Deficiencies in Clinical Record Maintenance for Secured Unit Residents
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for two residents on the secured unit. For Resident #32, there was no physician order for placement on the secured unit and no elopement assessment upon admission. The resident, a female with vascular dementia, delusional disorder, and amnestic disorder, was admitted without the necessary documentation, which was only completed almost two months later. The Director of Nursing (DON) acknowledged the oversight, noting that an elopement risk assessment should have been conducted on the day of admission. Similarly, for Resident #7, the facility did not have a physician order for placement on the secured unit, nor was there an elopement risk assessment completed before the transfer. The resident, who had severe cognitive impairment and was at risk for wandering, was transferred to the secured unit for safety reasons without the required documentation. The DON was unsure if a physician order was necessary and admitted that the care plan should have included the intervention of secure unit placement. The lack of proper documentation could lead to staff being unaware of the resident's needs and inconsistencies in nursing care.
Penalty
Resources
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The facility failed to maintain complete and accurate medical records for multiple residents, including missing and delayed documentation of a fall and hospital transfer, incomplete shower and meal intake records, undocumented bowel movements despite a PRN laxative order, and missing treatment administration entries for ordered tracheostomy care and inner cannula changes. Staff, including LPNs, an RN, and the DON, confirmed that assessments, investigations, and routine care were either not documented, left blank, or not signed in the EMR or on treatment records, contrary to the facility’s own documentation policy.
A resident with metabolic encephalopathy, muscle weakness, and a history of CVA experienced a fall in his room that was not documented in the medical record until the following morning as a late entry. Two RNs acknowledged that the fall was not recorded at the time it occurred and stated that fall incidents should be documented as soon as possible after the event, resulting in a deficiency for failure to maintain timely, professionally standard medical records.
A resident with severe cognitive impairment, depression, and multiple chronic conditions alleged that a male CNA attempted a sexual act during care and became agitated and combative. An LPN assessed the resident and noted increased delusions, wrist discomfort, and a report from the resident’s son about similar behavior with UTIs, but did not document the resident’s specific statements, gestures, or emotional status. A social worker designee and HR staff also interviewed the resident, who described a man by name and clothing and complained of wrist pain, and the social worker designee reported multiple follow-up visits to assess emotional and cognitive status. However, there was no documentation in the medical record of the alleged sexual abuse incident, the detailed behaviors, or any social services follow-up, resulting in an incomplete and inaccurate record related to the abuse allegation.
Surveyors found that the facility failed to maintain complete and accurate medical records for three residents, including inconsistent documentation of a leg wound’s location by a WNP compared with nursing notes and orders, missing documentation of an annual dental visit and treatment that existed only in email despite a care plan citing dental risk, and hospice records that were not uploaded into the EMR but kept in email after the medical records position was eliminated and no policy addressed record completeness.
A resident with multiple chronic conditions was hospitalized after a fall, yet an LPN documented over several days that the resident remained in the facility, had no change in condition, was receiving skilled PT/OT/speech therapy, and had comprehensive assessments completed. The notes also stated the resident reported generalized pain and was given PRN Percocet. Review of the MAR and narcotic count sheets showed no Percocet was administered during that time, and interviews confirmed the resident was in the hospital when these entries were made. Facility policy required objective, complete, and accurate documentation, which was not met.
The facility failed to maintain accurate and consistent medical records and treatment documentation for three residents. For a newly admitted resident, no medical diagnoses were entered into the record, medication orders, or care plan at the time of review. For a resident with a prior hip fracture, physician orders for nonskid strips in front of the commode and visual reminders to use the call light remained active, and staff signed treatment sheets twice daily as if these interventions were in place, even though the DON confirmed the strips and signage had been removed when the resident stopped using the bathroom. For another resident with multiple chronic conditions and a Stage II ankle pressure ulcer, there were two conflicting active physician orders for the same ankle area—one to pad and protect a healed ulcer and another for cleansing and duoderm application—and the DON verified that one of these orders did not appear on the treatment sheet for staff documentation.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely medical records for multiple residents, as required by regulation. For one resident with acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia, the care plan identified a risk for fall-related injury. A nursing note documented that the resident went to the hospital on a specific evening but did not include any additional information. An electronic change-in-condition assessment for that date was opened but left blank, and the fall investigation was opened but not signed until weeks later. The DON stated that the paper fall investigation used for QAPI was not considered part of the medical record. Another resident, admitted with dysphagia and developmental issues, had multiple missing entries in shower documentation over several weeks. The DON confirmed that shower documentation was missing on numerous identified dates. The same resident’s meal intake records also contained multiple gaps for specific meals and days, which the DON likewise confirmed as missing. The resident reported that she did receive her showers but that staff did not assist her with shaving, while the record did not consistently reflect the provision of showers or meal intake. A third resident with dementia, difficulty walking, and low back pain had bowel movement (BM) records showing no documented BM for a seven-day period and a separate five-day period. The resident had an active PRN order for Bisacodyl 10 mg suppository for constipation, in place since admission, but the MARs for the relevant months showed no administration of the medication during those intervals. An LPN confirmed the absence of documented BMs and the lack of recorded Bisacodyl administration, and later acknowledged that some BMs were not entered into the EMR. The resident’s daughter reported that the resident’s bowels moved regularly and that the family monitored this closely, expressing confidence that BMs occurred during the periods where none were documented. A fourth resident with chronic respiratory failure with hypoxia, COPD, asthma, chronic pulmonary edema, and a tracheostomy had physician orders for tracheostomy care and inner cannula cleaning every shift. Review of the treatment administration records for a given month revealed multiple shifts with missing nurse initials where tracheostomy care should have been documented. An RN confirmed that the TAR did not provide documented evidence that tracheostomy care was completed on those dates and explained that on those shifts a medication technician was assigned to the hall, and a nurse from another hall would have performed the care but failed to sign it. The facility’s “Documentation Expectations” policy required healthcare personnel to complete documentation in the medical record using accepted principles and for licensed nurses to audit documentation for completeness and accuracy, which was not met in these instances.
