Health inspection·November 30, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC, notice informing the resident that Medicare covered services will end) was issued in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the decision to discontinue Medicare covered services. Residents Affected - Few Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and her primary payer source was Medicare. The medical record indicated Resident 1's last day of Medicare covered services was on 10/3/23. Resident 1 was discharged from the facility on 10/4/23. Review of Resident 1's NOMNC indicated her Medicare covered services would end on 10/3/23. The NOMNC had typewritten instructions on how to appeal the decision to end Medicare covered services. The NOMNC had a section designated for the resident to sign in order to acknowledge she received the notice. Resident 1 signed this section on 10/3/23. The NOMNC also had a section designated to be filled out if the resident refused to sign the notice. This section was not filled out. Further review of Resident 1's medical record indicated there was no documentation that the facility attempted to issue the NOMNC to the resident prior to 10/3/23. There was no documentation that Resident 1 refused to sign the NOMNC at any time prior to 10/3/23. During an interview and concurrent record review with the social services director (SSD) on 11/30/23 at 12:09 p.m., she explained it was important to issue the NOMNC because it contained directions on how to file an appeal. The SSD stated the NOMNC should be issued two days before Medicare covered services end. She reviewed Resident 1's NOMNC and confirmed the resident signed the form on 10/3/23 (the same day Medicare covered services ended). The SSD stated she thought the facility tried to issue the NOMNC earlier, but the resident may have refused to sign. However, the SSD acknowledged that the portion of Resident 1's NOMNC designated to be filled out if the resident refused to sign was not completed. The SSD acknowledged that if Resident 1 received the form on 10/3/23, she did not have enough time to file an appeal. During an interview with the director of nursing (DON) on 11/30/23 at 4:04 p.m., she verified the facility was not able to find documentation that they attempted to issue Resident 1's NOMNC prior to 10/3/23. According to The Centers for Medicare & Medicaid Services (CMS.gov), The NOMNC must be delivered at (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: 055871 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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)