Failure to Maintain and Retain Required Resident Medical Records and Incident Documentation
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete and inaccurate medication orders were found for two residents after record review and staff interviews. One resident’s Toujeo insulin glargine order listed conflicting clinical indications, with staff stating the order had been mistyped, and another resident’s hydroxyzine HCl PRN anxiety order omitted the dose even though the resident had previously been receiving 25 mg tablets.
Missing discharge and transfer orders in resident records: The DON confirmed that discharge or transfer orders were not obtained or documented for multiple residents. One resident was discharged back to an ALF in stable condition after insulin instructions were reviewed, another had a note stating the MD ordered hospital transfer but the order was not completed in the record, and a third had respiratory distress and altered mental status with an MD order to send to the ER, but no transfer order was found. The facility policy required a physician order for emergency transfer or discharge.
Incomplete death documentation: A resident’s record lacked progress notes and an incident report describing what occurred when the resident passed away in the facility. Although the chart included the POLST, death record, MDS, and an encounter note stating CPR was started and 911 was called, facility leaders verified there were no documents covering the morning of the death.
A resident with depression, chronic pain, and COPD had an order for PRN oxycodone 10 mg. The medication was signed out on the narcotic accountability record multiple times, but there was no matching MAR documentation. The LVNs stated they administered the doses but failed to chart them on the MAR due to human error, and the DON confirmed the documentation was incomplete.
Incomplete Documentation of Care Conference Participation: The facility failed to accurately document whether two residents or their responsible parties were informed of, attended, or declined quarterly care plan conferences. One resident had COPD, seizures, dysphagia, hypotension, and cognitive impairment, while the other had AFib, HF, HTN, hypothyroidism, hyperlipidemia, dementia, and depression. Care conference forms showed staff attendance, but the sections for resident or RP participation were left blank, and an LVN acknowledged she did not document the invitations or attendance status in the EMR.
Incomplete Documentation of Chronic Scalp Wound: A resident with a chronic scalp lesion/wound had inconsistent and incomplete skin/wound documentation in the EMR. Weekly skin assessments sometimes omitted the lesion entirely, and when it was documented, key details such as size, shape, color, and drainage were missing. The record also lacked documentation of a comprehensive assessment after maggots were found and removed from the wound, and staff acknowledged the chart did not provide a complete picture of the wound status or care provided.
Incomplete and inaccurate medication orders in resident records
Penalty
Summary
The facility failed to ensure a physician order was clarified for its clinical indication and medication dosage, resulting in inaccurate documentation in the resident medical record. The deficiency was identified through record review and staff interviews and involved 2 of 2 residents reviewed. The facility’s documentation policy stated that the resident medical record should be accurate, objective, and clinically relevant. One resident was admitted and readmitted with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. A physician order listed Toujeo SoloStar insulin glargine 300 units/ml as 120 units subcutaneously one time a day related to morbid obesity with alveolar hypoventilation, and also listed Toujeo SoloStar insulin glargine 300 units/ml as 120 units subcutaneously at bedtime related to type 2 diabetes. During interview, the CRN stated the evening dose was for diabetes and the morning dose was for obesity, then later stated the insulin glargine order should have been for diabetes and not obesity and had been mistyped by the nurse. Another resident was admitted and readmitted with diagnoses including quadriplegia, depression, and anxiety disorder. That resident’s MAR showed an order for hydroxyzine HCl every 8 hours as needed for anxiety, but the order did not include a dose. The CNO confirmed the dose was missing and stated the resident had previously been receiving hydroxyzine 25 mg tablets and the person entering the order did not catch the 25 mg.
Missing discharge and transfer orders in resident records
Penalty
Summary
The facility failed to ensure that discharge or transfer orders were present in the medical records for 3 of 4 residents reviewed for discharge. Resident #120 was admitted with diagnoses including type I diabetes mellitus with hyperglycemia, gastroparesis, schizophrenia, depression, hypothyroidism, dysphagia, anemia, hypertension, cognitive communication deficit, and long-term insulin use. A health status note documented that the resident was discharged back to an ALF in stable condition, with discharge instructions provided and explained, insulin administration reviewed, and transportation arranged by facility staff; however, the DON stated that no discharge orders were obtained. Resident #3 was admitted with diagnoses including hyperkalemia, gastrostomy care, hypertensive chronic kidney disease, acute kidney failure, type 2 diabetes mellitus with diabetic chronic kidney disease, COPD, atherosclerotic heart disease, anemia in chronic kidney disease, and muscle weakness. A progress note stated that the MD reviewed labs and ordered the resident sent to the hospital, but the record did not contain the completed order, and the DON stated the paperwork had been completed for discharge but no physician order was written. Resident #118 was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, hypertensive heart disease with heart failure, dysphagia following CVA, and muscle weakness; a progress note documented respiratory distress and altered mental status, with the MD notified and ordered the resident sent to the ER, but the physician orders did not show an order to transfer the resident from the facility to the hospital. The facility policy required a physician order for emergency transfer or discharge and for anticipated discharge to the community.