Plan Of Correction
1. On 5/6/26 Resident #9 was assessed by Director of Nursing and shows no ill effect related to the lack of documentation for tracheostomy care. On 5/6/26 Resident #12 was assessed by Director of Nursing and shows no ill effect related to going greater than 3 days with no bowel movement documented. On 4/15/26 Resident #76 received a shower by the STNA. On 5/6/26 the Director of Nursing reviewed Resident #76 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. Resident #86's fall investigation was completed on 4/28/26 the Interdisciplinary Team. A new intervention of a reaching device was implemented and placed on the resident's care plan. The reaching device was implemented on 3/25/26 by the licensed nurse. The care plan was updated on 4/9/26 by the Director of Nursing to include intervention of a reaching device. 2. Like Residents are identified as residents who utilize a tracheostomy. An audit will be completed by the Director of Nursing or designee utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure tracheostomy care is documented in the medical record. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who go greater than 3 days with no bowel movement documented in the medical record. An audit will be completed by the Director of Nursing or designee utilizing the Change in Condition Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure appropriate documentation is completed when a resident goes greater than 3 days with no bowel movement. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who need assistance with showering. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers completed and documented in the medical record. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls for the past 30 days will be completed by the Director of Nursing or designee to ensure fall documentation is entered into the residents' medical record post fall. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Tracheostomy tube cannula and stoma care policy to include documenting the procedure. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on Notification of Change Policy to include follow up documentation related to a resident with no bowel movement documented within 3 days. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include documentation of bathing. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Food Acceptance Policy to include documenting meal intake in POC. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include fall documentation entered into the residents' medical record post fall. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of residents with tracheostomies to ensure tracheostomy care is documented in the medical record. This audit will be completed for all residents who have a tracheostomy weekly for 4 weeks, beginning 5/14/26 to ensure tracheostomy care is documented in the medical record. Noncompliance noted during audits will be corrected with tracheostomy care documented in the medical record. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Change in Condition Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of residents with no bowel movement documented for greater than 3 days to ensure appropriate documentation is completed. This audit will be completed for 4-6 residents weekly for 4 weeks, beginning 5/14/26 to ensure appropriate documentation is completed when a resident goes greater than 3 days with no bowel movement. Noncompliance noted during the audits will be corrected with appropriate documentation completed. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of resident showers to ensure that showers are completed and documented in the medical record. This audit will be completed for 4-6 residents weekly for 4 weeks, beginning 5/14/26 to ensure that showers completed and documented in the medical record. Noncompliance noted during audits will be corrected with showers completed and documented in the medical record. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of residents experiencing a fall within the last 7 days ensure fall documentation is entered into the residents' medical record post fall. This will be completed weekly for 4 weeks, beginning 5/14/26 to ensure fall documentation is entered into the residents' medical record post fall. Noncompliance noted from the audits will be corrected with documentation entered into the residents' medical record post fall. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Untimely Documentation of Resident Fall Incident in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall incident in the medical record in a timely manner, in accordance with accepted professional standards. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and cerebrovascular accident. According to the medical record, a progress note was entered as a late entry on 02/20/26 at 8:21 A.M., stating that the resident had suffered a fall in his room on 02/19/26 at 8:00 P.M. There was no evidence of any documentation of the fall incident entered in the medical record at the time of, or shortly after, the fall on 02/19/26 at 8:00 P.M. During an interview on 03/30/26 at 12:05 P.M., two RNs confirmed that the fall incident was not documented until the following morning and stated that fall incidents should be entered in the medical record as soon as possible following the event. This lack of timely documentation of the fall incident constituted non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Failure to Accurately Document Resident’s Allegation