F0842

E

Failure to Maintain and Retain Required Resident Medical Records and Incident Documentation

Mesa, Arizona Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and readily accessible medical records and related documentation for multiple residents, as required by professional standards and the facility’s own record retention policies. During the survey, records dated prior to March 1, 2025 were largely unavailable in the electronic health record (EHR) system, despite evidence from State Authority (S.A.) MDS submissions that numerous residents had been admitted and resided in the facility before that date. Surveyors requested care plans, nursing progress notes, five‑day investigation reports, and other clinical documentation for sampled residents, but the facility repeatedly stated it was not in possession of these records.

For several residents involved in alleged incidents or complaints, including resident‑to‑resident altercations, falls, and alleged misappropriation of funds, the facility could not produce contemporaneous care plans, nursing progress notes, incident reports, or five‑day investigative reports. Examples included a resident‑to‑resident altercation where one resident’s earliest care plan and nursing notes in the EHR began approximately a year after the reported event, and another resident involved in the same altercation had no clinical record in the EHR at all. In other cases, residents with documented admissions in the S.A. MDS had no EHR record, no care plans, and no nursing progress notes corresponding to the timeframes of reported incidents or allegations. The facility also reported that it did not possess grievance logs for entire prior years and for early months of a subsequent year, despite a record request for those periods.

Additional discrepancies were identified when the facility asserted that certain residents had never resided there, while iQIES data and MDS submissions showed those residents had been admitted with various diagnoses and documented BIMS scores. For multiple such residents, there was no evidence of any medical record in the facility’s EHR. Interviews with the Medical Records Supervisor and the Administrator confirmed that there were no medical records available for residents admitted and discharged prior to March 1, 2025, and that some records for current residents admitted before that date might also be missing. They acknowledged that incident reports and five‑day investigations prior to the ownership change were not available, and that they had no access to paper records from the previous owner. Facility policies reviewed by surveyors required maintaining resident medical records for 10 years and investigations for 5 years, and required documentation to provide a complete account of residents’ care, treatment, and progress, which was not met in these cases.

The deficiency also encompassed the facility’s inability to provide complete MDS, care plans, and progress notes for specific timeframes related to allegations of resident‑to‑resident aggression, falls, and financial misappropriation. For example, for a resident who reported being attacked by another resident, the earliest MDS and care plan on record did not cover the period of the alleged event, and requested progress notes and care plans for the months surrounding the allegation were not available. For another resident with an alleged misappropriation of benefit funds, no records could be located in the EHR, and the facility stated it did not possess information for incidents occurring before March 1, 2025. Across these cases, the survey findings consistently showed that required clinical and investigative documentation was missing or incomplete for residents whose presence and clinical status at the facility were documented in federal assessment systems, demonstrating a systemic failure to retain and maintain medical records and related documents in accordance with policy and accepted standards.

Interviews further clarified that the lack of records was linked to a change of ownership on March 1, 2025, after which the new Administrator reported having no access to prior physical records, including medical records, incident reports, and five‑day investigations. The Medical Records Supervisor, who assumed her role months after the ownership change, stated she had no knowledge of what the previous owners had done with the paper records and confirmed that no paper copies of incident reports or five‑day investigations for alleged incidents were available. Both staff members acknowledged that the expectation was to maintain resident medical records for 10 years and investigations for 5 years, and that upon transfer of ownership, the facility should have had access to all resident records within the required retention timeframe. Despite these expectations and written policies, the facility did not have the historical records necessary to provide a complete account of residents’ care and prior incidents.

The surveyors’ review of facility policies titled “Documentation and Charting” and “Record Retention Schedule” showed that the facility’s own standards required a complete account of residents’ care, treatment, response, signs and symptoms, and progress, and mandated retention of resident medical records for 10 years and investigations for 5 years. The absence of records for numerous residents, including those with documented admissions and MDS assessments, and the lack of incident reports, five‑day investigations, and grievance logs for multiple years, directly conflicted with these policies. The facility’s inability to produce these records during the survey, despite multiple requests and the presence of corresponding data in iQIES and S.A. MDS, formed the basis of the cited deficiency for failure to safeguard and maintain complete medical records in accordance with accepted professional standards.

The Administrator and Medical Records Supervisor both acknowledged during interviews that the facility did not have medical records for residents admitted and discharged prior to the ownership change, and that some records for current residents admitted before that date were also missing. They also confirmed that incident reports and five‑day investigations prior to the change of ownership were not available, and that they could not reach the previous owners, who had relocated to another country. These statements, combined with the documented absence of records in the EHR and the facility’s written responses to record requests, demonstrated that the facility lacked the required historical documentation for a significant number of residents and events, leading to the cited deficiency.

The survey findings also highlighted that, despite the facility’s dispute of the citation, the objective evidence from iQIES and S.A. MDS data showed that residents for whom the facility claimed no records or no residency had, in fact, been admitted and assessed at the facility. The lack of corresponding medical records, care plans, nursing notes, incident reports, five‑day investigations, and grievance logs for these residents and timeframes was inconsistent with both regulatory expectations and the facility’s own policies. This systemic absence of historical resident documentation and investigative records formed the core of the deficiency related to safeguarding and maintaining resident‑identifiable information and medical records.

Overall, the deficiency was based on the facility’s failure to ensure the presence of complete and readily accessible medical records for a large portion of the sampled residents, including those involved in reported incidents and complaints, and its failure to retain required records such as incident reports, five‑day investigations, and grievance logs for the mandated retention periods. The surveyors’ observations, record reviews, and staff interviews collectively demonstrated that the facility did not have the necessary historical documentation to meet accepted professional standards for medical record maintenance and retention.