Incomplete Death Documentation
Penalty
Summary
The facility failed to maintain a complete, accurate, and readily accessible medical record for one resident, R29, related to the resident’s death in the facility. R29’s hospital discharge summary showed discharge to the nursing home in stable condition, and the POLST indicated attempt CPR. The death record listed the date of death, and the MDS assessment indicated death in facility, but the progress notes did not document the resident’s death or what occurred. The encounter note stated that a call was received that R29 had passed away that morning, CPR was started, and 911 was called. When the state agency requested the incident report and medical record items related to the day of death, the facility did not have an incident report or progress note documenting what occurred that morning. During interview, the administrator and VPS-A and VPS-B verified the facility did not have documents of what occurred the morning of R29’s death.
Incomplete Documentation of Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that Resident #1’s medical record was accurately documented and complete when controlled substance administration was signed out on the narcotic accountability record but not documented on the MAR. Resident #1 was admitted with diagnoses including depression, chronic pain, and COPD, and had a BIM'S score of 15 indicating intact cognition. The care plan included administering medications as ordered, and the June 2026 physician orders included Oxycodone 10 mg every 6 hours as needed for pain. Record review showed that Oxycodone 10 mg was signed out on the controlled substance administration log on 6/15/2026 at 4:30 AM, 10:30 AM, and 4:30 PM, but there was no corresponding documentation on the MAR for those administrations. During interview, the resident stated he was not 100% sure whether he received the medication at those times. The LVN staff assigned to those shifts stated they administered the Oxycodone as recorded on the controlled substance log but did not document it on the MAR due to human error, and the DON confirmed that nursing staff had not been recording controlled substances on the MAR after signing them out on the narcotic count record.
Incomplete Documentation of Care Conference Participation
Penalty
Summary
The facility failed to maintain medical records that were complete and accurately documented for 2 residents reviewed for documentation. For both residents, the electronic medical record did not show whether the resident or the responsible party had been informed of, attended, declined, or otherwise participated in the quarterly care conference meetings. The deficiency was identified through record review and interviews, and the Care Conference & DC Case Management Evaluation forms did not reflect resident or responsible party attendance status. Resident #9 was a female with diagnoses including COPD, seizures, dysphagia, hypotension, and major depressive disorder. Her MDS showed unclear speech, moderate cognitive impairment with a BIMS score of 8, wheelchair use, and varying levels of assistance with eating, dressing, transfers, bed mobility, and toileting. Her care plan included impaired cognitive function and psychosocial well-being focus areas with interventions to provide opportunities for the resident and family to participate in care. The care conference evaluations reviewed for this resident showed that conferences were held in person with staff attendance, but the section for resident or responsible party participation was not completed, and no evaluation was available for two of the expected quarterly conferences. Resident #24 was a female with diagnoses including atrial fibrillation, heart failure, hypertension, hypothyroidism, hyperlipidemia, dementia, and major depressive disorder. Her MDS showed intact cognition with a BIMS score of 15 and no vision, hearing, or communication deficits, along with dependence in several activities of daily living. Her care plan included falls, altered cardiovascular status, discharge planning, and activity involvement, with interventions involving the resident or family. The care conference evaluations reviewed for this resident showed in-person conferences attended by facility staff, but the form did not document whether the resident or responsible party attended, refused, or were invited and absent. During interview, the resident stated she was aware of care plan meetings but could not recall being invited every 90 days and said she chose not to attend because little changed. An LVN acknowledged she invited the resident and sent invitations to the responsible party but did not document that information in the EMR, and the DON stated the form was expected to be completed in its entirety.
Incomplete Documentation of Chronic Scalp Wound
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a chronic scalp lesion/wound. Weekly skin assessments from 6/2/25-6/29/25 and 11/2/25-11/16/25 contained no documentation of the resident’s scalp lesion/wound, while assessments from 7/6/25-9/28/25 and 12/14/25-6/14/26 documented the presence of the lesion/wound but did not include complete details such as size, shape, color, or drainage characteristics. The resident’s electronic medical record also showed no documentation that a comprehensive assessment of the chronic scalp lesion/wound was completed after maggots were identified and removed from the lesion/wound on 6/12/26. During interviews, staff stated that weekly skin assessments were completed, that nursing staff were expected to document skin and wound assessments, and that documentation should include at minimum a description of the skin concern, wound description or measurements, shape, color, drainage, and odor. Staff acknowledged the record did not contain all information needed to provide a complete picture of the resident’s wound status and related care provided.
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