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 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 Page 1 of 3 105402 105402 01/12/2023 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating the refusal to sign and may list a witness to the refusal. The SNF should consider not furnishing the care. The regulatory instructions for NOMNC Signature and Date stated a Medicare provider or health plan (Medicare Advantage plans and cost plans , collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature. . 105402 Page 2 of 3 105402 01/12/2023 Bridgeview Center 350 S Ridgewood Avenue Ormond Beach, FL 32174

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure one (Resident #231) of 39 sampled residents had access to the call light while in bed. Residents Affected - Few The findings include: An observation was made of Resident #231 on 1/9/23 at 1:05 PM. She was in a double room in the bed nearest to the window and she had no roommate. No call light was seen near or next to the resident. She was asked where her call light was, but she was not able to locate it. During this time the call light was observed pinned to her privacy curtain. (Photographic evidence obtained) A second observation of resident #231's room on 1/9/23 at 2:20 PM. The call light was still hanging from the privacy curtain near the wall and out of the resident's reach. At this time Certified Nursing Assistant N was interviewed and reported that she had clipped the call light on the curtain 5 to 10 minutes ago. When asked where the call light should be in relation to resident, she stated, within reach of resident. On 1/11/23 at 12:25 PM, Resident #231's call light was observed on the floor out of reach of the resident. (Photographic evidence obtained) It was also observed that a red-colored drink had spilled in the resident's bed next to resident. On 1/11/23 at 2:10 PM, Resident #231's call light was seen hanging from the privacy curtain. (Photographic evidence obtained) The resident was asked how she got help without the use of her call light. She stated, I yell for it. She further stated if the call light was within reach, she would use it. An interview was conducted with Personal Care Assistant (PCA) P on 1/11/23 at 2:12 PM. She was asked how residents summoned for help when they were in their rooms. She reported, They use call light. She stated the call light should be next to the resident at bedside, next to their pillow. She confirmed that she did have Resident #231 on her assignment today, and the resident doesn't ask for help much. At this time PCA P was asked to enter Resident #231's room and check the call light. She confirmed that the call light was not within reach of the resident and reported, I don't know why its hanging from the privacy curtain. Housekeeping must have come in and moved it. PCA P confirmed that the resident did know how to use her call light and had used it in the past. PCA P was observed moving the call light within reach of the resident. A medical record review was conducted and revealed an admission date of 1/6/23. The resident's diagnoses included wedge compression fracture of unspecified lumber vertebra, unspecified encounter for fracture with routine healing; malignant neoplasm, bronchitis, anxiety disorder, unspecified fracture of sacrum, mild protein calorie malnutrition, and depression. A review of the facility's policy titled Answering the Call Light (Undated) was reviewed. The policy noted the purpose of this procedure was to ensure timely response to the resident's requests and needs. The policy's General Guidelines read, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. . 105402 Page 3 of 3