Inspection·June 6, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on interview and record review, the facility failed to provide copies of Resident's medical record requested from the Representing Party (RP) for one of three residents (Resident 1). Residents Affected - Few This failure violated Resident 1's right and resulted in Resident 1's PR received Resident 1's medical record six days late. Findings: A review of Resident 1's admission Record, indicated the facility initially admitted Resident 1 to the facility on 5/9/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 1's History and Physical dated 5/12/2024, indicated the Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Authorization form For the Release of Medical Information Health Insurance Portability and Accountability Act (HIPPA COMPLIANT) (Federal regulation that outline how protected health information (PHI) can be used and disclosed in the United Stated), dated 5/21/2024, indicated authorization for release of medical records from Resident 1's RP. During a concurrent interview and record review on 6/6/2024 at 12:05 p.m. with the Medical Record Assistant (MRA), the MRA stated Resident 1's medical record request was received on 5/29/2024. The MRA stated, I did not follow up on sending medical record request and it has been six days. The MRA stated the facility's policy and procedure indicated records request should be available within two working days and I did not make the records available to RP. During a concurrent interview and record review on 6/6/2024 at 1:30 p.m., the Medical Record Director (MRD) stated Resident 1's medical record request was received on 5/29/2024. The MRD stated the records should have been sent out within two working days and they were not. The MRD stated the facility's policy and procedure indicated the facility had two days to prepare and send requested records to Resident 1's RP. During a review of the facility's policy and procedure (P&P) titled, Medical Records Requests and Facility Responses, (undated,) the P&P indicated, The facility can produce records directly to the resident: IF CURRENTLY A RESIDENT: Record Requests That The Facility Can Produce Only If The Requestor Provides Further Documentation: The authorization is signed by the resident's child, spouse, sibling, parent, relative or friend and seeks records of a living resident: Permit review within 24 hours, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055449 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covina Rehabilitation Center 261 W. Badillo Street Covina, CA 91723 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)