§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 review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of seven residents reviewed (Resident 1, 3).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 26, 2026, indicated that the resident was cognitively impaired and dependent on staff for daily care needs.
A nursing note for Resident 1, dated June 29, 2026, at 11:18 a.m. indicated that the resident representative was notified of room change pending confirmation of type of insect found in room.
Resident 1's clinical record, including the nursing notes, for June and July 2026 revealed no documented evidence that the type of insect found in her room was confirmed or that the facility's policy for bed bugs was followed.
A quarterly MDS assessment for Resident 3, dated May 21, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care needs and had diagnoses that included dementia.
A nursing note for Resident 3, dated June 29, 2026, at 11:18 a.m. indicated that the resident's representative was notified of room move pending confirmation of type of insect found in room.
Resident 3's clinical record, including the nursing notes, for June and July 2026 revealed no documented evidence that the type of insect found in her room was confirmed or that the facility's policy for bed bugs was followed.
Interview with the Director of Nursing on July 15, 2026, at 1:02 p.m. confirmed that there was no documented evidence in the clinical records of Residents 1 and 3 that the type of insect found in their room was confirmed or that facility's policy for bed bugs was followed and should have been.
28 Pa. Code 211.5(f) Clinical records.
| | Plan of Correction - To be completed: 07/31/2026
The facility cannot retroactively correct for Residents R1 and R3 as the issue has resolved.
Moving forward, the facility will identify any insects by type and show proof of policy being followed by documenting in the resident medical record.
Education on complete and accurate medical records will be completed by the Staff Development Coordinator/ Designee to all licensed staff.
Audits will be completed by the Director of Nursing/Designee to ensure if insects are found they are identified and policy followed is documented in the resident medical record. This audit will occur weekly times 4 weeks.
Results of these audits will be reviewed in the monthly Quality Assurance Performance Improvement committee for further recommendations as necessary.
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