Health inspection·May 28, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. 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 resident's medical records for 1 of 4 residents (R2) reviewed for medical records (MR) in the sample of 4. The Findings Include: R2's admission Record, dated [DATE], documents R2 was admitted to the facility on [DATE], and was discharged on [DATE], and expired on [DATE]. On [DATE] at 9:15 AM, V3, Business Office Manager, stated The previous medical record person (V5) was terminated on Thursday [DATE] and I am coordinating with the Regional Medical Records person (V4) for any medical record requests. I have not had any medical record requests since I have been assisting. The process depends on who is requesting it, if it is an Attorney, it automatically has to go through our corporate office, and if it is family, paperwork has to be completed, then corporate office will let us know if we can process the request at the facility level or if they will be doing it, and either way, the payment for the record request has to be received before any medical record request gets processed. On [DATE] at 9:20 AM, V1, Administrator, stated (V5, Previous Medical Record staff), was terminated on Thursday [DATE] so (V3) is working with the Regional Medical Record person (V4) with any record requests. I am not aware of anyone who has recently requested their medical records, or anyone who is waiting for their medical records. On [DATE] at 11:08 AM, V5, Previous Medical Records staff, stated I was working on (R2's) medical record request, which I believe was from an attorney, and not (R2's) family. I had completed the paperwork and sent the request up to our Regional Medical Records person (V4). I had to wait to get it back from (V4), and when I called inquiring about it, (V4) told me to send it to Corporate Legal. I was in the process of doing that on Thursday [DATE], when I was called into (V1, Administrator's) office and was fired. The request could have started back in March, but I'm not sure. I remember working on an ADR (Additional Documents Request) on the request, which is a way of only getting the things out of the chart that is requested, and not giving all the other stuff. (V4) called me and told me I did not need to do the ADR and to just send it to Corporate Legal. I was in the process of changing offices and had a lot of things going on at once, so the original request could have been back in March, but I have no control of it once it gets to Corporate. On [DATE] at 12:08 PM, V4, Regional Medical Records, The first time I was aware of (R2's) medical records request from the Attorney was on Thursday [DATE], when the facility called me after they Page 1 of 3 145655 145655 05/28/2025 Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. received a letter from the Attorney. I immediately called the Attorney's office and faxed the requested paperwork on Friday [DATE]. (V5) was not doing her job correctly, and that is why she was terminated. (V5) would send me a lot of things and I would have to tell her what to do with them. I do not remember seeing anything from (V5) regarding (R2), and there should not have been any delay with that request. If things are done correctly, it is a very smooth process and would have been processed immediately, especially from an Attorney. When I spoke with the Attorney's office, they were very understanding, was not upset, and felt like everything was ok. I do not remember talking to (V5) about (R2), however, it could have been via email, which I would have told her how to handle it. On [DATE] at 12:58 PM, V7, Attorney, stated I have assistants that request medical records and things like that, so I am not sure exactly when it was requested for (R2). I know that I don't send a letter or complaint to the State unless it is longer than 30-days, so I know it had to be later than that. I know we received paperwork from the facility this past Friday ([DATE]). On [DATE] at 1:14 PM, V8, Paralegal, stated We use an outside company to ask for medical record requests so I will reach out to them to get the original request to the facility. From what I can see, our report shows that the first fax was sent to the facility on [DATE] at 2:29 PM. We then called the facility on [DATE] but was unable to talk to someone about it. We did receive all of the requested records this past Friday [DATE] which was given to (V7) for his review. V3's Email, dated [DATE], sent to V1 and V5, documents I have attached what was received today [DATE] via mail for a medical records request on (R2). I have the original if needed. The attachment was the medical record request for R2, dated [DATE]. V8's Email, dated [DATE], documents I spoke with our team at (medical records company) and they said that the fax number was auto populated in their system, but they called and followed up with the facility to confirm receipt. The facility confirmed the fax had been received on [DATE]th by (V5). This was the first time we were able to contact a live agent. We had called the facility 8 times prior to try and confirm receipt. However, I did a quick google search of the fax number to double check it and found multiple sites that provide the same fax number for (this facility). All timestamps are shown in the client portal I originally sent you (MR request tracking), but I have attached our original fax including our medical authorization and all necessary documents for release, which was sent on [DATE], and the violation fax that was sent on [DATE]. The same request had also been mailed to the facility on [DATE]. The Medical Record Request Tracking, dated from [DATE] to [DATE], documents several faxes were sent to the facility's (Fax Number B), including the first medical record request dated [DATE], as well as multiple phone calls to the facility's main phone number. The facility's website documents the facility's fax number is (Fax Number B). On [DATE] at 4:00 PM, V1 verified the facility's fax numbers and stated The (Fax Number A) is the secured fax/email number, and the (Fax Number B) is the one that goes directly to our copier/fax machine and does not go to anyone's email. So, if anyone faxes to (Fax Number B), it would have been picked up by someone. On [DATE] at 2:40 PM, V1 stated I am supposed to be notified of any medical record request, and I was not notified of (R2's) request until the email sent by (V3) on [DATE]. A medical record request can come two ways, one by email/fax - comes as an email (Fax Number A), and the other as a regular 145655 Page 2 of 3 145655 05/28/2025 Bria of Woodriver 393 Edwardsville Road Wood River, IL 62095

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation. fax (Fax Number B). If it comes as an email/fax, then (V3) would get it, and if it comes by regular fax, then most likely (V5) would have gotten it. I would expect anyone who receives a medical record request to make sure I am aware of it as mentioned in the policy. The Facility's Resident Rights Policy, dated [DATE], documents The facility shall: follow HIPAA (Health Insurance Portability and Accountability Act) guidelines. This includes insuring that residents have personal privacy, access to their personal records upon request and that the privacy and confidentiality of their records is protected. The Facility's Medical Records Request Policy, dated 9/2024, documents General: To provide a process for Medical Record Requests. Responsible Party: Medical Records, Administrator. Guidelines: 1. All requests for medical records will be given to the Administrator. 2. If the request is determined to be in anticipation of litigation, the RNC (Regional Nurse Consultant) will complete a review of the medical record. 3. Once a medical record review is complete and the requesting party has been determined to have authority to obtain a copy, the facility will notify the requesting party of the cost of copies. 4. All parties requesting copies of medical records will be charged for the copies in accordance with State regulations. 5. The Administrator may, after consultation with the RNC, waive the copying cost in order to reduce the likelihood of litigation. 6. Medical records should be sent offsite to be scanned in order to reduce copying costs. 145655 Page 3 of 3