F639

Based on observation, interview, and record review the facility failed to ensure resident care plans, resident assessments and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As evidenced by Resident #1's discharge, wound/skin and admission assessments were noted to be recorded as late entries ranging from 6 to 92 days later respectively. Resident #1's wounds and care plans contained inaccurate classification and description of Resident #1's wounds and the care plans did not reflect the current treatment process in place for the resident's wound care. …

Pines Nursing Home · Florida

Based on interviews and record review the facility failed to ensure all resident assessments completed within the previous 15 months in the resident's active record were maintained in the resident's active medical records for 6 of 6 residents reviewed for MDS assessments. (Resident #1, Resident #10, Resident #13, Resident #18, Resident # 21, and Resident #35) in that -MDS assessments for Resident #1, Resident #10, Resident #13, Resident #18, Resident # 21, and Resident #35 were not accessible to staff and ready to review, when the DON/Owner was not on site and able to unlock the cabinet in which all resident MDS assessments were stored. These failures affected 6 residents and placed them at risk of not having their assessments available for review. …

San Jose Nursing Center · Texas

Based on interview and record review facility staff failed to maintain fifteen (15) months of Minimum Data Set (MDS), a federally mandated resident assessment tool, assessments in the resident's active record for eight (Resident #1, #7, #13, #17, #23, #24, #26, and #32) of eight of sampled residents who were admitted greater than 15 months. The census was 54. 1. Review of the facility's MDS completion and submission timeframes policy dated 2010, showed the policy did not contain direction for maintaining MDS assessments. …

Rest Haven Health Care Center · Missouri