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.
Based on Interviews and record reviews, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of four residents reviewed for accurate clinical records, in that:
The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE].
An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. …
D · No harm, potential for more than minimal, isolatedSeptember 10, 2026
Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Resident #5) reviewed for accuracy and completeness of clinical records. The facility failed to ensure LVN B documented the amount of insulin she administered on the MAR to Resident #5 before lunch on 09/04/26. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included: Record review of Resident #5's face sheet dated 09/09/26 reveled an [AGE] year-old female with an initial admission date of 02/17/22 and a current admission date of 05/29/26. …
B · No harm, potential for minimal, patternAugust 13, 2026
Based on interview and record review the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for 1 of 1 (Resident #1) residents reviewed for documentation. Resident #1's EMR did not contain complete and accurate documentation that reflected multiple room changes in that there was no documentation in the EMR of all completed room changes between 12/2025 through 08/2026. This failure could result in inaccurate medical records in that the residents or family notification of room changes and reason for room changes were not documented. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction