Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident's medical record included a physician's final summary of the resident's stay, and an inventory list of personal belongings for one of five sampled residents. (CL1)
Findings include:
Clinical record review revealed that CL1 expired on May 13, 2025. There was no documented evidence that the resident's medical record included a physician's final summary of the resident's stay that included the course of illness and treatment provided, a reconciliation of all medications that were administered, and an inventory list of the resident's personal belongings that included the resident's hearing aids.
In an interview on October 23, 2025, at 1:00 p.m., the Administrator confirmed that the facility did not have the required information in the medical record for CL1.
| | Plan of Correction - To be completed: 11/06/2025
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because the provisions of state and Federal law require it.
1.The affected resident (CL1) is deceased. No further corrective action can be taken for this resident. The facility verified that no personal property remains onsite. The family provided a receipt confirming ownership of the hearing aids, and the facility has issued a refund to the family for the documented cost. The physician's final summary and medication reconciliation for this resident cannot be completed retroactively; however, all current discharges/deaths are now reviewed to ensure completion prior to record closure.
2. An audit was completed for all current residents to ensure that each has a completed and up-to-date Personal Belongings Inventory Sheet in their medical record. Moving forward, all discharges/deaths and physician's final summary will be audited to confirm completion of the belongings inventory form and documentation of release. Any identified gaps will be corrected immediately, and involved staff will be re-educated on the process.
3. A Review of the Personal Belongings Inventory Policy has been initiated with all nursing personnel requiring the belongings inventory to be completed on admission, updated with any changes, and finalized upon discharge or death. Nursing staff are responsible for completing and reviewing belongings forms with residents and/or families prior to discharge. Nursing is responsible for documenting. Education has been provided to all licensed nursing and medical records staff on completing and maintaining belongings inventory documentation and the completion of Physician's summary.
4. The DON/designee will conduct weekly audits for four weeks, then monthly for three months, reviewing all discharges and deaths for the presence of a completed belongings inventory and discharge documentation. Audit results will be reviewed during QAPI meetings, and any identified noncompliance will result in immediate correction and staff retraining.
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