Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure clinical records were accurate and complete for monitoring of the code alert device for three (3) of nine (9) sampled residents, Residents #1, #5, and #6. In addition, review of Resident #1's Admission Assessment revealed the facility failed to complete the elopement, skin, pressure sore, and nutritional risk assessments upon admission to the facility. Review of Resident #1's clinical record also revealed Resident #1's behaviors of wandering were not consistently documented. Also, the clinical record failed to accurately detail the incident of Resident #1's elopement from the facility. …
F514
Administration Deficiencies
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The harm level
How severely F514 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D583.3% | E116.7% | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F514 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and staff interview, the facility failed to assure that the medical record of 1 of 3 residents reviewed (Resident #1) was accurately and completely documented. Findings include: 1. A faxed medical order from a podiatrist (doctor with foot specialty) was received by the facility on 8/21/17 at 3:48 PM. This medical order included specifics regarding an antibiotic medication, a request for a vascular (blood flow) consultation appointment, and orders for care of a wound on the right foot which was found to have wet gangrene (serious infection) and resting ischemia (lack of blood flow). Per review of the medical record of Resident #1, the vascular appointment was made for 8/24/17 at noon, and the antibiotic was started. …
Based on interview and record review, the facility failed to maintain accurate medical records in accordance with accepted professional standards when drug allergies [REDACTED]. Resident 1's allergy to [MEDICATION NAME] [MEDICATION]) was not recorded on her Face Sheet (a document that lists pertinent information about the resident), physicians orders, and her Medication Administration Records (MAR). This action had the potential for medications to be administered to residents that could cause an allergic reaction. Findings: Resident 1's record was reviewed and indicated she was admitted to the facility on [DATE] from a an acute care hospital with [DIAGNOSES REDACTED]. Resident 1's Face Sheet indicated she was allergic to Clinoril (a non-steroidal anti-[MEDICAL CONDITION] medication). …
Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 5 (Resident #69, #318, #242, #310, #327) of 5 records reviewed. Findings: A review of the medical record for Resident #69 revealed a Nursing Home Transfer and Discharge Notice, AHCA form 3120-0002 that was incomplete. The date of notice, effective date, location of transfer or discharge and reason for discharge were blank on the form. A review of the medical record for Resident #318 revealed a Nursing Home Transfer and Discharge Notice, AHCA form 3120-0002 that was incomplete. …
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