§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 facility policy, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding oral hygiene for one of three residents reviewed (Resident R1).
Findings include:
Review of facility policy entitled "Mouth Care" dated 1/14/25, revealed "Documentation -The following information should be recorded in the residents clinical record: The date and time the mouth care was provided."
Review of Resident R1's clinical record revealed an admission date of 5/28/21, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically) and hypertension (high blood pressure).
Review of Resident R1's task (charting area in the clinical record where nursing assistant's document) under section GG oral hygiene every shift revealed that for day shift on 10/1/25, 10/4/25, 10/14/25, there lacked documentation that oral care was completed. On evening shift 10/2/25, 10/11/25, there lacked documentation that oral care was completed and "Not Applicable" (NA) was marked on 10/5/25, 10/10/25, 10/13/25. On the overnight shift on 10/11/25, there lacked documentation and NA was marked on 10/2/25, 10/3/25, 10/4/25, 10/5/25, 10/6/25, 10/8/25, 10/10/25, 10/12/25, 10/13/25, and 10/14/25 that oral hygiene was completed.
During an interview on 12/3/25, at 9:55 a.m. the Director of Nursing (DON) confirmed that Resident R1's clinical record did not have complete documentation regarding oral hygiene. The DON also confirmed that oral hygiene should be done per the order/task and documented in the clinical record.
28 Pa. Code 211.5(f)(viii) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 12/29/2025
Resident 1 ceased to breathe on 10/15/2025
All residents tasks (clinical documentation area where nurse aides document provisions of care) were reviewed to ensure that they have the oral hygeine task assigned and can be documented on by nursing assistants in Point of Care by the Director of nursing designee
All licensed practical nurses, registered nurses and certified nursing assistants were educated on mouth care policy and the documentation in Point of Care (clinical documentation area where nurse aides document provisions of care) for performing mouth care by the Director of nursing/designee
The Director of nursing/designee will audit 8 residents documentation to ensure mouth care/oral hygiene is documented in Point of Care (clinical documentation area where nurse aides document provisions of care) weekly for 4 weeks then monthly ongoing.
Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations
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