056430
03/03/2025
Northgate Postacute Care
40 Professional Center Parkway San Rafael, CA 94903
F 0712
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to ensure physician visits for one resident (Resident 1)of three sampled residents timely. This failure had the potential to delay detection of declining health and the provision of care.
Residents Affected - Few
Findings: A review of Resident 1's admission record indicated admission to the facility on 2/14/15 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left dominant side. A review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool), dated 2/19/25 indicated a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 13, which indicated no cognitive (related to processes of thinking and reasoning) impairment. During an interview on 3/3/25, at 10:23 A.M., Resident 1stated there was a period of time she, .doesn't have a physician and has gone a long time without seeing one. During an interview on 3/3/25, at 2:52 P.M., the Administrator (ADM) stated the expectation for physician visits was upon admission and every 30 days and as needed. During a concurrent interview and record review on 3/3/25, at 2:56 P.M., the ADM and Medical Records Director confirmed there was documented evidence of physician or nurse practitioner visits in Resident 1's medical chart for the months of August, September, October and November of 2024. During a review of document titled Physician Services , dated 6/2022, indicated It is the facility's policy to ensure its residents are provided with an attending physician that will supervise and direct its medical care . the residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.
Based on interview and record review, the facility failed to ensure physician visits for one resident (Resident 1) of three sampled residents timely. This failure decreased the facility's potential to delay detection of declining health and the provision of care.
Findings:
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056430
056430
03/03/2025
Northgate Postacute Care
40 Professional Center Parkway San Rafael, CA 94903
F 0712
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
A review of Resident 1's admission record indicated admission to the facility on 2/14/15 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left dominant side. A review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool), dated 2/19/25 indicated a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 13, which indicated no cognitive (related to processes of thinking and reasoning) impairment. During an interview on 3/3/25, at 10:23 A.M., Resident 1stated there was a period of time she, .doesn't have a physician and has gone a long time without seeing one. During an interview on 3/3/25, at 2:52 P.M., the Administrator (ADM) stated the expectation for physician visits was .upon admission and every 30 days and as needed. During a concurrent interview and record review on 3/3/25, at 2:56 P.M., the ADM and Medical Records Director confirmed there was no documented evidence of any physician or nurse practitioner visits in Resident 1's medical chart for the months of August, September, October and November of 2024. During a review of document titled Physician Services , dated 6/2022, indicated, It is the facility's policy to ensure its residents are provided with an attending physician that will supervise and direct its medical care . the residents must be seen by a physician at least .at least once every 60 thereafter [admission].
056430
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