Incomplete and Inaccurate Documentation After Abuse Allegation
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for one resident following an allegation of abuse. The resident, who had diagnoses including a right femur fracture, dementia, major depressive disorder, and anxiety disorder, and who was assessed as having severe cognitive impairment and dependence for ADLs, reported on 3/14/2026 that a CNA hit her on the head during a shower. RN 1 stated he performed a full body assessment at that time and identified a finger-length bluish discoloration/bruise on the resident’s left hip. However, this full body assessment and the bruise were not documented in the resident’s medical record or on the Change of Condition (COC) form; instead, the skin assessment was recorded on a separate paper form kept in the abuse investigation file. The COC form dated 3/14/2026 documented that the resident’s PCP was notified at 4:24 p.m. and included a PCP recommendation to monitor for pain and episodes of sadness/depression for 72 hours, but the form did not indicate that a full body assessment was completed or that any discoloration/bruise was present. In a later interview, RN 1 stated he had been unable to reach the PCP on that date and acknowledged that the PCP recommendation documented on the COC was incorrect and should not have been entered. The DON confirmed that if staff did not reach the PCP, the recommendation section should have been left blank and attempts to contact the PCP documented in progress notes, and also confirmed that the COC lacked documentation of the bruise found during the assessment. The facility’s policy on charting and documentation required that medical record documentation be objective, complete, and accurate, and that procedures and treatments include assessment data and unusual findings, as well as notification of the physician when indicated.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0842 Resident Records - Identifiable Information How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:Resident 2's medical record was immediately corrected on 03/27/2026 to reflect a complete and accurate clinical picture. A late entry was entered by the Licensed Nurse documenting the full body assessment completed on 03/14/2026, including the identified bruise/discoloration to the left hip. The Change in Condition (COC) documentation was corrected to remove the inaccurate "PCP recommendation," and a clarification note was entered indicating that the physician was not reached at the time of the incident. The attending physician was notified on 03/26/2026, and appropriate clinical follow-up was completed. Staff involved (RN 1) received immediate re-education by the Director of Nursing on 3/26/2026 regarding accurate, complete, and non-speculative documentation per facility policy "Charting and Documentation". No adverse outcome to the resident was identified. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.A 12-day look-back audit was conducted by Medical Records Supervisor from 03/14/2026 through 03/26/2026 for residents with documented Change in Condition (COC), skin assessments, or incident reports. The audit focused on completeness of documentation, and validation of physician communication. No additional residents were found to have inaccurate physician recommendations documented without verification. Licensed nurses were re-educated on requirements by the Director of Staff Developer (DSD) on 3/27/2026 emphasizing that all clinical findings must be documented in the medical record. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur.The facility reinforced the standardized EMR documentation review for Change in Condition (COC) events requiring completion of a full body assessment, inclusion of all skin findings, and verification of physician communication prior to documenting any recommendations.The abuse investigation workflow was reenforced to ensure that clinical findings are integrated into the medical record to support continuity of care and regulatory compliance. Licensed nurses were re-educated by the DSD ON 03/27/2026 on documentation standards, including accuracy, completeness, and prohibition of speculative entries, as well as confidentiality requirements. These system changes were implemented to ensure medical records remain complete, accurate, and readily accessible, and to prevent recurrence of the deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained.To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program.The facility will reinforce the structured monitoring system to ensure sustained compliance. A weekly audit by the Medical Records Supervisor of randomly selected residents with Change in Condition documentation will be conducted for four consecutive weeks focusing on completeness, accuracy, and verified physician communication. Following this period, audits will be conducted monthly for three months. Audit results will be reviewed by the Director of Nursing and reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Any identified discrepancies will result in immediate corrective action, including re-education and documentation correction. If no trends or repeat deficiencies are identified after three months, the issue will be considered resolved and removed from active QAPI monitoring. If trends are identified, the audit frequency will be increased and additional interventions implemented. The facility will evaluate the effectiveness of corrective actions through ongoing compliance rates. Dates when corrective action will be completed. 4/17/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to keep complete and accurately documented clinical records for two residents. One resident had conflicting MD/NP notification orders for elevated blood glucose, with one order to notify for BS >250 and another sliding-scale insulin order directing a call if BS was >400. Another resident’s facesheet omitted insomnia and anxiety diagnoses even though the care plan and psych services note documented those conditions; the DON confirmed outside-provider diagnoses should have been included in the record and facesheet.
