The resident, identified as R3 in inspection documents, was readmitted to the facility in December with end-stage renal disease, altered mental status, and a stage 4 pressure ulcer on their tailbone. Their family member submitted a written request for medical records on December 3.
The nursing home administrator initially denied the request because R3 was still making their own decisions at that time. But seven days later, on December 10, R3's Power of Attorney for Healthcare was activated, naming the same family member as their legal representative.
Nobody at the facility followed up on the original request.
When a federal inspector interviewed R3's healthcare agent on December 22, the family member confirmed they had never received any medical records. The form requesting the records "was not valid," they said, despite their new legal status giving them clear authority to access the information.
The nursing home administrator who signed the original denial told inspectors they "did not realize R3's Power of Attorney for Healthcare was not activated" when they rejected the December 3 request. The administrator acknowledged they "did not follow-up with the medical record request from 12/3/25 that was denied."
R3 couldn't sign the records release form themselves because they were hospitalized from December 2 through December 11. During this critical period, when the resident was receiving treatment elsewhere and their condition was deteriorating, their family had no access to their nursing home medical history.
The facility's own policy, updated in May 2025, states that medical record information is released "only upon receipt of a properly executed authorization from the resident for their legal representative." Once R3's healthcare power of attorney was activated on December 10, their representative had exactly that authorization.
Yet the facility's legal representatives told inspectors they "could not release the medical records due to R3 being their own person on 12/3/25" — ignoring the fact that R3's legal status had changed a week later.
The inspection revealed a gap between the facility's written policies and actual practice. While CHI Franciscan Villa had clear procedures for releasing medical records to legal representatives, staff failed to act when a resident's legal status changed, leaving a family member without access to critical healthcare information.
Federal regulations require nursing homes to provide residents or their legal representatives with access to all medical records. The violation occurred during a complaint inspection on December 23, suggesting someone reported the facility's failure to respond to the records request.
R3's case illustrates how administrative oversights can prevent families from accessing vital medical information during critical periods. The resident was dealing with multiple serious conditions — kidney failure, mental status changes, and a severe pressure wound — while their designated healthcare representative remained locked out of their medical records.
The facility received a citation for minimal harm with few residents affected, but the violation highlights broader concerns about nursing home responsiveness to families' legal rights. When residents can no longer advocate for themselves, their chosen representatives must be able to access the medical information necessary to make informed healthcare decisions.
The timing proved particularly problematic. R3's hospitalization from December 2-11 coincided with the period when their family member was seeking medical records and their power of attorney status was being activated. During those crucial days, the family had neither direct access to the resident nor access to their medical history from the nursing home.
CHI Franciscan Villa's failure to revisit the December 3 request after R3's legal status changed left a healthcare representative without the medical records they were legally entitled to receive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chi Franciscan Villa from 2025-12-23 including all violations, facility responses, and corrective action plans.