Health inspection·October 1, 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 interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of three sampled residents (Resident 1) within two working days per the facility's policy and procedure (P&P) titled, Release of Information. This deficient practice violated Resident 1 and the LR's rights to obtain a copy of the resident's medical record. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including severe sepsis (a life-threatening condition that occurs when an infection causes organ damage) with septic shock (a life-threatening condition that occurs when a body-wide infection causes dangerously low blood pressure and organ failure), and vascular dementia (a chronic condition that affects the brain ' s ability to think, remember, and behave due to poor blood flow). During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 6/5/2024, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment. During a review of Resident 1 ' s Authorization for the Release of Information (any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) faxed form dated 8/13/2024, and faxed 8/14/2024, indicated LR 1 signed a release to disclose the Medical Records Information for Resident 1. During a review of an email dated 9/24/2024, the email indicated the facility provided LR ' s requested records on 9/24/2024. During an interview on 10/1/2024 at 10:36 a.m., the Medical Records Director (MRD) stated their policy had been changed 9/2024 to release medical records from 15 calendar days to 48 hours from the time requested by residents or their legal representative. During an interview on 10/1/2024 at 12:00 p.m., the Administrator (ADM) stated the facility had 48 hours to submit requested records from the resident or representative. The ADM stated LR ' s request (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: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Los Palos Post-Acute Care Center 1430 West 6th Street San Pedro, CA 90732 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)