of Sexual Abuse and Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with severe cognitive impairment and multiple medical diagnoses, including stroke, dementia, depression, lung disease, and hypertension. The resident required extensive assistance of two staff for bed mobility, transfers, and ambulation, and had documented severe depression and a history of altered mood/behaviors with delusional thinking and yelling out. Despite this, the medical record contained no documentation of events related to an allegation of staff-to-resident sexual abuse that occurred on a specific date. On the morning of the alleged incident, a CNA reported to an LPN that the resident was combative when being assisted off a bedpan. When the LPN assessed the resident, the resident was very agitated and reported that a man tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas. The LPN acknowledged that not everything the resident said made sense but recognized the need to report the concern and informed the social worker designee. The LPN later entered a note in the medical record describing the resident as having increased delusions and false beliefs, with discomfort to the left wrist after becoming combative, and that the son stated the resident behaves this way with a UTI. However, the LPN did not document the resident’s specific statements, gestures, or emotional status from that assessment. The social worker designee reported being notified of the allegation that morning and, along with the human resources director, interviewed the resident, who was upset and yelling about a man trying to put his “thing” in her mouth, and identified a man by name and clothing description that matched the CNA. The social worker designee also noted the resident complained of right wrist pain and stated she had multiple follow-up contacts with the resident to assess emotional and cognitive status and to check in. Despite these interactions, the social worker designee confirmed that she did not document the resident’s behaviors, allegations, or any follow-up visits or psychosocial assessments in the medical record. The ADON verified that there was no documentation in the medical record of the incident, the nature of the delusions, or what led to the resident becoming combative, and that social services had made no entries for the resident during the period in question, resulting in an incomplete and inaccurate medical record related to the abuse allegation.
Plan Of Correction
The facility will continue to maintain accurate resident medical records. Resident #171 continues to reside at the facility and seen by CNP on 3/12/26 with no noted injuries or negative effects. Psych nurse practitioner assessed residents #171 on 3/19/26 with no changes noted to psychosocial wellbeing. Resident #171 denied any complaints and appeared calm and relaxed stating to the NP that she feels safe. Further SSD follow up was conducted on 3/27/26 with resident #171, no negative findings noted. On 4/8/26, Resident #171 care plan was reviewed by the IDT team on 4/8/26. On 3/18/2026, care conference was completed with son and Administrator reviewing allegation of sexual abuse discussing everything done throughout investigation. Son voiced understanding and was appreciative of the thoroughness of reviewing the matter. On 4/9/26, care conference was conducted with son and IDT team reviewing resident's medical record. Son voiced understand and had no concerns at this time. An initial audit was conducted, by the Regional LISW-S, of the last 30 days ensuring SSD has proper follow up and documentation in medical record for changes in condition related to mood and behavior. Initial audit was completed on 3/30/26. The DON reviewed the facilities change in condition policy with SSD on 3/27/26. The Regional LISW-S, reviewed Facility expectations for support of a resident with a change in condition and documentation requirements to ensure the psychosocial well-being of residents. Reeducation for facility SSD was completed on 3/31/26. The regional Clinician conducted an Audit of last 3 months of incidents and progress notes ensuring proper documentation is noted in resident's medical record related to incidents. Initial audit was completed on 4/6/26. No negative findings noted. On 4/6/26, the Administrator, Nurse Management team, and SSD were reeducated on the facility procedures for maintaining an accurate and complete record related to allegations of abuse, accidents and incidents and current changes in mood and behavior by the Regional Clinician. A QA committee meeting was held on 4/8/26 reviewing survey results and findings, investigation and medical record documentation requirements, policy and procedures for abuse prevention and reporting abuse, SS policy and procedure, and facilities change in condition policy and procedure. Weekly for 2 weeks, or as directed by the QA committee, the Regional Clinician or designee will audit facility incidents and accidents and allegations of abuse, ensuring accuracy in the medial record. Negative findings will be corrected immediately and reported to the QA committee for review. Weekly for 2 weeks, or as directed by the QA committee, audits will be conducted by the Regional LISW-S. Negative findings will be corrected by reeducation and providing immediate support to residents. Negative findings will be reported to the QA committee for review. The Regional Administrator will ensure the completion of the audits. The Administrator is responsible for the ongoing compliance.
