F0842

E

Incomplete Documentation of ADL Care and Turning/Repositioning

New Wilmington, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation for multiple residents regarding personal hygiene, oral care, toileting, dressing, and, for one resident, turning and repositioning. Facility policy titled "Flow of Care" dated 3/27/25 requires that targeted care needs be documented on Care Tracker/Point of Care/ADL flow records. For one resident admitted on 12/12/25 with diagnoses including a left femur neck fracture, COPD, and hypertension, review of the tasks section for December 2025 showed missing documentation on multiple dates for oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing. The same resident had a physician’s order dated 12/14/25 for turning and repositioning every two hours, but the clinical record lacked evidence that this turning and repositioning was completed as ordered.

Two additional residents also had incomplete documentation of ADL care. One resident admitted on 11/15/25 with heart failure, hypertension, and a need for assistance with personal care had numerous days in December 2025 with no documented evidence that oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing were completed. Another resident admitted on 11/26/25 with anxiety, respiratory failure, and hypertension similarly had multiple dates in December 2025 without documentation of these same ADL tasks. In an interview on 1/23/26 at 10:15 a.m., the Nursing Home Administrator and the Director of Nursing confirmed that the clinical records for these three residents did not contain complete documentation for turning and repositioning, personal hygiene, oral hygiene, toileting, and dressing, and acknowledged that such care should be documented in the clinical record after completion.