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:
A resident with a Stage 4 pressure ulcer and a physician’s order for Tramadol 50 mg to be given on the day shift 30 minutes before wound care had multiple missing and unexplained entries on the MAR, even though the Treatment Record showed that wound care was performed daily. On several days, there were no nurse signatures for the ordered Tramadol, and on other days the MAR was marked as “out of parameters” without any supporting progress notes. The wound care nurse reported relying on the MAR to confirm that pain medication was given before she performed wound care, and the DON stated that nurses are expected to follow physician orders and document refusals, but the record did not contain adequate documentation to demonstrate proper administration or explanation of the ordered pain medication.
Incomplete and inaccurate resident clinical records: The facility’s EMR did not accurately reflect one resident’s active psych diagnoses, with schizophrenia/bipolar history and schizoaffective disorder not carried through the MDS, care plan, diagnosis tab, or PL 1 screening. For another resident, the chart lacked a valid resident-signed MPOA and physician certification of incompetence, the admission agreement was signed by family and BOM only, and staff did not document the resident’s behaviors and statements despite noting she could express her needs and wanted to go home.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
A resident with intact cognition and diagnoses including CHF, COPD, respiratory failure with hypoxia, O2 dependence, sleep apnea, and A-fib had inconsistent documentation about the ability to self-administer nebulizer treatments. The MAR stated the resident could self-administer meds and nebulizers after set-up, but a self-administration assessment found the resident was not safe to self-administer inhalants without supervision. Surveyors also observed a handheld nebulizer still connected with medication remaining in the cup, while the MAR showed the treatment as completed and signed off by an RN.
The facility failed to accurately document PRN opioid pain medication administration on the MAR for four residents, despite corresponding removals recorded on controlled substance declining count sheets. On multiple occasions, an RN removed Oxycodone or Hydrocodone/Acetaminophen for pain from the controlled drug supply but did not chart the administrations on the MAR. In an interview, the RN reported relying on her own system, administering medications without checking the order and then failing to return to sign the MAR due to being busy and forgetting. The prior DON and current DON both stated they expect nursing staff to document pain medications on the MAR, and the NP reported she depends on MAR entries to evaluate residents’ responses to PRN pain treatment.
A resident with emphysema, muscle weakness, and a need for assistance with personal care had multiple scheduled medications that were not documented as administered on the MAR over two consecutive days. The MAR entries for midday and bedtime medications on one day and early morning medications on the following day were left blank, with no codes or notations indicating why the medications were not given. The DON later confirmed the resident was in the hospital during this period and stated that nursing staff should have documented this on the MAR and that there should never be blanks on the MAR, resulting in an incomplete and inaccurate medical record.
Incomplete Documentation of Ordered Pain Medication Prior to Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurately documented medical records related to pain medication administration prior to wound care for one resident with a pressure ulcer. The resident was admitted with diagnoses including peripheral vascular disease and had a care plan for a Stage 4 pressure ulcer that included administering medications and treatments as ordered. A significant change MDS indicated the resident had no cognitive impairment, required setup/cleanup assistance for eating and oral hygiene, had a Stage 4 pressure ulcer, received a scheduled pain medication regimen, and experienced moderate, occasional pain. A physician’s order dated 04/23/2026 directed that Tramadol 50 mg be given orally on the day shift for pain, 30 minutes before wound care. Review of the May 2026 Medication Administration Record (MAR) showed missing nurse signatures for the ordered Tramadol on multiple dates (05/02, 05/03, 05/09, and 05/10), despite the Treatment Record reflecting that wound care was performed daily on the day shift. On additional dates (05/04–05/06 and 05/11), the MAR entries for Tramadol were signed with code “4” indicating “out of parameters” by a registered nurse, but there were no associated progress notes explaining these entries. The wound care nurse reported that the resident had an order for Tramadol prior to wound care, that she performs wound care Monday through Friday, and that the floor nurse performs it on weekends, and she stated she checks the MAR to ensure the medication was given. The DON stated that nurses are to follow physician orders and document if a resident refuses medication. The facility’s pressure ulcer/skin breakdown protocol required pain assessment and documentation, but the medical record lacked adequate documentation to show that the ordered pain medication was administered or appropriately addressed on the identified dates.
Plan Of Correction
The facility continues to ensure that resident's medical records are complete and accurately documented. IMMEDIATE CORRECTIVE ACTION Resident #62 was assessed by Director of Nursing upon notification of surveyor and resident #62 did not have any adverse outcome related to the alleged deficient practice on 5/13/26. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Director of Nursing and/or designee conducted a comprehensive chart audit to ensure that residents with pain medications were accurately documented on EMAR on 5/15/26. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with clinical staff on standards of accurate medication administration documentation with emphasis on accurate documentation of Pain Medication Refusal. MONITORING Nursing Supervisor and/or designee will conduct random observation and/or audits to ensure accurate documentation of pain medication administration and refusal, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance is achieved and maintained.
