Inspection·November 16, 2023

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 closed record review, review of court records, review of facility policy and interviews, the facility failed to timely release requested resident records for Resident #49. This affected one resident (#49) of three reviewed for timely release of medical records. The facility census was 50. Findings include: Review of the closed medical record for Resident # 49 revealed an admission date of 08/13/21 with diagnoses including congestive heart failure, chronic kidney disease, primary hypertension, and malignant neoplasm of the bladder. The resident was discharged on 10/05/21 to his home with his wife. Review of a document from the Summit County Probate Court titled Order Authorizing Release of Descendant's Medical Records, dated 02/10/23, revealed the court had authorized the release of Resident #49's medical records to Resident #49's wife. Review of the facility documentation of a fax dated 03/02/23 revealed a medical records request was signed by Resident #49's wife and faxed to the facility medical records director which included a letter requesting the records, a copy of Resident#49 death certificate, a Court Order from The Probate Court of Summit County Authorizing Release of Decedent's Medical Records and a HIPAA Privacy Authorization Form. The form also indicated that pursuant to the (HITECH) Health Information Technology for Economic and Clinical Health Act the facility had 30 days from the date of request, March 2, 2023, to provide the records in the format requested. Further review of the closed medical record for Resident #49 revealed the facility did not mail Resident #49's requested medical records to the resident's wife/her legal council until 05/01/2023. Interview with the Director of Medical Records #102 on 11/16/23 at 1:11 P.M. confirmed she received the request for the release of Resident #49's medical records on 03/02/23 but did not mail them until 05/01/23. An interview with the Administrator on 11/16/23 at 2:05 P.M. revealed Residents #49's records were not released within 30 days because they had to go through a process of being reviewed by the corporate personnel and lawyers before releasing the records to Resident #49's wife. Review of the facility policy titled Release of Information, dated 10/21/16, revealed the following: The Resident may initiate a request to release information contained within his/her records to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed and dated request from the Resident or Legal Guardian. A Resident may have access to his/her records within (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: 366275 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 366275 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northfield Village Retirement Community 10267 Northfield Road Northfield, OH 44067 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)