Health inspection·September 20, 2024

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 record review and interview, the facility failed to provide a resident and or representative a copy of medical records following a written request for 1 of 3 residents reviewed for resident rights (Resident 1). This failure could potentially violate Resident 1 (R1) rights to access her medical records. Findings: During a review of Residents 1 ' s (R1) admission Record (general demographics), the document indicated R1 was admitted to the facility on [DATE] , with diagnosis to include sepsis, (complication of an infection), urinary tract infection ( bladder infection), generalized muscle weakness ( decreased strength in muscle ), type 2 diabetes mellitus ( a long term condition in which the body has trouble controlling blood sugar and using it for energy ), dementia (is a condition that can be caused by a number of diseases which destroy nerve cells and damage the brain). During an interview with Medical Record Director (MRD) on September 16,2024 at 2:04 PM. MRD denies getting a fax request or e-mail requests to release R1 medical records. MRD stated that they have 48 hours to comply with a written request from the resident, responsible party, or legal representative. During an interview with R1 ' s Legal Representative (LR) on September 17,2024 at 10:05am. LR stated they have a successful fax transmittal confirmation on August 22,2024 at 1:06pm faxed to (909) [PHONE NUMBER]. LR stated that a copy of the successful transmittal was sent to California Department of Public Health (CDPH) on August 26, 2024. During a record review on September 17,2024 at 10:10 am, a successful confirmation receipt of facsimile sent to the facility was reviewed. During an interview with Administrator (ADM) on September 18, 2024, at 2:40 PM, ADM stated that the facility never received a facsimile from the law office requesting for the R1 ' s medical records on August 22, 2024. During an interview with MRD on September 18, 2024, at 3:00 pm, MRD stated that she received a fax on September 18, 2024, requesting for R1 ' s medical record and MRD stated that she also received a follow up phone call from the Law Office. During a concurrent interview and record review, on September 18, 2024, at 2:40 PM, with the Page 1 of 2 055374 055374 09/20/2024 Upland Rehabilitation and Care Center 1221 E Arrow Hwy Upland, CA 91786

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator (ADM). A facility Policy and Procedure (P&P), titled, Resident Rights Release of Information revised October 2022, was reviewed. The P&P indicated the following: Our facility maintains the confidentiality of each resident's personal and protected health information. Policy Interpretation .10. A resident may obtain photocopies of his or her records by providing the facility at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged . ADM stated that R1 ' s medical records were not sent. ADM also stated, the facility did not receive a Facsimile on August 22, 2024, requesting for R1 medical records. 055374 Page 2 of 2