Health inspection·April 9, 2025

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 ensure residents' rights to access and obtain medical records was honored for one of four sampled residents (Resident 1), when Resident 1' s representative requested medical records on 1/8/25 and the facility did not provided records within 30-60 days according to their policy and procedure (P&P). This failure resulted in Resident 1's representative not being provided medical records needed and not respecting Resident 1's right to access and obtain medical records. Findings: Resident 1's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 4/11/2024. During an interview on 4/9/25 at 12:31 p.m. with the director of nursing (DON), the DON stated the facility did not have a medical records director (MRD) since 1/23/2025. The DON stated the facility did not have a medical records assistant or a designated staff member to assist with medical record requests. The DON stated she was not aware of a request for records for Resident 1 and was not informed by the MRD prior to 1/23/25 that a request had been made. The DON stated the former administrator (FADM) had not made her aware of the request for records prior to the ADM 's exit from the facility and therefore the record request was not completed. During a concurrent interview and record review on 4/9/25 at 12:02 p.m. with the DON, the facility ' s form titled, . Authorization For Release Of Health Information, dated 3/2013 was reviewed. The form indicated, . I understand to the extent I am a current resident, I must provide the center with two working days advance notice to make any copies of the records that I would like to pick up at the center . The DON stated this form was to be completed and signed by the person or resident requesting records. The DON stated the facility process for current residents was to provide the requested records within two business days of submitted request. The DON stated she was not aware what the process or timeframe was for resident record requests when the resident was discharged . During an interview on 4/9/25 at 12:17 p.m. with the Administrator (ADM), the ADM stated the facility did not have a MRD. The ADM stated all requests for records submitted to the facility were fulfilled by the ADM or the DON. The ADM stated he was not aware of the record request submitted for Resident 1's records and therefore was not completed following the MRD and FADM's leave from the Page 1 of 2 056301 056301 04/09/2025 Golden Modesto Care Center 1900 Coffee Road Modesto, CA 95355

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility. The ADM stated the expectation was for the facility to provide medical records to the resident or representative within five business days of the request. The ADM stated the facility followed the policy and regulations in place for medical record requests. During a record review of the facility ' s policy and procedure (P&P) titled, Protected Health Information (PHI), Residents ' Rights Relative to, dated 3/2014, the P&P indicated, . Residents have the right to access and copy their protected health information (PHI) and any other information in their medical records maintained/retained by this facility . our facility will act upon a resident ' s request for access to his/her medical records or other information no later than thirty days after receipt of such request, unless the time period is extended as described . if the information to be accessed is not maintained or accessible on premises, our facility will act upon such request within 60 days of receipt of such request. If the facility is unable to act on the request within applicable 30- or 60-day period, the facility may extend the time for response by 30 days, provided that the resident is given a written notice of the reason(s) for the delay and the date by which a responsive action will be taken . During a record review of the facility's P&P titled, Resident Rights, dated 12/2021, the P&P indicated, . Federal and state laws guarantee certain rights to all residents of this facility. The rights include the resident's right to .q. access personal and medical records pertaining to him or herself . 056301 Page 2 of 2