A resident receiving PT had multiple scheduled therapy sessions with no documentation in the service log matrix. The resident said therapy had been inconsistent, and the DON of Therapy acknowledged missed sessions without recorded reasons, stating the therapist should have documented why the sessions were not completed. The resident later said he had missed therapy when he was not feeling well and that the therapist had been sick once.
Failure to Document Ordered Skin Treatments: The facility failed to accurately document ordered skin treatments for a resident with a great toe condition. The MAR and TAR did not show the ordered Epsom salt soaks or triple antibiotic ointment, even though the DON, an LPN, the wound care nurse, and the resident stated the treatments were provided. Facility policy required all medications administered to be documented on the MAR immediately after administration.
Inaccurate Face Sheet Diagnosis Documentation: A resident’s face sheet failed to list pain as a diagnosis even though the H&P, care plan, and physician orders all reflected ongoing pain management, including scheduled morphine. The resident reported chronic pain from an old military back injury, and the MDS nurse acknowledged the diagnosis had not been entered on the face sheet and that diagnoses had not yet been audited against the H&P.
Incomplete influenza vaccination records were found for two residents. The EMR had no evidence that either resident was offered, received, or declined the 2025 influenza vaccine. Interviews showed an RN who had been assigned resident vaccination responsibilities destroyed the vaccine consents/records, and the HIM confirmed the influenza information was not entered into the EMR.
Incomplete documentation of elevated heart rate and medication administration. A resident with cerebral infarction, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm, but the record did not show a reassessment or any documentation of symptoms later that day. The MAR also showed evening meds as not given because the resident had died, while an RN stated the meds were actually given earlier and the DON confirmed the record did not match the nurse’s statement.
Incomplete Clinical Records and Missing Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 residents reviewed. For one resident with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, the clinical record contained conflicting blood glucose notification orders: one order directed staff to notify the MD/NP if blood sugar was less than 90 or greater than 250, while another order for sliding-scale insulin stated to give 10 units if blood sugar was greater than 400 and call the MD. The resident also had a BIMS score of 6, indicating severe cognitive impairment, and the care plan identified diabetes mellitus. For another resident with vascular dementia, cerebral infarction, and paranoid personality disorder, the facesheet did not include diagnoses of insomnia and anxiety. The resident’s care plan stated the resident used anti-anxiety medications due to anxiety disorder, and a psychological services progress note listed diagnoses of primary insomnia and anxiety disorder. The DON confirmed that the diagnoses from outside providers should have been included in the facility clinical record and on the facesheet, and also confirmed that the facesheet was used to communicate the resident’s status to hospitals and other outside providers.
Missing Documentation for Scheduled Therapy Sessions
Penalty
Summary
The facility failed to document therapy sessions for one resident receiving rehabilitation services. The resident stated during interview that he wanted to know whether he would have therapy that day and reported that the physical therapist had been on vacation and that he had not received therapy in weeks. Review of the physician order showed a PT recertification order for treatment every day, one time per week for 60 days, including therapeutic exercise, therapeutic activity, gait training, and caregiver education for diagnosis R53. The resident’s service log matrix showed no documentation for therapy visits on 4/14/2026, 4/28/2026, and 5/19/2026. During interviews, the Director of Therapy acknowledged that the resident missed the listed dates and stated there was no documentation explaining why the sessions were not completed. The Director of Therapy said the resident was on the assignment board for functional maintenance and that, for whatever reason, if the resident refused or was not feeling well, it was not documented. The Director also stated the therapist was in Thailand and could not communicate about what happened, and that the therapist should have documented the reasons the therapy sessions were not completed. The resident later stated he had missed therapy once or twice because he was not feeling well and that his therapist had been sick once, with someone else sent in that time. The facility policy required resident care documentation to be maintained in a complete, timely, and orderly fashion.
