Health inspection·February 6, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident's medical records within the required 48-hour time frame for one of four sampled residents (Resident 7). This failure had the potential to deny the resident representative access to review records and delay critical legal or medical decision making for the resident. Findings: On February 4, 2025, at 4:05 p.m., a telephone interview was conducted with Resident 7's legal representative. The legal representative stated, a valid authorization and request for Resident 7's medical records were sent to the facility on January 16, 2025. A review of Resident 7's medical records indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (damage to an area of the skin) and diabetes mellitus (high blood sugar level). A review of the Minimum Data Set (an assessment tool) dated April 26, 2024, indicated no cognitive impairment. Further review of Resident 7's medical records indicated that Resident 7 was discharged home on July 8, 2024. On February 5, 2025, at 1:55 p.m., during an interview with the Medical Record Director (MRD), the MRD stated the residents could request their medical records at any time. The MRD stated a resident had to provide authorization for family members to request their medical records on their behalf. The MRD stated, the medical record requests were required to be processed and fulfilled within 24 to 48 hours. The MRD stated, he recalled receiving a medical record request from a legal representative on behalf of Resident 7 on January 16, 2025. A review of the letter sent by Resident 7's legal representative, dated January 16, 2025, indicated that Resident 7 had authorized the release of her medical information on January 8, 2025. The legal representative submitted a written request to the facility for the release of Resident 7's records on January 16, 2025. On February 5, 2025, at 2:25 p.m., during a follow up interview and record review with the MRD, the MRD stated he received the medical record request for Resident 7 on January 16, 2025. The MRD Page 1 of 2 555566 555566 02/06/2025 Corona Post Acute Center 2600 South Main Street Corona, CA 92882

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, he instructed the Medical Record Assistant (MRA) to forward the request to facility's corporate legal team via e-mail (electronic mail) the same day (January 16, 2025). The MRD further stated he did not hear back from the legal team until January 22, 2025. He further stated, he should have followed facility's policy and processed the request within the 48 hours. On February 6, 2025, at 5:15 p.m., during an interview with the Administrator (ADM), the ADM stated when the facility received medical record requests from attorneys, the facility's legal team assisted in reviewing the requests. The ADM stated, the facility's protocol required medical record to be provided within approximately 48 hours. The ADM further stated Resident 7's legal representative received the requested records on February 5, 2025, which was 14 business days after the facility initially received the request on January 16, 2025. A review of the facility 's policy titled, Release of Information, dated 2001, indicated, . residents may initiate a request to release such information contained in his/her records and charts 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 representative (sponsor) .A resident may have access to his or her records within 48 hours (excluding weekends or holidays) of the resident 's written or oral request . 555566 Page 2 of 2