Health inspection·November 19, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on interviews and record reviews, the facility failed to provide a copy of medical records to Resident 1 within 2 days after a written request was made by Resident 1 on 11/14/24. Residents Affected - Few This failure delayed Resident 1's right to obtain his medical records in a timely manner. Findings: During a review of Resident 1's, admission Record, dated 5/5/23, the admission record indicated that Resident 1 was his own Responsible Party (person responsible for making health care decisions). During an interview on 11/19/24 at 9:55 a.m. with Social Services (SS), the SS stated Resident 1 called on 11/4/24 to ask for a copy of his discharge paperwork. The SS informed Resident 1 he would need to fill out a medical records request form and send it back to the facility. The SS stated the medical records request form was sent to Resident 1 on 11/4/24. During an interview on 11/19/24 at 10:17 a.m. with Medical Records (MR), the MR stated she received a fax number from SS to send Resident 1's discharge paperwork to. The MR stated there was a protocol in place for medical record requests. The MR stated once a signed request for medical records was received, it must be uploaded into a shared drive for review and approval. The MR stated she got approval to send the documents to Resident 1 on 11/15/24 but was not aware of this approval because she did not follow up to confirm. During an interview on 11/19/24 at 10:22 a.m. with Resident 1 via cell phone, Resident 1 verified he had not yet received his medical records. Resident 1 verified the fax number given to the facility and stated he would wait for the requested discharge records to arrive. A review of Resident 1's Resident/Resident Representative Request for Access to Protected Health Information indicated, .Need discharge paper showing month/date/years .of [Resident 1] discharge . Resident 1's signature on the request was dated 11/14/24. During an interview on 11/19/24 at 11:19 a.m. with the Administrator (Admin), the Admin stated for a medical records request after 2 days, we have it to them. The Admin stated he was usually in the email group to see emails sent for approval. The Admin stated he did not see an email for this request. The Admin stated it was the expectation of the medical records request process the MR should gather requested documents, put them into a shared drive for approval, and within 2 days, issue the records. (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: 555105 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 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 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)