F0842

E

Incomplete MAR and TAR Documentation for Multiple Residents

Corry, Pennsylvania Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical records, specifically MARs and TARs, for multiple residents as required by facility policy and professional standards. The facility’s medication administration policy dated 12/2/25 states that the individual who administers a medication must record it on the MAR directly after administration, review the MAR at the end of each pass, and never leave duty without documenting all administered medications. Despite this, surveyors found numerous missing entries for ordered medications and treatments across several residents’ records. The DON confirmed that the clinical records for the affected residents were incomplete regarding treatment and medication documentation.

For one resident with dementia, osteoarthritis, and hypertension, there was a physician’s order for Dakins solution wound care to the coccyx every shift, including cleansing, packing, and dressing changes twice daily and as needed. Review of this resident’s TAR from 12/11/25 to 2/3/26 showed 16 missing documentation entries out of 109 opportunities for the ordered wound treatment. Another resident with A-fib, PVD, and pain had an order for Triad Hydrophilic Wound Dressing to the buttocks every shift for wound healing, but the TAR from 1/2/26 to 2/3/26 lacked documentation for seven of 65 opportunities. The DON acknowledged that these treatment records were incomplete.

A resident with COPD, bipolar disorder, and diabetes had extensive medication and treatment orders, including oxygen as needed, pulse oximetry every shift, multiple psychotropic and cardiac medications, insulin (Novolog and Toujeo), inhalers, diuretics, seizure medications, pain monitoring, oxygen maintenance, skin care, bruising/bleeding monitoring, compression stockings, head-of-bed elevation, and a pressure-reducing cushion. Review of this resident’s MAR from 12/1/25 to 2/3/26 revealed numerous blank entries: missing documentation for Gabapentin, Metoprolol, Toujeo, Anoro Ellipta, Atorvastatin, Nortriptyline, Risperdal, Lasix, oxygen use, Levetiracetam, chin tuck maneuver, pulse oximetry, pain monitoring, Novolog, and Baclofen. The TAR for the same period also had multiple blanks for oxygen maintenance, application of Gold Bond lotion, monitoring for bruising/bleeding, compression stockings, elevating the head of bed, and use of a pressure-reducing cushion.

Another resident with epilepsy, Down syndrome, and hypothyroidism had numerous physician orders for catheter-related care, skin protection, pain monitoring, intake and output, wound care products, and multiple daily medications including Aricept, Flomax, Trazodone, Baclofen, Lamictal, Memantine, Zonisamide, Tylenol, Renacidin irrigation, Nystatin-Triamcinolone, artificial tears, Levothyroxine, and a one-time Ceftriaxone injection. Review of this resident’s MAR from 12/1/25 to 2/3/26 showed missing documentation for the Ceftriaxone dose, several doses of Levothyroxine, Aricept, Flomax, Trazodone, Baclofen, Lamictal, Memantine, Zonisamide, artificial tears, pain monitoring, and Tylenol. The TAR review showed missing entries for cleansing a skin tear, Triad paste, skin prep to foot blisters, Renacidin irrigation, Phytoplex ointment, catheter care, bleeding monitoring, Nystatin-Triamcinolone, pressure-reducing cushion, catheter securement, privacy bag, intake and output, and maintaining the Foley catheter to gravity.

A further resident with COPD, diabetes, and A-fib had complex orders related to respiratory care, tracheostomy care, enteral feeding, pain monitoring, multiple oral and inhaled medications, catheter care, skin protection, and IV therapy. Orders included weekly changes of oxygen and nebulizer tubing and trach mask, oxygen saturation checks every four hours, trach care twice daily, pain monitoring, enteral feeding equipment changes, Trazodone, Apixaban, Bactroban to the tube site, water flushes before and after medications, continuous Diabetasource AC at specified rates, Clonazepam, Docusate, nasal saline spray, documentation of total enteral intake and flushes, Baclofen, Metoprolol, Nexium, catheter care, pressure-relieving devices, privacy bag, head-of-bed elevation, gastric residual checks, Acetylcysteine inhalation, zinc oxide to coccyx/buttocks, skin prep to toes, Piperacillin IV, saline IV flushes, midline dressing changes, and infection monitoring. From 12/1/25 to 2/3/26, the MAR showed multiple blank entries for Piperacillin, IV flushes, enteral syringe and bag changes, Trazodone, Nexium, Diabetasource at both 50 cc/hr and 60 cc/hr, Bactroban, Apixaban, Clonazepam, Docusate, nasal spray, Baclofen, Metoprolol, pain monitoring, gastric residual checks, water flushes, Acetylcysteine, and documentation of total enteral intake and flushes. The TAR showed missing documentation for midline dressing changes, weekly oxygen/nebulizer/trach tubing changes, infection site monitoring, pressure-reducing devices, skin prep to toes, trach care, privacy bag, head-of-bed elevation, catheter care, bruising/bleeding monitoring, oxygen at 5L, zinc oxide application, maintaining Foley drainage to gravity, triple antibiotic to tube site, and oxygen saturation checks. The DON confirmed that the MARs and TARs for this resident and others were incomplete.