Grafton Oaks Nursing Center
GRAFTON OAKS NURSING CENTER in DAYTON, OH — inspection on August 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on medical record review, staff interview, and review of the facility policy, the facility failed to maintain the confidentiality of resident private health information.
This affected one (Resident #82) of three residents reviewed for confidentiality.
The facility census was 78 residents.
Findings include:
Review of the medical record for Resident #82 revealed an admission date of 07/01/25 with diagnoses including acute myeloblastic leukemia, type two diabetes mellitus, atherosclerotic heart disease, and hypertension and a discharge date of 07/14/25.
Review of the Minimum Data Set (MDS) assessment for Resident dated 07/07/25 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.)
Review of the discontinued physician orders for Resident #82 revealed an order for Lasix 40 milligrams (mg) one tablet daily for hypertension.
Review of the facility investigation dated 07/17/25 revealed Resident #82's medication card for Lasix 40 mg was given to another resident (Resident #81) at discharge.
Review of the investigation revealed Resident #81's family notified the facility they received Resident #82's medication in error.
Interview on 08/18/25 at 10:13 A.M. with the Administrator and the Director of Nursing (DON) verified staff accidently sent Resident #82's medication card for Lasix home with Resident #81 at discharge.
The Administrator stated Resident #81's family contacted the facility to inform staff of the error, but did not return the medication as requested.
Review of the facility policy titled Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security undated revealed it was the policy of the facility to protect the confidentiality of resident protected health information.This deficiency represents noncompliance investigated under iQIES Complaint Number 2582200.
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.
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