Health inspection·October 20, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure records were provided within 48 hours following a request by the resident's Responsible Party (RP) for one out of two sampled residents (Resident 1). This deficient practice resulted in the inability of Resident 1 and/or Resident 1's RP to access requested records and violated Resident 1's rights to have access to their records. Findings: During a review of Resident 1's admission Records (Face Sheet), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1's family member was listed as Resident 1's RP. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 7/10/2023, the MDS indicated, Resident 1's cognitive skills for daily decision-making were severely impaired. During a concurrent interview and record review on 10/20/2023, at 1:51 p.m., with the Medical Records Director (MRD), Resident 1's Medical Record Request was reviewed. The Medical Record Request, per the post mark on the envelope, indicated the Medical Records Request was mailed to the facility on [DATE]. The Medical Records Request indicated a fax confirming successful transmission of the Medical Records Request to the facility on [DATE] at 12:53 p.m. The Medical Record Request indicated, Resident 1's RP gave authorization via their signature for a 3rd party to have access to Resident 1's medical records, billing records from 1/2021 to present, the facility's administration and patient care policies and procedures and the posted nurse staffing data for the past 18 months. The MRD verified the fax number on the Medical Records Request was correct with a confirmation indicating the fax was sent successfully. The MRD stated the Medical Records Request was received at the facility on 10/16/2023 in the afternoon at 2 p.m., but she left the facility that day (10/16/2023) at 2:30 p.m. and forgot to open the mail and therefore did not give the Medical Records Request to the Administrator (ADM). The MRD stated she should have opened the mail prior to leaving the facility so she would know the contents in the envelope, to meet the expected deadlines. During an interview on 10/20/2023, at 2:20 p.m., the ADM stated they did not keep a log documenting when Medical Records Request were received. The ADM stated when the MRD was not available the Medical Record Requests should be endorsed to her (the ADM) but that was not done. During a review of the facility's policy and procedure (P&P) titled, Chapter IV Privacy and Page 1 of 2 555785 555785 10/20/2023 Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806

F 0573 Security, dated 7/13/2022, the P&P indicated: Level of Harm - Minimal harm or potential for actual harm 1. Send requested copies of the record by mail with return receipt requested within 48 hours (excluding weekends and holidays) of the receipt of a valid written request. Residents Affected - Few 2. Notify the following of receipt of request: Administrator/Executive Director Designated responsible person in Administration's absence Director of Nursing Services 3. Communicate with resident directly and/or telephone representative acknowledging request for inspection/copy 555785 Page 2 of 2