated 12/18/25 and a Physician's annual wellness visit dated 3/31/26. …

Clay County Health and Rehabilitation · North Carolina