Health inspection·January 12, 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 Based on record review and an interview with the Social Worker, the facility failed to keep complete records of Notice of Medicare Non-coverage (NOMNC) and Advance Beneficiary Notice of Non-coverage (ABN) for two (Residents #30 and #40) of six sampled residents, discharged within the last six months, from a Medicare A-covered stay with benefit days remaining. Residents Affected - Few The findings include: A review of six residents' records with remaining Medicare Part A days, revealed that two residents (#30 and #40) had missing signatures on both the NOMNC and ABN forms. (Copies obtained) The signature areas had no information or date on either form. The two residents' ABN forms did not have an Options box selected, a signature, or a date of contact on them. On the NOMNC forms for the two residents, the signature area and date areas were blank. This form had an additional information (optional) area filled out, but did not indicate whether the residents had declined, planned to appeal, or were not available to sign the forms. A receipt for certified mail was given, but there was no verification with signature or verification of forms sent with receipt. An interview was conducted with Social Services Director on 1/12/23 at 11:54 AM. She stated she went to the resident and let them know about their remaining days if they were their own responsible party. She would call the family about the benefits ending, and mail the forms if the resident was not their own responsible party. She stated she sent the form via Certified mail. when asked how she obtained the signatures for the forms, she produced a receipt for certified mail, but here was no verification with signature or verification of forms sent with receipt. She reported she either mailed them or verified by telephone. She reported she usually got a phone call from the representative/family to verify the forms were mailed. She stated if the representative did not send the form back, she didn't have a signature. She replied that she had done it this way for 10 years. A review of the form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 and Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections (update 1/21/2022) was conducted. The Regulatory instructions for ABN Signature and Date were as follows: The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The Skilled Nursing Facility (SNF) may fill in the date if the beneficiary needs help. This date should reflect the date that the SNF gave the notice to the beneficiary in person, or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for the beneficiary, write (rep) or (representative) next to the signature. If the authorized representative's signature is not clearly legible, the authorized representative's name must be printed. If the beneficiary refuses to choose an option and/or refuses to sign the SNF ABN when required, the SNF should annotate the original copy of the SNF ABN (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 3 Event ID: 105402 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 105402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174 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)