Incomplete and Inaccurate Medical Records for Wound, Dental, and Hospice Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for multiple residents. For one resident with severe cognitive impairment, multiple chronic conditions, and a documented skin tear to the left outer/lateral leg, the care plan and weekly non‑pressure skin grids consistently identified the wound on the left leg with specific measurements and drainage descriptions. However, a series of weekly Wound Nurse Practitioner progress notes from December through March inaccurately documented the wound as being on the right lateral leg, despite physician orders and nursing staff confirming the wound was on the left lower leg. An LPN verified during interview that the WNP documentation did not accurately reflect the actual wound location being treated. For another resident with multiple chronic diagnoses and no documented cognitive deficit, the comprehensive and quarterly MDS assessments indicated no issues with teeth, mouth or facial pain, or chewing difficulty. The care plan later identified the resident as being at risk for dental or chewing problems related to poor dental hygiene and included interventions such as arranging periodic dental consults and follow‑up dental visits. The medical record showed a refusal of dental services on one date and no documented evidence of a dental visit since admission. However, the facility’s contracted dental assistant had in fact seen the resident for an annual visit, performed a cleaning, and applied silver diamine fluoride to several teeth, with follow‑up dependent on insurance. During interview, the social worker acknowledged that this dental progress note was not in the resident’s medical record and was likely only available in email. A third resident, admitted with cerebral infarction and asthma and later enrolled in hospice, also had incomplete documentation in the medical record. Hospice documentation for this resident was not uploaded into the resident’s medical record and was instead maintained in email, as confirmed by facility staff. Further interview revealed that the medical records position had been eliminated, resulting in resident documents remaining in email and not being incorporated into the official medical record. Staff also confirmed that there was no medical records policy addressing the completeness of medical records, contributing to the absence of required hospice and dental documentation and the inaccurate wound location documentation in the residents’ charts.
Inaccurate Documentation on Hospitalized Resident’s Condition and PRN Narcotic Use
Penalty
Summary
Facility staff failed to maintain accurate and complete medical record documentation for one resident during a hospitalization period. The resident, admitted with diagnoses including Parkinson's disease, Lewy Body dementia, diabetes mellitus, and congestive heart failure, had an MDS indicating intact cognition. Nursing progress notes showed the resident was transferred to a local hospital following an overnight fall and returned to the facility via stretcher several days later. Despite this, Skilled Progress Notes completed by an LPN on three consecutive days during the hospitalization documented that the resident had no change in condition, no cognitive impairment, and was receiving skilled PT, OT, and speech therapy services. These notes also described assessments of neurological/musculoskeletal, skin, cardiac/respiratory, gastrointestinal/genitourinary status, and monitoring for medication side effects, all indicating no new or negative findings. The same Skilled Progress Notes further documented that the resident complained of generalized pain and that PRN Percocet was administered as ordered. However, review of the narcotic count sheets and the MAR for the month showed no Percocet was administered during the period in question. Interviews with the LPN who authored the notes and another LPN confirmed that the resident was hospitalized and not in the facility on the dates when these assessments and medication administrations were charted, and they could not explain why documentation was completed on an absent resident. The Administrator verified there were no discrepancies in the narcotic count sheets. Facility policy on charting and documentation required that medical record entries be objective, complete, and accurate, and made only by licensed personnel in accordance with state law and facility policy, which was not followed in this instance.
Failure to Maintain Accurate and Consistent Medical Records and Treatment Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents. For one newly admitted resident, the medical record contained no listed medical diagnoses under the diagnoses category, with the medication orders, or in the care plan at the time of review. The DON confirmed that the resident’s diagnoses were not entered at admission and were only added six days later. For another resident with a history of a fall and left femur fracture, physician orders included nonskid strips on the bathroom floor in front of the commode every shift and visual reminders in the bathroom to use the call light for assistance with transfers twice a day. March and April 2026 treatment sheets showed staff signing off twice daily that these interventions were in place. However, the DON verified that this resident did not have fall strips in front of the toilet or a sign as a reminder to call for assistance, and that the facility had removed these interventions from the plan of care after the resident returned from the hospital and was no longer using the bathroom. The DON acknowledged that the corresponding physician orders were not discontinued and that nursing staff continued to document completion of treatments that were not actually in place. For another resident admitted with multiple diagnoses including cerebral infarction, protein calorie malnutrition, adjustment disorder with anxiety, anorexia, GERD, constipation, glaucoma, vascular disease, history of falling, muscle weakness, and difficulty walking, the record showed an in-house Stage II pressure ulcer to the left outer ankle. Active physician orders included one to pad and protect a healed left lateral ankle pressure ulcer twice weekly and as needed, and another to cleanse the left outer ankle and apply duoderm on specified days. The DON confirmed there were two contradicting active orders and that the pad and protect order was present in the physician orders but did not appear on the treatment sheet for staff to sign off.
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