§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 and clinical and facility records, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to a resident's change of status for one of two closed records reviewed (Resident CR1).
Findings include:
Review of facility policy entitled "Charting and Documentation " dated 1/07/25, revealed "All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care."
Resident CR1' s clinical record revealed an admission date of 9/17/25, with diagnoses that included pneumonia (an infection of the lungs), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe), acute respiratory failure with hypoxia (a condition when the lungs can't release enough oxygen into your blood), and severe protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their body's needs).
Resident CR1's progress notes dated 9/28/25, 10:35 p.m. revealed resident continues to remove oxygen. Oxygen (O2) saturation 55% on room air. Reapplied oxygen and recheck O2 saturation O2 saturation at 77%. Resident is confused and talking to people that are not visible. Resident refusing all meds and refused dinner. Resident did drink his milkshake. Registered Nurse (RN) supervisor made aware of oxygen saturation. Will continue to monitor. Further review of Resident CR1 ' s clinical record lacked evidence of further documentation of resident progress, nursing follow-up care and treatment, and physician notification related to low oxygen saturations and confusion.
Review of facility provided nursing documentation, a nurse's written statement provided by the Nursing Home Administrator (NHA), for Resident CR1's care and treatment on 9/28/25, indicated per report resident non-compliant with oxygen therapy, oxygen low all day. After report, resident vital signs obtained by this writer. RN aware. Throughout shift resident assessed multiple times oxygen reapplied and education provided. Overnight shift resident restless and removing oxygen, as needed medications offered at time refused. This writer 1:1 resident in room 2:00 a.m.-3:30 a.m. incontinence care provided by nursing assistant at 0330 this writer returned to desk 4:15 a.m. resident reassessed oxygen reapplied resident restless.
During an interview on 10/23/25, at 4:10 p.m. the NHA confirmed that the facility provided nursing documentation for Resident CR1's care and treatment provided 9/28/25, was not part of Resident CR1's permanent clinical record. The NHA further confirmed that Resident CR1's clinical record lacked evidence of the nursing response to Resident CR1's change in condition including resident's progress, changes, and communication between the interdisciplinary team regarding the resident's condition and response to care.
28 Pa. Code 211.5(f)(ii)(iii) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 12/30/2025
For Resident CR1, the facility reviewed the closed record and attached all available documentation from 9/28/25 so the record now accurately reflects the care provided. To identify other potentially affected residents, the Director of Nursing (DON)/designee reviewed all residents with a documented change in condition in the previous 72 hours and corrected any missing follow-up notes or provider notifications. All nursing staff were re-educated by the Director of Nursing/designee on the "Charting and Documentation" policy. Nursing supervisors will complete a targeted daily review only for residents with a recent change in condition or new provider orders to verify required documentation. To ensure ongoing compliance, the DON/designee will audit 10 residents five days per week for two weeks, then weekly for two weeks, and then monthly for two months to verify that all change-in-condition events, nursing follow-up, and provider notifications are properly documented. Results will be reviewed in the Quality Assurance and Performance Improvement [QAPI] meeting, and committee to determine if further action is required.
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