Health inspection·May 21, 2024

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 record reviews, interviews, and facility policy and procedure review, the facility failed to ensure a refund was issued to the resident or resident representative within 30 days from the resident's date of discharge from the facility for three (Residents #1, #5, and #6) of six residents sampled for refunds. Residents Affected - Few The findings include: 1. Review of Resident #1's records revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 3/25/24. Review of Resident #1's refund request form dated 4/9/2024 revealed the facility had not refunded the total amount due to the resident. (Photographic evidence obtained) 2. Review of Resident #5's records revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 9/13/23. Review of Resident #5's refund request form dated 1/11/2024 revealed the facility issued a refund to the resident on 3/26/24. (Photographic evidence obtained) 3. Review of Resident #6's records revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 3/2/24. Review of Resident #6's refund request form dated 3/4/24 revealed the facility had not issued a refund to the resident. (Photographic evidence obtained) During an interview on 5/20/24 at 2:18 pm with the Business Office Manager (BOM), she reviewed the refund requests received from 12/23 to the present date (5/20/24). The BOM stated some of the refunds had not been issued or were issued past the required time. When asked why the refunds were issued past the due date or not at all, she replied, I cannot provide an answer for that. She confirmed the refund for Resident #1 was requested on 4/9/2024 and the total refund had not been issued. Resident #1's refund was being paid in increments at the family's request. The BOM stated the family had been dealing directly with their corporate office and therefore she could not provide any additional information. She stated the facility's corporate office is responsible for issuing the actual checks for requested refunds. She puts in the request for the full refund amount; however, she was not sure how corporate issued the actual refunds. When asked about the refund checks for Residents #5 and #6, she stated she would have to contact corporate for additional information. Page 1 of 2 105423 105423 05/21/2024 Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/20/24 at 3:08 pm, a follow up interview was conducted with the BOM regarding Residents #5 and #6's refund. She confirmed that Resident #5's refund was dated on 3/26/24, which was more than 30 days past the resident's discharge date . The BOM was not able to explain why Resident #5's refund was issued after the 30-day timeframe. The BOM explained the refund for Resident #6 was requested on 3/4/2024, however, the refund had not been issued. She said she would have to contact corporate for additional information. On 5/20/24 at 3:57 pm, the BOM provided a copy of the refund check for Resident #6 dated 5/12/2024. However, she confirmed the check had not been mailed yet, but was going to be mailed on 5/20/2024. On 5/21/24 at 10:37 am, a phone interview was conducted with the Corporate Controller, Employee A. He stated the refund requests are made at the facility and the corporate office is responsible for issuing the refund checks. He confirmed the refund for Resident #6 was issued after the 30-day timeframe which was an oversight. He confirmed the refund for Resident #1 was being sent in installments. He stated initially the check was issued for the full amount however, it had to be canceled due to fraudulent activity, not related to the requestor. He stated the facility wasn't able to retrieve the check and are awaiting a refund from their bank. He stated they are sending the refund in installments while they are awaiting resolution. Review of the facility's policy on Refunds, version 1.2 (H5MAPL0722) revealed: 2. Within thirty (30) days of a resident's discharge or death, the facility will refund the resident's personal funds and provide a final accounting of those funds to the resident, the resident's representative or to the resident's estate, as applicable. (Photographic evidence obtained) . 105423 Page 2 of 2