Health inspection·April 29, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond in a timely manner to a request for medical records for Resident 1, 1 of 1 sample resident. Failure to provide requested medical records in a timely manner violated Resident 1's right to access her medical records. Additionally, the facility's policy of subjecting residents to a wait of 30-60 days before providing a copy of their medical records does not meet the regulatory definition of timely provision of medical records upon request. Findings: During an interview on 04/25/2024 at 12:16 PM, the Complainant stated she faxed a medical record request to the facility on [DATE] and followed up with two voicemails on 04/05/2024 and 04/08/2024 asking about the requested medical records. The Complainant stated as of today (36 days later), she still has not received the requested medical records for Resident 1. Nor has the facility contacted her regarding her request. The Complainant then provided this Department with a copy of a medical record request faxed to the facility, including the fax confirmation page and dates and time of voice mail communications with the facility. During an interview on 04/29/2024 at 11:17 AM, the Assistant Director of Nursing (ADON) stated the facility will respond to a medical record request within .24 to 48 hours . The ADON was shown a fax for a medical record request for Resident 1. The confirmation page from the fax indicated it was sent 03/19/2024 and documentation within the fax indicated the fax was received by the facility. After viewing the fax confirmation page, the ADON confirmed the fax phone number was indeed the fax number for the facility. The ADON said the facility never received the fax. The ADON was asked if the complainant had called back to follow up on the fax request. The ADON stated I remember hearing her voice mail and writing her name down .I just forgot to call her back. On 05/02/2024, the facility was asked to provide their policy regarding medical record requests. Review of a facility policy titled Protected Health Information (PHI), Residents' Rights Relative to, revised on March 2014, indicated .Our facility will act upon a resident's request for access to his/her medical records or other information no later than thirty days after receipt of such request, unless the time period is extended as described below: a. If the information to be accessed is not maintained or accessible on premises, our facility will act upon such request within sixty (60) days of receipt of such request. b. lf the facility is unable to act on the request within the applicable thirty (30) or sixty (60) day period, the facility may extend the time for response by thirty (30) days, provided that the resident is given a written notice of the reason(s) for the delay and the date by which a responsive action will be taken. (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: 555856 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 555856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010 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)