Resident records.
- The facility shall provide for secure maintenance and storage of all resident
- Resident records must include:
- The resident’s name, social security number, marital status, age, sex, previous address, religion, personal licensed health care practitioner, dentist, and designated representative or other responsible
- The licensed health care practitioner’s orders and report of an examination of the resident’s current health status.
- An admission
- A copy of an initial and current assessment and care
- Documentation of resident observations by authorized
- Documentation of death, including cause and disposition of the resident’s personal effects, money, or valuables deposited with the
- A quarterly progress note documenting the resident’s current health condition, level of functioning, activity involvement, nutritional status, psychosocial interactions, and
- Documentation of review of prescribed
- Transfer forms that are completed, signed, and sent with the resident when transferred to another
- A medication administration record documenting medication administration consistent with applicable state laws, rules, and practice
- Documentation of an annual medication regimen
- A written report of any funds kept at a resident’s request. Such record shall show deposits to and withdrawals from the
- Documentation of a fire drill walk-through within five days of
- All agreements or contracts entered into between the facility and the resident or legal representative.
- A discharge
- The facility shall maintain resident records for a period of not less than five years from the date of discharge or