Health inspection·January 17, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure a medication bubble pack labeled with resident information was kept secured and confidential when it was found on top of a treatment cart, in a hallway, for public view and access. This failure resulted in a resident's confidential medical information compromised and could potentially impact 154 residents. Findings: During a concurrent observation and interview on 1/8/25, at 10:50 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated recycle bins and boxes on top of them were moved from the hallway to the Office Manager's room. On inspection, inside the room were two gray bins. One bin had a brown box on top of it. The box was overflowing with paper documents, empty medication bubble packs labeled with resident information, and a cannula tubing dated 1/5/25. During a concurrent observation and interview on 1/8/25, at 11:00 a.m., with LVN 1, two treatment carts were in the hallway outside the Soiled Utility room. On top of one treatment cart were two white plastic bags with empty medication bubble packs with resident information labels. The top end of one plastic bag was open and resident labels were visible. These plastic bags with bubble packs were accessible to anyone who uses the hallway including staff, residents, and visitors. A paper document inside the bag could be read from the outside. This paper document had resident names and vital signs information. On top of the second treatment cart was a gray plastic wash basin which had an empty medication bubble pack with resident information label visible. The bubble pack label had resident first and last names, name of medication, dosage, and route of administration. During an interview on 1/8/25, at12:10 p.m., with Director of Staff Development (DSD), DSD stated medication bubble packs were not supposed to go in the boxes for shredding. DSD added there should not be any tubing in boxes. Per DSD, boxes should be in a private location and should be behind locked doors. DSD stated it was everyone's responsibility to protect patient information. During an interview on 1/8/25, at 12:30 p.m., with Medical Records (MR) staff, MR stated she did not go through each box as they were someone else's trash. During an interview at 1:00 p.m., MR stated boxes were supposed to have lids for patient privacy. During an interview on 1/8/25, at 1:35 p.m., with Administrator (ADM), ADM stated the boxes should not be open due to patient confidentiality. Per ADM, MR is responsible for documents being properly handled. On medication bubble packs, patient information label should be ripped away. Tubing should Page 1 of 2 555446 555446 01/17/2025 Rossmoor Post Acute 1226 Rossmoor Parkway Walnut Creek, CA 94595

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not be in boxes. Plastic bags had to be in a box in Medical Records and bubble packs needed to be removed. During an interview on 1/17/25, at 8:16 a.m., with Director of Nursing (DON), the DON stated the concern is HIPAA (Health Insurance Portability and Accountability Act - federal law that protects medical records and personal health information) and protecting patient records and information is the responsibility of all staff. A review of the facility's policy and procedure (P&P) titled, Shred Policy Effective November 2024 , undated, the P&P indicated, The boxes will be kept in a secure location. All documents that have any patient information or any other confidential information will be placed in the box. A review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, dated 2001, the P&P indicated, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 555446 Page 2 of 2