Incomplete Medical Record: Missing Diagnoses on Resident Facesheet
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate and complete medical records for one resident, as evidenced by the absence of a list of diagnoses on the resident's facesheet. Record review showed that the facesheet, dated 04/17/2025, did not include any diagnoses for the resident who had recently been admitted. During an interview, the DON explained that the admitting nurse was typically responsible for entering diagnoses, with oversight from the ADONs or DON, but this process was interrupted due to the commencement of the survey. The DON acknowledged that her expectation was for resident records to be complete, accurate, and updated in a timely manner to ensure resident needs could be addressed.