§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 clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for four of 12 residents reviewed (Residents 1, 2, 8, and CR1).
Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for two of 12 residents reviewed (Residents 1, 2, 8, and CR1).
Findings include:
Review of information provided to the Department of Health through the Event Reporting System (ERS, platform for facilities to report incidents, or unusual events) dated February 3, 2026, noted Resident CR1 was observed in Resident 8's room at 2:30 PM pulling up Resident 8's pants. ERS documentation revealed Resident CR1 reported that he wanted to have sex with Resident 8. Resident CR1 admitted to rubbing his penis against Resident 8's hip.
Review of facility investigation into Residents CR1 and 8 incident dated February 3, 2026, revealed at shift change a nurse aide found Resident CR1 in Resident 8's room, and Resident 8 was noted to be completely naked. Review of Employee 1's (nurse aide) witness statement revealed Resident CR1 stated he took Resident CR1's shirt and pants off and then took his own pants off. When Employee 1 asked Resident CR1 if he had sexual intercourse, Resident CR1 stated Resident 8 would not spread her legs, so he rubbed his penis on her side.
Review of Resident 8's clinical record on February 26, 2026, revealed there was no nursing assessment of Resident 8 after the resident-to-resident sexual abuse allegation, prior to her transfer to the hospital on February 3, 3036.
Review of Resident 8's clinical record revealed nursing documentation dated February 4, 2026, at 2:26 PM noting Resident 8 returned from the hospital from overnight observation at the emergency room.
Review of hospital documentation revealed Resident 8 was admitted for possible evaluation of sexual assault
There was no documentation in Resident 8's clinical record relating to the above-mentioned incident.
Review of documentation provided to Department of Health through the Event Reporting System dated February 16, 2026, revealed Resident 2 was sleeping in her geri-lounger in the common area when Resident 1 was observed rubbing Resident 2's genital area, on top of her clothing.
Review of Resident 1's clinical record revealed social service documentation dated February 16, 2026, at 10:16 AM noting social services received a notice from the interdisciplinary team to follow up with Resident 1 due to recent behaviors that occurred.
There was no documentation in Resident 1's clinical record relating to the above-mentioned incident.
The facility failed to ensure clinical records were complete and accurate. The above information for Residents 1, 2, 8, and CR1 was reviewed with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 2:28 PM.
483.70(h) Medical Records
Previously cited deficiency 5/28/2025
28 Pa. Code 211.5(i) Medical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 03/17/2026
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.
1. Resident 8's record updated with late note of nursing assessment related to incident which was completed on 2/26/26 including documentation of sexual assault.
Resident 1's record updated to include Social Service late note regarding follow up with resident's sexual behavior on 2/16/26 .
IR's updated to now have option of resident to resident sexual so to include complete information in IR that will transfer to both resident records instead of only aggressor.
IDT notes for IRs now to be documented in portion of IR that transfers to clinical record.
2. Audit completed on all Incident reports in past 30 days to ensure clinical record includes nursing assessment note and any follow up notes as indicated by IDT notes.
3. All nursing and social services staff will be educated on DOH regulation 483.70 regarding clinical documentation.
4. Follow up audits will be completed by DON or designee: IR's will be reviewed to ensure clinical record includes nursing assessment note and any follow up notes as indicated by IDT weekly x 8 weeks.
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