Inspection·February 29, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, resident interview, review of the facility handbook, and review of the facility policy, the facility failed to ensure resident personal and medical information was kept confidential. This affected four (Residents #18, #23, #36 and #37) of five records reviewed for privacy and confidentiality. The facility census was 59. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 08/29/23 with diagnoses including [NAME]-Danlos Syndrome, anxiety disorder, protein-calorie malnutrition, dysuria, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/08/23 revealed the resident was cognitively intact and required limited assistance with activities of daily living (ADLs.) Review of email records revealed the Administrator sent an email on 02/19/24 regarding Resident #10 with an attached Medicaid Pending Log to Resident #10, Ombudsman #107, Corporate [NAME] Representative #501, Hearing Officer #502, Business Office Manager #102, the Director of Nursing (DON), and Social Service Designee (SSD)#100. Review of the file attached to the email dated 02/19/24 titled Medicaid Pending Log revealed it included Resident #10's name, date of birth , Medicaid number, Medicaid application date and case manager progress notes. The form also listed Resident #18, #23, #36, and #37's names with a black line crossed through their names, but the names were still identifiable. Resident #18, #23, #36, and #37's date of birth , Medicaid number, Medicaid application date and case manager progress notes were also visible. Interview on 02/28/24 at 1:02 P. M. with the Administrator confirmed he sent the email with the Medicaid Pending Log to the Ombudsman, facility staff, and to Resident #10 on 02/19/24. Further interview with the Administrator confirmed he had crossed out the names of Residents #18, #23, #36, and #37 but the names were still visible. Interview with the Administrator further confirmed the Medicaid Pending Log attached to the email included personal and confidential information regarding Residents #18, #23, #36 and #37, and these residents had not consented to have their private health information shared with other residents. Interview on 02/28/24 at 5:30 P. M. with Resident #10 confirmed on 02/19/24 she received an email and a copy of the Medicaid Pending Log with her personal information along with private health information for Residents #18, #23, #36, and #37 from the Administrator. Review of the confidential information section of the employee handbook undated revealed disclosure (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: 365577 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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)