Incomplete and inaccurate resident clinical records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the record contained diagnoses of major depressive disorder and schizoaffective disorder, while the admission MDS reflected depression and a history of schizophrenia and bipolar disorder that were not documented as active diagnoses. The care plan did not include bipolar disorder or schizoaffective disorder, the EMR diagnosis tab did not show bipolar disorder, the PL 1 Screening was coded No for Mental Illness despite documentation that the resident had a mental illness, and the EMR did not show submission of Form 1012. A psychiatry evaluation later documented a history of schizophrenia and bipolar disorder, described as schizoaffective disorder, depressive type, per hospital records and collateral review. For the second resident, the EMR did not contain a valid MPOA signed by the resident, and the admission agreement was signed only by the family member and the business office manager. The MPOA document in the record showed the signature acknowledged before a notary was that of the family member, not the resident. The EMR also did not contain physician certification that the resident lacked competence to make health care decisions, and it did not contain documentation signed by the resident authorizing the family member as legal guardian or agent under a medical power of attorney. Staff interviews confirmed that the resident could express needs and wants, and multiple staff members stated the MPOA was not valid because it was not signed by the resident. The record also did not include progress notes documenting the resident’s behaviors and statements while at the facility. An administrator note documented a discharge dispute involving the resident, the family member, and another family member, including the resident insisting on going home and law enforcement being called. Interviews with the Activities Director, LVN, ADON, MDS Coordinator, BOM, and Administrator reflected that the resident participated in activities, verbalized needs and wants, and discussed wanting to return home, but staff did not recall whether these statements were documented in the EMR. The facility policy stated that documentation must be complete, accurate, timely, and properly signed, and that active diagnoses and required forms should be placed in the clinical record.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Inconsistent documentation of self-administration status for nebulizer treatments
Penalty
Summary
The facility failed to ensure documentation of one sampled resident’s ability to self-administer medication was consistent and accurate throughout the medical record. The resident’s quarterly MDS, accepted on 4/6/26, identified intact cognition and multiple diagnoses including heart failure, COPD, respiratory failure with hypoxia, dependence on supplemental oxygen, sleep apnea, and atrial fibrillation. The resident required moderate assistance from one staff member for transfers, dressing, and hygiene. On 5/4/26 at 5:30 p.m., surveyors observed a handheld nebulizer in the resident’s room still connected to the nebulizer machine, with approximately half of the medication remaining in the cup, while the resident was not present. The May 2026 MAR documented that the resident received an ipratropium/albuterol nebulizer treatment at 2:00 p.m. and that RN-B signed off the treatment as completed. The MAR also stated the resident was able to self-administer oral medications and nebulizers after set-up. However, the resident’s 4/13/26 self-administration assessment completed by RN Consultant-B stated the resident was not capable of self-administering inhalants or using inhalers without supervision and was not safe to self-administer at that time. During interview, RN Consultant-B acknowledged the assessment was accurate and agreed he did not update the MAR to show the resident was no longer safe to self-administer nebulizer treatments. The interim DON stated it was her expectation that the MAR be updated immediately following the change with re-assessment.
Failure to Accurately Document PRN Controlled Substances on MAR
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration of controlled substances on the Medication Administration Record (MAR) for four residents, despite corresponding entries on the controlled substance declining count sheets. For one resident with an order for PRN Oxycodone 5 mg every 8 hours, Nurse #1 repeatedly documented removal of tablets on the declining count sheet on multiple dates and times, but did not document administration on the MAR for those same dates and times. A second resident with an order for PRN Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours had doses removed per the declining count sheet on two occasions, yet Nurse #1 did not record those administrations on the MAR. A third resident with PRN Oxycodone 5 mg orders (first every 4 hours for up to 7 days, then every 6 hours) had doses removed on two separate days at 8:00 AM and 12:00 PM, but again, Nurse #1 failed to document these administrations on the MAR. A fourth resident with an order for PRN Oxycodone 5 mg every 6 hours for 3 days had a dose removed per the declining count sheet, but there was no corresponding documentation on the MAR for that date. In a phone interview, Nurse #1 stated that her “system was not good,” that she knew which medications residents received and would administer them without looking at the order, and that she did not sign the MAR because she was too busy and forgot to return to complete the documentation. The previous DON stated she expected nursing staff to sign off on the MAR whenever administering pain medications and emphasized the importance of MAR documentation to determine if pain was being managed. The Nurse Practitioner reported that she relies on the MAR to assess residents’ responses to PRN pain medications, and the current DON stated she expected accurate documentation of pain medication administration on the MAR and identified that the nurse did not follow the medication administration process, which includes documentation.
Incomplete MAR Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident, specifically on the medication administration record (MAR). Resident #11, admitted with emphysema, muscle weakness, and a need for assistance with personal care, had multiple scheduled medications that were not documented as administered on specific dates. On 4/16/26, the resident’s midday and bedtime medications were not recorded as given, and on 4/17/26, the early morning medications were not recorded as given. The MAR contained blank spaces with no code or notation explaining why the medications were not administered. During an interview on 4/30/26 at 4:52 PM, the DON stated that Resident #11 was in the hospital on 4/16 and 4/17 and that the nurses administering medications should have documented this on the MAR, adding that there should never be blanks on the MAR. This failure to document the reason for non-administration of medications on the MAR for Resident #11, who was hospitalized during the relevant time, resulted in an incomplete and inaccurate medical record, as identified through record review and staff interview.
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