Health inspection·March 20, 2025

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, staff interview, and policy review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055 form) to 1 of 3 sampled residents reviewed for beneficiary notices. The SNF ABN provides information to beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. (Resident #64) Residents Affected - Few The findings include: Based upon facility documentation, Resident #64 was discharged from a Medicare Part A stay on 2/24/25 and remained in the facility. Review of the Beneficiary Notification review form (CMS 20052) completed by the Business Office Manager (BOM) on 3/18/25 revealed the facility initiated the discharge of Resident #64 from Medicare Part A services when benefit days were not exhausted. The form indicated the SNF ABN (CMS 10055) was not provided to the resident because the resident was not picked up under skilled Medicare Part B services. An interview was conducted with the Administrator on 3/18/25 at 1:11 PM. The Administrator confirmed the notice (SNF ABN) was not served to the resident and agreed if the resident was discharged from Part A and remained in the facility, the resident should have received the SNF ABN notice. Review of the facility policy for SNF Advance Beneficiary Notification (ABN) & Notice of Medicare Provider Non-Coverage (BO-510 revised 5/1/18) revealed that the SNF Advance Beneficiary Notification (SNF ABN) & the Notice of Non-Coverage will be used to properly notify a Medicare Part A resident and/or responsible party of the clinical team decision that the resident, no longer meets the Medicare criteria for daily skilled services. SNF's must provide the Notice of Medicare Provider Non-Coverage and the SNF ABN to Medicare beneficiaries no later than two days before the effective date of the end of the coverage that their Medicare coverage will be ending. 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 3 Event ID: 105148 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 105148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Emerald Shores 626 N Tyndall Pkwy Callaway, FL 32404 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)