Inspection·April 3, 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. Based on record review, interview, review of Authorization for Release of Specialized Privileged Information and facility policy review, the facility failed to provide copies of the medical record to Resident #8's representative. This affected one resident (#8) of one resident reviewed for medical record requests. The facility census was 89. Findings include: Review of the medical record for Resident #8 revealed an admission date of 07/19/22. Medical diagnoses included cerebral atherosclerosis, chronic obstructive pulmonary disease, generalized anxiety disorder, and vascular dementia. Review of the emergency contacts for Resident #8 revealed the resident's daughter was the only emergency contact listed. Review of the medical record did not contain documented evidence that the facility processed a request for medical records to be received by Resident #8's representative. Interview on 04/02/24 at 10:51 P.M. with Resident #8's representative revealed she made a verbal request to the Administrator for release of medical records related to dental services provided at the facility. Resident #8's representative stated that she was denied access to the dental records in Resident #8's medical records due to the dental services being provided by a third party. Interview on 04/02/24 at 3:53 P.M. with the Administrator confirmed she had denied access for Resident #8's representative to have copies of dental records. The Administrator stated it would be a breach of the Health Insurance Portability and Accountability Act (HIPAA) if she were to provide prints of services provided by third party providers. However, the Administrator further stated she read the results from the dental visit in question to Resident #8's representative, so she was aware of the results. The Administrator stated that the facility does not provide any third-party medical records such as lab work, imaging, or wound care. Review of the document titled Authorization for Release of Specialized Privileged Information revealed the opportunity to have the following information released: • Discharge Summary (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 4 Event ID: 365412 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 365412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483 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)