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
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
- 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.