Health inspection·January 6, 2026

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide copies of requested medical records within two business days from written request as indicated by the facility's policy and procedure (P&P) titled, Access to Personal and Medical Records for one of three sampled resident (Resident 1). This deficient practice violated Resident 1's right to obtain copies of resident's medical records in a timely manner and had the potential to affect Resident 1's psychosocial well-being. Findings: a) During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included obesity (an abnormal or excessive body fat accumulation), acute respiratory failure without hypoxia (an impairment in oxygenation), basal carcinoma (a type of skin cancer) of skin of right upper limb including shoulder, unilateral primary osteoarthritis (a joint disease where protective cartilage wears down, causing bones to rub, leading pain, stiffness, and swelling) of left hip, and muscle wasting and atrophy (a partial or complete wasting away of a part of the body). During a review of Resident 1's Initial History and Physical (H&P), dated 12/14/2025, the H&P indicated that Resident 1 has the capacity to understand and make decisions. During a review of the Authorization for Use or Disclosure of Protected Health Information form, dated 3/6/2025, the form indicated the facility received a request for release of Resident 1's medical records on 3/6/2025. During a review of the facility's email dated 3/26/2025, the email indicated that the requested medical records were sent to Resident 1 on 3/26/2025. During a review of the Authorization for Use or Disclosure of Protected Health Information form, dated 4/4/2025, the form indicated the facility received a request for release of Resident 1's medical records on 4/4/2025. During a review of the facility's email dated 4/14/2025, the email indicated that the requested medical records were sent to Resident 1 on 4/14/2025.? During a review of the Outlook Medical Records Request email from Resident 1, dated 6/23/2025, the email indicated that Resident 1 sent the facility a request for release of medical records on 6/23/2025. The facility did not release Resident 1's medical records. During a review of the Authorization for Use or Disclosure of Protected Heath Information form, dated 7/1/2025, the form indicated the facility received a request for release of Resident 1's medical records on 7/1/2025 without resident's signature. During a review of the facility's email dated 11/12/2025, the email indicated the requested medical records were sent to Resident 1 on 11/12/2025. During a concurrent interview and record review on 1/2/2026 at 3:05 PM with the Administrator (ADM), Resident 1's Authorization for Use or Disclosure of Protected Health Information forms, dated 3/6/2025, 4/4/2025, and 7/1/2025, were reviewed. The ADM stated that on 3/6/2025 and 4/4/2025, Resident 1 requested a large volume of records, which could take several days to provide. The ADM stated that on 7/1/2025, Resident 1 refused to sign the form and the facility was only able to show the medical records but could not provide copies without a signature. The ADM stated that the requested medical records were provided to Resident 1 via email on 11/12/2025. During a concurrent interview and record Page 1 of 2 055259 055259 01/06/2026 Monrovia Post Acute 1220 E. Huntington Drive Duarte, CA 91010

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review on 1/2/2026 at 3:05 PM with the ADM, the ADM stated, If the resident requests their medical records and it is something small, then it can be provided the same day, but if it is a lot, it can take several days to provide their records - it depends on the amount of records that are being requested. During an interview on 1/5/2026 at 10:00AM with the Director of Medical Records (DMR), the DMR stated medical records department visits the residents and guides them to fill out the consent to request medical records. The DMR stated that the resident signs as well as the employee who helped to fill out the form. The DMR stated that depending on the size of the record, it can be provided on the same day, but for the large volume of record request, it can take a few days. The DMR stated that residents are informed of how long it may take and are asked in what format they would like to receive the documents. During an interview on 1/5/2026 at 12:31 PM with Resident 1, Resident 1 stated that she had requested medical records in November with the Ombudsman (an independent government official to advocate for residents). Resident 1 stated she had previously requested the records via email and phone call without success. Resident 1 stated that she refused to sign the medical records release form because the form releases the facility from liability. During an interview on 1/5/2026 at 2:52 PM with the DMR, the DMR stated that the medical records does not document on the resident's record when they visit the resident to fill a Medical Records form. During an interview on 1/5/2026 at 3:03 PM with Resident 1, Resident 1 stated that the DMR was the only medical records employee she had ever spoken to and he never mentioned how long it would take to receive the records. During a concurrent interview and record review on 1/5/2025 at 4:20 PM with the ADM, the ADM stated that the 6/23/2025 medical record request was not honored for Resident 1. The ADM further stated that the medical records department may need more time to compile the records, and they will tell the residents that they need more than the two days, or 48 hours as indicated in the policy. The ADM stated medical records does not chart in the resident's record. ? During a review of the facility's P&P, titled Access to Personal and Medical Records, revised on May 2017, the P&P's Policy Statement section indicated that each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. The P&P's Policy Interpretation and Implementation section indicated:Access to the resident's personal and medical records will be provided to the resident within 24 hours (excluding weekends and holidays) of his or her request.The resident may obtain a copy of his or her personal and medical record within two business days of oral or written request. 055259 Page 2 of 2