Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
of F842 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20252,425
Every F842 citation surveyors wrote nationally that year.
Facilities cited2,080
Distinct nursing homes with at least one F842 finding.
The harm level
How severely F842 is cited
0.1% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J80.1%
K—
L—
Actual harm
G10.0%
H—
I—
No harm, potential for more than minimal
D6,69576.0%
E1,72819.6%
F720.8%
No harm, potential for minimal
A—
B2963.4%
C130.1%
Every recorded F842 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F842 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.
J · Immediate jeopardy, isolatedJune 23, 2025
Based on record review and staff interview, it has been determined that the facility failed to ensure that resident records are complete and accurately documented, relative to the monitoring of an elopement prevention device, a TekTone device (a device that allows at-risk residents to move freely about a facility, while preventing them from exiting the facility), for 1 of 1 resident reviewed who eloped from the facility and sustained a hip fracture, Resident ID #1.
Findings are as follows:
Review of a facility's policy titled Wanderguard [TekTone device] System and Assessments checks states in part .The bracelet will be checked each shift to assure placement, the nurse will sign this as checked in the treatment record . …
Based on observation, interview, record review, and policy review, it was determined the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for one (1) of 51 total sampled residents, Resident (R) 19. The facility failed to document assessments for R19 from 11/24/2025 to 11/27/2025 when R19 had a decline in intake and level of consciousness. R19 was transferred to the hospital on [DATE]. R19 expired on 12/04/2025.The findings include:The facility did not provide a policy for nursing documentation. …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on observation, document review, and interview, the facility failed to ensure the medication administration record (MAR) accurately reflected the administration of a scheduled medication for 1 of 1 resident (R4) reviewed for accurate clinical records. R4's scheduled olanzapine was administered by nursing staff; however, the MAR identified the medication as U-SA, which indicated unsupervised self-administration, and did not provide nursing staff the ability to document when the medication was administered.Findings include:R4's 5-day Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and required assistance with activities of daily living (ADLs). …
B · No harm, potential for minimal, patternAugust 26, 2026
Based on interview and record review that facility failed to capture leaves of absence from the facility for two of three residents (Residents 3 and 4) reviewed for admission, transfer and discharge. This failure placed residents at risk for potential billing errors and an incorrect medical record.Findings included. Resident 3Review of electronic health record (EHR) on 08/26/2026 showed that Resident 3 was admitted to the facility on [DATE]. The EHR showed that Resident 3 was alert and oriented, with no documented cognitive impairment, and was their own responsible party. Review of progress notes, dated 07/25/2026 through 07/28/2026, showed that Resident 3 had left the faciity on [DATE], and notified the facility on 07/28/2026 that they would not be returning. …
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Cited in the same inspection, not caused by one another.
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