Health inspection·April 16, 2021

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 Based on record review and interview, the facility failed to issue proper notices to inform each resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. This affected one of three residents reviewed. (Resident #22) Residents Affected - Few The findings include: On 4/14/2021 at 3:03pm, the Business Office Manager provided the survey team with three incomplete Beneficiary Notice forms. She inquired about possible changes in the Skilled Nursing Care Advanced Beneficiary Notice (ABN), Centers for Medicare and Medicaid (CMS) form 10055. She was advised to provide the documentation that was given to the residents selected for the beneficiary notice task. On 4/14/2021 at 3:21 pm, the Social Services Director provided the survey team with incomplete beneficiary notice forms. The ABNs, CMS forms 10055, were incomplete and not signed by the residents, and there were no Notice of Medicare Non-Coverage (NOMNC), CMS forms 10123 found for the residents. The form for Resident #22 indicated the last day of coverage was 1/20/21 with days not exhausted and a facility initiated discharge,. On 4/15/2021 at 4:53 pm, the Business Office Manager confirmed that the NOMNC's were not given to any of the residents. She confirmed this with the Social Services Director. On 4/16/2021 at 12:53 pm, the Social Services Director confirmed that she is responsible for issuing the cut letters. She stated that she inherited the duty when the building was purchased by the current owners and the previous Business Office Manager retired. She had not received any training, but knew they needed to be done and so she began doing them to the best of her knowledge. She was not familiar with the NOMNC. . 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: 105002 Printed: 05/28/2026 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 105002 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beach Street Health and Rehabilitation Center 1001 S Beach Street Daytona Beach, FL 32114 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)