Resident 37 asked for her medical records on March 9. Medical Records Manager 218 told her the copier was broken but promised to provide copies once it was repaired.
The copier was fixed that same day.
The manager never offered the records to the resident again. When inspectors interviewed her in September, she pointed to a pile of papers on her desk and confirmed those were the resident's copied medical records. She said the resident had never asked again, so the records just sat there.
The resident told inspectors she had been waiting since March and never received her records.
Resident 37, who has multiple sclerosis, COPD, anxiety, and PTSD among other conditions, is cognitively intact according to her assessment. She can eat independently and handle her own upper body dressing and personal hygiene, but needs help with medications and some other daily activities.
Federal law requires nursing homes to provide residents access to their medical records upon request. The facility's own policy, dated September 2021, confirms residents have the right to access their medical records at any time.
The inspection found New Lebanon Rehabilitation violated this requirement for one of 96 residents at the facility. The violation was classified as causing minimal harm or potential for actual harm to few residents.
During the September 24 interview, the medical records manager acknowledged the resident had requested her records six months earlier. She confirmed telling the resident about the broken copier and promising delivery once repairs were complete.
But she made no effort to follow through after March 9, despite the copier being operational.
The resident, meanwhile, continued waiting. She told inspectors she had requested the records but never received them, exactly as she had been told to expect once the equipment was fixed.
The copied records remained untouched on the manager's desk through the summer and into fall, when federal inspectors discovered them during their complaint investigation.
New Lebanon Rehabilitation operates as a 96-bed facility in southwestern Ohio. The September inspection was conducted in response to a complaint, though the specific nature of the complaint that triggered the investigation was not detailed in the available records.
The facility's Release of Information policy explicitly states that residents have the right to access their medical records at any time. This policy, established in September 2021, aligns with federal regulations requiring nursing homes to provide residents or their legal representatives with access to or copies of all resident records.
The medical records manager's explanation that the resident never asked again after the initial March request highlights a fundamental misunderstanding of the facility's obligations. Once a resident requests their records, the facility must provide them regardless of whether the resident makes follow-up inquiries.
The violation demonstrates how administrative failures can deny residents their basic rights. Resident 37's medical history includes serious conditions requiring ongoing monitoring and care coordination. Access to her complete medical records could be essential for her healthcare decisions or for sharing information with other providers.
The six-month delay meant the resident was unable to access documentation of her care, medications, test results, or treatment plans during that entire period. For someone managing multiple chronic conditions including multiple sclerosis and COPD, such records access can be critical for continuity of care.
Federal inspectors classified this as a complaint investigation, suggesting someone reported the facility's failure to provide requested records. The inspection focused specifically on medical records access, reviewing policies, interviewing staff and the affected resident, and observing the physical evidence of the undelivered records.
The facility must now submit a plan of correction addressing how it will ensure residents receive requested medical records promptly and how it will prevent similar delays in the future.
Resident 37's experience illustrates how simple administrative oversights can escalate into federal violations. What began as a routine records request became a six-month denial of basic resident rights, discovered only when inspectors found the forgotten paperwork gathering dust on a manager's desk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Lebanon Rehabilitation and Healthcare Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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