Health inspection·February 20, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of his or her own personal medical records for 1 (Resident #94) of 2 residents investigated for privacy of medical records. Residents Affected - Few The facility failed to ensure when Resident #93 discharged from the facility Resident #94's Personal Private Information was not handed to Resident #93's Resident's representative. This failure could place residents at risk of having medical information exposed to others and possible misuse of personal information. Findings included: Review of an attachment to the complaint intake revealed two pictures of a document that was discerned to be Resident #94's Face Sheet which contained Resident #94's name, birthdate, social security number and all diagnosis. In an interview on 02/14/2025 at 10:21 AM with the resident representative for Resident #93 the resident representative stated that she had been at the facility to assist with the discharge of Resident #93 when she was handed Resident #93's medical/personal records by an unknown staff member. She stated it was not until a few days later that she discovered that the facility had also included Resident #94's face sheet. In an interview on 02/20/2025 at 2:12 PM , the DON stated after reviewing the pictures of the documents in the possession of Resident #93's resident representative that the documents were the Face Sheet for Resident #94. She stated that the incident must have happened two years ago, but that all staff should always be aware of protecting resident information. She stated that they have not had any other similar incidents in the past 12 months that she had been working as the DON at the facility. She stated it was important to protect resident private/medical information or residents could be at risk of psychological or financial harm. Record Review of facility provided policy, Labeled, Protected Health Information (PHI) Management and Protection, date Revised on April 2023, stated: Policy Statement: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. Policy Interpretation and Implementation: (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 6 Event ID: 676413 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 676413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044 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)