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. (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 2 Event ID: 105423 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 105423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257 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)