Health inspection·November 21, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure confidential medical information was maintained in a safe and secure manner. This affected one resident (#137) of one resident reviewed for privacy. Residents Affected - Few Findings include: Review of the medical record for Resident #137 revealed an admission date of 10/30/19 with diagnoses including major depressive disorder, dementia, heart disease, mass and/or lump in neck, obstructive and reflux uropathy, anemia, moderate protein-calorie malnutrition. Review of most current Minimum Data Set (MDS) 3.0 assessment, dated 11/06/19 revealed the resident exhibited cognitive impairment with a Brief Interview for Mental Status (BIMS)score of three. Interview on 11/18/19 at 10:54 A.M. with Resident #137's daughter revealed when she arrived to take her mother to a cardiologist appointment her packet of information was not available. Licensed Practical Nurse (LPN) #269 told her it was given to the family that left earlier to another appointment. Resident #137's information was printed again and she left to the appointment with her mother. Interview on 11/21/19 at 9:03 A.M. with the Director of Nursing (DON) reported being present when the information needed printed out again for Resident #137's daughter and she thought that was unusual. The DON revealed the printed information that had been printed prior had been given to another resident's family. Interview on 11/21/19 at 9:44 A.M. with Office Personnel #290 revealed she scheduled the appointments, printed out the required documents prior to the appointment, placed the information in an envelope and delivered the envelopes to the units the day before the appointment date. She reported on this date, Resident #137's envelopes was stuck to another resident's information and both packets were given to the other resident's family member. Interview on 11/21/19 12:18 P.M. LPN #269 revealed she worked the day the information was given to the wrong family. She did not realize she had given Resident 137's envelope of information to the wrong family. She discovered it was not available when she could not find it for Resident #137 and her daughter. LPN #269 left the floor to print out the required documents and while she was gone, the pharmacy tech was able to print out the information after confirmation from the DON. She stated both parties returned to the facility but did not know what happened to the documents. Review of the Notice of Privacy Practices policy, reprinted from the HIPAA Privacy Reference Manual, revealed how medical information may be used and disclosed and how you can get access to this (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 5 Event ID: 365800 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 365800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Woods 12340 Bass Lake Road Chardon, OH 44024 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)