§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 interview with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to treatments and observations for two of five residents reviewed (Resident 15, and Resident 217).
Findings include:
Resident 15 has medical diagnoses that include Dysphagia (difficulty swallowing) following Cerebral Infarction (a condition that occurs when blood flow to a part of the brain is interrupted), Aphasia (impaired speaking and understanding), following Cerebral Infarction, Gastrostomy (a medical procedure that creates an opening from the abdominal wall into the stomach to provide nutrition), Hemiplegia (a neurological condition characterized by paralysis or severe weakness affecting one side of the body) and Hemiparesis (weakness or partial paralysis affecting one side of the body, often caused by brain, spinal cord, or nerve damage) following other Cerebrovascular Disease affecting right dominant side.
Review of Resident 15's care plan revealed a focus initiated on November 5, 2025, revised on July 17, 2026, documenting the resident has a nutritional problem or potential nutritional problem related to age, need for therapeutic/mechanically altered diet, need for enteral feed (a soft, flexible tube that delivers nutritionally complete liquid feeds, including protein, carbohydrates, fats, vitamins, minerals, and water, directly into the gastrointestinal tract to meet nutrition and hydration needs), risk for malnutrition, on hospice care, and historic need for oral nutritional supplements secondary to malnutrition risk.
Further review of Resident 15's care plan revealed a focus dated November 14, 2024, documenting the resident has Aphasia related to Cerebral Infarction.
Review of Resident 15's physician orders revealed an order dated July 17, 2026, for Enteral Feed every 4 hours (hr.) for Enteral Nutrition/Hydration flush Percutaneous Endoscopic Gastrostomy (PEG tube)(a small, flexible tube placed through the abdominal wall into the stomach to deliver nutrition, fluids, and medications) with 200 milliliters (ml) of water every 4 hours, total volume of flush to equal 1200 ml every 24 hrs. (excluding medication flushes). Total volume of nutrient plus flush to equal 1980 ml every 24 hrs.
Review of Resident 15's July 2026 Medication Administration Report (MAR) revealed total daily flush amounts as follows:
July 18, 2026, total volume of 2768 ml. for the day.
July 19, 2026, total volume of 1620 ml. for the day.
July 21, 2026, total volume of 1065 ml. for the day.
On July 17, 2026, at 1:00 p.m. the resident's MAR documents a flush volume of 400 ml.
Per Resident 15's July MAR, there were three days in July 2026, when the resident's total volume of flush every four hours exceeded the physician ordered amount. There was one day when the resident's total volume of flush was less than the physician ordered amount.
Interview conducted with the Director of Nursing (DON) on July 22, 2026, at 1:20 p.m., when the above was presented, the DON confirmed there were days when the resident did not receive the accurate daily total flush amounts. The DON stated the order was probably being misunderstood by the staff and the wording would be changed to avoid confusion.
Resident 217 has medical diagnoses that include Heart Failure, Cerebral Infarction, Cirrhosis of Liver (advanced scarring of the liver), and Major Depressive Disorder, Adjustment Disorder, Thigh Pain, and Muscle Weakness.
Review of Resident 217's care plan revealed a focus initiated on January 19, 2026, documenting the resident has a diagnosis of depression.
Review of Resident 217's care plan revealed a focus initiated on January 19, 2026, documenting the resident has potential for pain related to arthritis and neuropathy.
Review of Resident 217's physician orders revealed an order dated February 3, 2026, for Tramadol (medication for moderate to severe pain) HCl Oral Tablet 50 milligrams (mg) give 1 tablet by mouth every 12 hours as needed for severe pain.
Review of Resident 217's physician orders revealed an order dated January 23, 2026, for Sertraline (medication used to treat depression) HCl Oral Tablet 25 mg give 1 tablet by mouth one time a day for depression.
Review of Resident 217's physician orders revealed an order dated January 17, 2026, for Observation: Pain - Observe every shift. If pain is present complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the progress notes.
Review of Resident 217's July MAR revealed the following:
July 4, 2026, pain level of 7 during 2nd shift.
July 5, 2026, pain level of 5 during 2nd shift and 3rd shift.
July 17, 2026, pain level of 9, during 2nd shift.
July 21, 2026, pain level of 4, during 3rd shift.
Review of Resident 217's progress notes revealed no non-pharmacological interventions documented.
During interview conducted with the DON on July 22, 2026, at 1:20 p.m., the DON stated the facility does not utilize pain flow sheets, the MAR is considered their pain flow sheet.
Review of Resident 217's physician orders revealed an order dated January 17, 2026, for Observation: Antidepressant Medication - Observe for behavior of depression. Observe for side effects: GI upset, insomnia, fatigue, dizziness, dry mouth, headache. Document "Y" if resident is free of side effects. Document "N" if the resident is NOT free from side effects. If "N" document side effects in the progress notes every shift for protocol.
Review of Resident 217's July MAR revealed the following:
July 1, 2026, No was documented for the 2nd and 3rd shifts.
July 2, 2026, No was documented for all shifts.
July 3, 2026, No was documented for all shifts.
July 4, 2026, No was documented for 1st and 2nd shifts.
July 5, 2026, No was documented for 1st and 3rd shifts.
July 6, 2026, No was documented for all shifts.
July 7, 2026, No was documented for all shifts.
July 8, 2026, No was documented for all shifts.
July 9, 2026, No was documented for all 2nd and 3rd shifts.
July 10, 2026, No was documented for all shifts.
July 11, 2026, No was documented for 3rd shift.
July 12, 2026, No was documented for 2nd and 3rd shifts.
July 13, 2026, No was documented for all shifts.
July 14, 2026, No was documented for 1st and 3rd shifts.
July 15, 2026, No was documented for all shifts.
July 16, 2026, No was documented for all shifts.
July 17, 2026, No was documented for all shifts.
July 18, 2026, No was documented for 1st and 3rd shifts.
July 19, 2026, No was documented for all shifts.
July 20, 2026, No was documented for all shifts.
July 21, 2026, No was documented for 1st shift.
July 22, 2026, No was documented for 1st shift.
Review of Resident 217's progress notes revealed no side effects were documented for the antidepressant observations.
Interview conducted with the Director of Nursing (DON) on July 22, 2026, at 1:20 p.m., when the above was presented, the DON stated the order was probably being misunderstood by the staff and the wording would be changed to avoid confusion.
28 Pa. Code 211.5(f)(h) Clinical records.
28 Pa. code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 09/09/2026
NPI was put in place for Tramadol order
Peg Flush orders were clarified for understanding
The DON/Designee completed an audit of all residents with G-tubes to ensure daily flush amounts were accurate and consistent with current orders. No additional issues or concerns were identified during the audit.
An audit was also completed by DON / Designee for all residents on antidepressant medications to ensure appropriate side effect monitoring was in place. Medication orders were reviewed and updated, as needed, to include required side effect monitoring and NPI documentation to ensure accurate and complete records are maintained.
Licensed nursing staff were re-educated on accurate documentation related to NPI's for and side effect monitoring for
The DON/Designee will complete weekly audits x4 and monthly x2 of five residents receiving antidepressant medications and five residents with PEG tube flushes to ensure accurate documentation.
Results will be brought to QAPI for review and recommendations as needed.
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