Health 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 Page 1 of 4 365412 365412 04/03/2024 Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

F 0573 • Level of Harm - Minimal harm or potential for actual harm Nurses Notes • Residents Affected - Few Physician Progress Notes • Physician Orders • Lab Work • X-Rays • Psychosocial Documents • Dietary • Activities • Restorative Nursing • Therapy Review of the facility provided table of medical record copy prices revealed the patient or the patient's personal representative had an opportunity to request copies of imaging such as X-Ray, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) at a set cost. Interview on 04/02/24 at 3:53 P.M. with the Administrator was unable to say why there was information regarding the cost of receiving imaging results on the medical record copy prices chart since they do not provide certain third-party documentation. Review of the undated policy titled Medical Records Request revealed if a request is made by the 365412 Page 2 of 4 365412 04/03/2024 Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

F 0573 Level of Harm - Minimal harm or potential for actual harm patient or patient's personal representative, or an individual authorized to access the patient's medical records, total costs for copies and all services related to those copies shall be made reasonable. This deficiency represents non-compliance investigated under Complaint Number OH00151861. Residents Affected - Few 365412 Page 3 of 4 365412 04/03/2024 Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of self-reported incident (SRI) and facility policy review, the facility failed to thoroughly investigate an allegation of sexual abuse as required. This affected one resident (#47) of three residents reviewed for abuse. The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #47 revealed an admission date of 03/04/24. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, epilepsy, essential hypertension, and generalized anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired and had hallucinations. Review of SRI #245110 dated 03/11/24 revealed Resident #47 alleged she had been raped. She was interviewed by three different staff members on three different occasions, all findings were inconclusive. Further review of SRI #245110 revealed no documented evidence of a skin assessment for Resident #47 and no interviews conducted with like residents or staff members. Interview on 04/01/24 at 10:46 A.M. with the Administrator stated because of the SRI investigation Resident #47's medications were reviewed and adjusted on 03/29/24 due to increased confusion. The Administrator stated that information collected from the interviews with Resident #47 revealed there was no conclusive evidence that sexual abuse occurred. Interview on 04/01/24 at 1:30 P.M. with the Director of Nursing confirmed no skin assessment was completed on Resident #47 after the sexual abuse allegation was made. Interview on 04/01/24 at 1:42 P.M. with the Administrator stated no like residents were interviewed as the like residents were all confused, and interviews would have been inappropriate. The Administrator further confirmed no skin assessments were completed on like residents, and no staff were interviewed who worked with Resident #47. Interview on 04/01/24 at 5:02 P.M. with the Administrator confirmed since Resident #47 was so confused she did not find it appropriate to send the resident to the hospital to have a rape test completed. The Administrator stated she felt that would have caused more harm than good and denied offering opportunity for Resident #47 to be sent to hospital to the resident's Power of Attorney (POA). Review of the facility policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, dated 2016, revealed it is the facility's policy to investigate all allegations, suspicious and incidents of Abuse, Neglect, Misappropriation of Resident Property and Exploitation, as well as injuries sustained by its residents. The investigation protocol included interviewing the resident, the accused as well as all witnesses. If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit or shift. Lastly, to review the resident's records. This deficiency represents non-compliance investigated under Complaint Number OH00152182 and Complaint Number OH00152024. 365412 Page 4 of 4