Failure to Document Resident Incident in Clinical Record
Penalty
Fine: $12,735
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 complete documentation in the clinical record for one resident following an incident. According to the facility's Incident and Accidents Documentation policy, all unusual occurrences, including actual, alleged, or suspected abuse, must be documented. On August 24, 2025, an incident involving a resident occurred in the front lobby during a family visit. Staff confirmed during interviews that there was no documentation of this incident in the resident's clinical record, despite the policy requirements. This lack of documentation was verified by both the Administrator and the weekend supervisor.