Failure to Document Ordered Skin Treatments
Penalty
Summary
The facility failed to accurately document treatments ordered for Resident #112, who had a physician order dated 4/6/2026 for daily Epsom salt soaks for 14 days and application of triple antibiotic ointment to the great toe. Review of the resident’s Medication Administration Record and Treatment Administration Record for April 2026 did not show documentation of either the Epsom salt soaks or the triple antibiotic ointment to the great toe. During interviews, the DON stated the order existed but was not documented and that she could not find it in the treatment records, although staff said they had provided the care. An LPN stated she saw nursing provide the treatment and that the Epsom salt remained in the medication cart, adding that staff wrote the order but forgot to check off the box so it would appear on the MAR. The wound care nurse stated she was doing the treatments daily for Resident #112, and the resident confirmed staff provided the Epsom salt soaks and triple antibiotic ointment. The facility policy stated that the MAR is used to document all medications administered and that administration is documented immediately after it is given.
Inaccurate Face Sheet Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that Resident #28’s medical record was accurately maintained in accordance with accepted professional standards because the resident’s face sheet did not include a diagnosis of pain. Record review showed the resident was a [AGE]-year-old male admitted on [DATE] and remitted on 7/23/2025 with diagnoses including bipolar disorder, dementia, and diabetes. The face sheet dated 6/3/26 did not list pain as a diagnosis, even though the resident’s history and physical dated 4/23/2025 documented pain, and the care plan had a focus on pain. Additional record review showed the resident’s June 2026 physician orders included Morphine Sulfate 30 mg, one tablet twice daily, and the resident stated he had experienced pain for years due to an old military back injury. The BIMS assessment completed 5/13/26 showed a score of 14, indicating intact cognition. The MDS nurse stated she was responsible for entering diagnoses on face sheets and that the pain diagnosis had not been entered, and she had not yet audited diagnoses against the corresponding histories and physicals. The ADON stated he had been in his role for two months and had not yet audited all prior admissions for face sheet accuracy. The facility policy stated documentation in the medical record would be objective, complete, and accurate.
Incomplete influenza vaccination records
Penalty
Summary
The facility failed to ensure complete clinical records for two residents reviewed for vaccination status. For one resident admitted on 07/29/25 and another admitted on 08/05/21, there was no evidence in the EMR that either resident was offered, received, or declined the 2025 influenza vaccine. The missing documentation was identified during clinical record review and involved the residents' vaccination status in the record. During interviews, the DON stated that RN4 destroyed the 2025 consents and records for the influenza vaccines, and the Administrator stated that RN4 destroyed all records associated with the 2025 influenza vaccination status. The HIM stated that the IP was typically responsible for resident vaccination data and that RN4 should have entered the influenza information into each resident's EMR, but this was not done. The DON also stated she had delegated resident vaccination responsibilities to RN4 when he was hired, and a facility policy on retention of medical records indicated discharged residents' medical records were to be retained for 7 years from the date of service.
Incomplete Documentation of Elevated Heart Rate and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Resident #2 was admitted with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. The resident’s heart rates from one period in the record ranged from 57 to 89 bpm, but the MAR documented a heart rate of 122 bpm at 9:00 AM on one date. Nursing progress notes, evaluations, and the vital sign section of the electronic medical record did not show that the resident’s heart rate was reassessed between 9:00 AM and 8:00 PM, and there was no documentation about whether the heart rate decreased or whether the resident had symptoms related to the elevated heart rate. The MAR also showed that at 8:00 PM the medications Atorvastatin, Famotidine, Metoprolol, and Acetaminophen were signed off as not given because the resident had passed away suddenly. However, a change in condition note documented that the resident was assessed with no pulse, no BP, and no respiration at 10:00 PM, with a code blue and 911 called, and paramedics continuing CPR until the resident was pronounced deceased at 10:36 PM. RN #12 stated she gave the evening medications at 9:00 PM but did not sign the MAR until later, and the DON confirmed that the medical record did not reflect the medications were given or the resident’s status as described in the nurse’s statement.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.