§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
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Observations:
Based on the review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to appropriately document skin evaluations for two of four sampled resident records (Residents R1 and Resident R5).
Findings include:
The facility "Charting and documentation" policy last reviewed 12/9/25, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record:
-Objective observations
-Medications administered
-Treatments or services performed
Review of Resident R1's admission record indicated she was originally admitted on 3/20/24 and readmitted on 9/1/25.
Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/23/26, indicated she had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and an anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry).
Review of Resident R1's care plans dated 3/23/26, indicated to provide skin inspections to Resident R1. Resident R1 required one person assist for skin inspection twice weekly on Wednesday and Saturday 3-11 shift. Observe skin for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.
Review of Resident R1's weekly skin integrity review (a form with documented skin evaluation observations) dated 6/13/26, indicated skin was intact.
Review of Resident R1's clinical nurse notes and physician documentation did not include weekly skin evaluations until 8/10/26.
Review of Resident R5's admission record indicated she was admitted to the facility on 7/17/24.
Review of Resident R5's MDS assessment dated 7/21/26, indicated that she had diagnoses that included anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and protein malnutrition.
Review of Resident R5's care plan dated 1/2/26, and revised on 8/4/26, indicated to provide skin inspections to Resident R5. Resident R5 required one person assist for skin inspection twice weekly on Wednesday and Saturday 3-11 shift. Observe skin for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.
Review of Resident R5's weekly skin integrity review dated 6/16/26, indicated skin was intact.
Review of Resident R5's clinical nurse notes, consultation documentation and physician documentation did not include weekly skin evaluations.
During an interview on 8/13/26, at 2:07 p.m. Registered Nurse (RN) Employee E5 asked about skin checks documentation: "skin checks are done when a resident has a shower. That is different from a skin assessment."
During an interview on 8/13/26, at 2:10 p.m. Registered Nurse (RN) Employee E6 was asked how skin checks are done? "Nurse aides do a skin check sheet on shower days. The sheet is also done on admission."
During an interview on 8/13/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that the facility failed to appropriately document skin evaluations for Resident R1 and Resident R5 as required.
28 Pa. Code: 211.5(f)(g)(h) Clinical records.
| | Plan of Correction - To be completed: 08/27/2026
DON/designee immediately completed a full skin assessment on R1 and R5, including documentation of all skin conditions, wounds, pressures areas and risk factors
DON to ensure any missed weekly skin assessments on R1 and R5 are completed and entered into the medical record.
DON verified treatment orders were accurate for R1 and R5 and updated based on current skin findings.
DON assessed R1 and R5 for any adverse outcomes related to missed documentation
No residents experienced harm
Other Residents Potentially Affected
DON/designee conducted a facility wide audit of-
Weekly skin assessments for the last 30 days
All skin check documentation
All residents with wounds or skin conditions
Education
DON/designee provided education to all licensed nurses on-
Importance of weekly skin assessments for early identification of skin breakdown
Proper documentation standards for skin checks and skin assessments
Process Improvement
Unit Managers or designee will verify completion of skin assessments weekly
DON/designee received PCC alerts for overdue skin assessments and addresses their completion promptly
Staff who fail to complete required documentation will receive re-education and progressive discipline per policy
Compliance
DON/designee will conduct-
Weekly audits of all skin assessment completion for 4 weeks
Weekly wound documentation for completion for 4 weeks
Monthly audits of wound documentation completion for 2 months
Random observation of 5 skin assessments weekly for 4 weeks
Review of skin integrity trends/wounds monthly at QAPI meeting
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