F0842

E

Untimely Documentation of Resident Progress Notes

Saxonburg, Pennsylvania Survey Completed on 03-14-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to appropriately and timely document progress notes in the clinical records for four residents. For one resident with anxiety, depression, and lung cancer, the initial admission visit was documented as a late entry on 3/1/26 for an encounter that occurred on 2/25/26, resulting in a four-day delay in documentation. Another resident with dementia, tremor, and a history of falling received a right shoulder injection on 3/5/26, but the corresponding progress note was not entered until 3/13/26, eight days later.

A third resident with gastroparesis, anemia, and esophagitis with bleeding was seen for increased swelling in both lower extremities on 1/19/26, but the progress note was entered as a late entry on 1/23/26, four days later. A fourth resident with emphysema, oxygen dependence, and alcohol dependence with withdrawal was evaluated for nausea, vomiting, and diarrhea on 2/23/26, yet the related progress note was not entered until 2/25/26, two days later. During an interview, the Director of Nursing acknowledged that the facility failed to appropriately and timely document progress notes in the clinical records for all four residents, in violation of 28 Pa. Code 211.5(f)(g)(h) regarding clinical records.