Medical records · 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.
F842 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F842 more often than its own record predicts
Versus expected share1.18×
1.18 times the share F842 takes of citations nationally.
Share of North Carolina citations2.65%
Of every deficiency written in North Carolina in 2025, this is the portion that was F842.
North Carolina2.65%
National2.24%
Share of all citations that were F842.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F842 findings written in North Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
D · No harm, potential for more than minimal, isolatedAugust 21, 2026
Based on observations, record review, and staff, Registered Dietician and Medical Director interviews, the facility failed to maintain an accurate medical record related to documentation of medication and dietary supplement administration for 2 of 38 residents reviewed for accurate medical records (Resident #17 and #105). Findings included:
1. A review of Resident #17's medication orders revealed the resident had a current order initiated on 10/6/2023 for diclofenac (a medication that helps reduce pain and inflammation where it was applied) 1% gel to apply 2 grams (g) to top of each hand and bilateral feet twice daily, do not exceed 8g/day for pain. …
B · No harm, potential for minimal, patternAugust 18, 2026
Based on record review and staff interviews, the facility failed to maintain accurate medical records related to a heart monitor for 1 of 3 residents (Resident #1) reviewed for medical record accuracy. Resident #1's heart monitor was documented in place from 7/10/26 to 8/17/26 despite it not being applied to the resident.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (condition where the arteries that supply blood to the heart become narrowed or blocked because of plaque buildup).A review of Resident #1's medical record indicated a physician's order dated 7/10/26 that read: Ensure heart monitor is plugged up at all times. (Plugged up meant plugged up to the outlet in the wall and charged). …
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