§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, and staff interviews, it was determined the facility failed to maintain complete and accurate resident records for two of 35 residents reviewed (Resident R9 and R14).
Findings include:
Review of Resident R9's clinical record revealed the resident was admitted to the facility on January 29, 2026, with diagnoses including, but not limited to, wandering, history of falling, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks).
Review of Resident R9's care plan revealed an intervention, dated December 17, 2025, which stated "Wander Guard device...applied to right ankle".
Review of Resident R9's clinical record revealed a progress note from May 21, 2026, at 4:07 a.m. that stated a Wander Guard device (a small device applied to the resident which triggers an alarm if the resident attempts to leave a designated area) was applied to the resident's left lower leg, per family request.
Review of Resident R9's physician orders revealed that the most recent order for a Wander Guard device was dated December 17, 2025, and stated, "Wander Guard...every shift for elopement risk....applied to RT (right) ankle". This order was discontinued on January 12, 2026.
Observations on June 22, 2026, at 10:30 a.m. of Resident R9, the surveyor was unable to locate any Wander Guard device on the resident.
In an interview with Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, it was confirmed that Resident R9 had no current order for a Wander Guard device, was not wearing one at the time of the survey, and had not had one since January 2026. It was further confirmed that it is the expectation of the facility that care plans be updated when residents care needs change, and that progress notes accurately reflect the resident's current status.
Review of Resident R14's clinical record revealed the resident was admitted to the facility on December 29, 2023, with diagnoses including malignant neoplasm of bladder (bladder cancer), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side (weakness or paralysis of left half of the body following a brain bleed that was not caused by trauma), and hypertensive heart disease without heart failure (structural and functional changes of the heart muscle resulting from long-term high blood pressure, but not to the extent where the heart has lost its ability to pump blood effectively).
Continued review of Resident R14's clinical records revealed an order dated June 27, 2025, for Mirtazapine (Remeron) 7.5 milligram (mg) tablet to be given by mouth at bedtime for depression (mood disorder characterized by persistent feelings of sadness).
Additional review of Resident R14's clinical records revealed no diagnosis of depression listed among his diagnoses.
Continued review of Resident R14's clinical records revealed a psychological evaluation, dated July 2, 2025, at the request of the facility, noting resident has a history of depression and substance abuse. The evaluation continues by saying, "Per chart review, he currently receives medication management for depression." The evaluation indicated: "Resident reported symptoms of depression related to interpersonal difficulties with his children" with goals for the treatment session including, "Resident will learn adaptive methods to cope with symptoms of depression."
Review of Resident R14's care plan dated October 11, 2025, revealed the resident is at risk related to use of antidepressant medication for depression.
Interview on June 25, 2026, at 9:45 a.m. with Registered Nurse Assessment Coordinators (RNAC), Employees E13 and E14, confirmed the lack of a depression diagnosis amongst Resident R14's list of diagnoses.
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.5 (f) (viii) Medical records.
| | Plan of Correction - To be completed: 08/17/2026
Resident R9's clinical record cannot be retroactively corrected. Review reflects resident had no current order for a Wander Guard device, was not wearing one at the time of the survey and had not had one since January 2026. Review has been completed to ensure that clinical record accurately reflect the resident's current status related to Wander Guard device on the resident. No ill effect noted.
Other residents identified reviewed to ensure that clinical record x10days look back accurately reflect the residents' current status related to Wander Guard device on the residents.
Education provided to UM/ RN Supervisors to ensure that clinical record accurately reflect the residents' current status related to Wander Guard device on the residents.
To monitor and maintain ongoing compliance, the DON/ Designee will audit to ensure clinical record accurately reflect the residents' current status related to Wander Guard device on the residents weekly x4 then monthly x2. The results of the audits will be forwarded to facility QAPI for further review and recommendations.
Resident R14's clinical record has been reviewed to reflect the diagnosis of depression listed among his diagnoses. No ill effect noted.
Other residents identified reviewed to ensure clinical record reflect the diagnosis of depression listed among diagnoses
Education provided to RNAC to ensure clinical record reflect the diagnosis of depression listed among diagnoses
To monitor and maintain ongoing compliance, the DON/ Designee will audit to ensure clinical record reflect the diagnosis of depression listed among diagnoses weekly x4 then monthly x2. The results of the audits will be forwarded to facility QAPI for further review and recommendations.
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