§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 facility policy, medical records, and staff interview the facility failed to maintain medication administration records that were complete and accurate for one out of three residents reviewed (Resident 1).
Findings include:
Review of Resident 1's latest annual MDS (Minimum Data Set - a comprehensive evaluation of a resident's functional, medical, psychosocial, and cognitive status) dated December 12, 2025 revealed that Resident 1 was re-admitted to the facility on August 15, 2025 with multiple diagnoses including: bladder cancer, diabetes mellitus, depression, adjustment disorder with mixed anxiety and depressed mood, insomnia due to mental disorder, acquired absence of right leg below the knee, chronic pain syndrome, and lumbago with sciatica, unspecified side. Resident 1's BIMS (Brief Interview of Mental Status - a standardized tool to evaluate a resident's cognitive status) was a 15 (indicating the resident is cognitively intact).
Review of facility policy titled "Administering Pain Medications", undated, revealed: "Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose; 4. Route of administration; and 5. Results of the medication (adverse or desired)."
Review of Resident 1's February 2026 MAR (Medication Administration Record) revealed an order for Oxycodone HCL (a controlled medication used for moderate to severe pain) oral tablet 15MG, give 1 tablet by mouth every 8 hours as needed for chronic pain, moderate, severe with a start date of January 16, 2026 and an end date of February 16, 2026.
Review of Resident 1's Individual Patient Controlled Substance Administration Record for 30 doses of Oxycodone revealed the following:
February 2, 2026, one dose administered at 00:00 (midnight), 9:00AM, and 4:00PM. Only one dose is documented in the resident's EMR at 5:55AM.
February 3, 2026, one dose administered at 00:00 (midnight), 7:50AM, 3:20PM, and 11:20PM. The 7:50AM dose is not recorded in the resident's EMR.
February 4, 2026, one dose administered at 8:00AM, 3:05PM, and 11:00PM. The 8:00AM dose is not recorded in the resident's EMR.
February 6, 2026, one dose administered at 4:15PM and 11:30PM. The 11:30PM dose is not recorded in the resident's EMR.
February 11, 2026, one dose administered at 5:30AM, 1:30PM, and 9:00PM. The 1:30PM dose was not recorded in the resident's EMR.
February 15, 2026, one dose administered at 7:00AM, 4:00PM and 11:15PM. The 7:00AM dose was not recorded in the resident's EMR.
Review of Resident 1's February 2026 MAR revealed the order for the Oxycodone every eight hours was changed to every six hours due to the resident having a surgical procedure. The new order for Oxycodone HCL oral tablet 15MG, give 1 tablet by mouth every 6 hours as needed for chronic pain, moderate severe was entered on February 16, 2026 and had a duration of 5 days (end date February 21, 2026).
Review of Resident 1's Patient Controlled Substance Administration Record for 30 doses of Oxycodone revealed the following:
February 17, 2026, one dose administered at 3:00AM, 8:00AM, 2:00PM, and 9:00PM. The resident's EMR revealed one dose administered at 3:00AM, 9:11AM, 3:00PM, and 9:00PM.
February 21, 2026, one dose administered at 4:00AM, 10:00AM, 4:00PM, and 10:00PM. The 4:00PM and 10:00PM doses were not recorded in the resident's EMR.
Review of Resident 1's February 2026 MAR revealed the order for Oxycodone every six hours was discontinued and the order for Oxycodone HCL oral tablet 15MG, give 1 tablet by mouth every 8 hours as needed for chronic pain, moderate severe was entered on February 21, 2026 with no stop date.
Review of Resident 1's Patient Controlled Substance Administration Record for 30 doses of Oxycodone revealed the following:
February 23, 2026, one dose administered at 4:15AM, 12:30PM, and 8:30PM. The 12:30PM and 8:30PM doses were not recorded in the resident's EMR.
February 25, 2026, one dose administered at 4:00AM, 12:30PM, and 8:00PM. The 8:00PM dose was not recorded in the resident's EMR.
March 4, 2026, one dose administered at 4:20AM, 12:00PM, and 7:30PM. The 4:20AM dose was not recorded in the resident's EMR.
Findings were reviewed with the DON on 3/5/2026 at approximately 2:20PM, who agreed that the documentation in the EMR was incomplete in that it did not reflect the documentation in the Patient Controlled Substance Administration Record.
28 Pa. Code 211.5(f) Clinical records
| | Plan of Correction - To be completed: 04/07/2026
Facility unable to correct deficiency retroactively to resident R1.
To identify potential affected residents' DON/Designee will complete an audit of current residents with PRN controlled substances to ensure they are being documented in the MAR.
To prevent this from happening again, licensed nursing staff will be inserviced on the electronic MAR orders and the proper way to document PRN controlled substances on the electronic MAR.
To monitor and maintain compliance the DON/designee will complete random audits on residents that receive PRN controlled substances to ensure they are documented accurately in the electronic MAR weekly x 4. The results of the audits will be forwarded to facility QAPI committee for further review and recommendations as needed.
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