Health inspection·April 18, 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 Based on interview and record review, the facility failed to provide Medicare coverage and liability notice to resident representative for 1 of 3 residents reviewed for notice of Medicare non coverage, Resident #1. Residents Affected - Few Findings include: Review of Resident #1's admission record showed Resident #1's daughter as the responsible party, with the power of attorney for financial affairs, healthcare Surrogate, and care conference person. Review of Resident #1's medical records showed Health Care Surrogate signed by Resident #1 on 4/11/2005, appointing Resident #1's Daughter as health care surrogate. Review of Resident #1's care plan initiated on 1/23/2024 showed a focus for impaired cognition as evidence by decision making problem, short term memory deficit, long term memory deficit, and problems understanding others. Review of Resident #1's MDS (Minimum Data Set) dated 1/29/2024 showed BIMS (Brief Interview for Mental Status) score of 5 (severe cognitive impairment) under Section C. Cognitive Patterns. Review of Resident #1's Determination of Incapacity form dated 12/18/2023, showed the resident lacked the capacity to give informed consent to make medical decisions. Review of Resident #1's Transaction Report for the period from 2/1/2024 through 3/31/2024 showed a total due from Medicare A- Coinsurance Private of $4080.00 under Medicare A- Coinsurance Private from 2/1/2024 to 2/19/2024. Review of Resident #1's Insurance Explanation Courtesy Letter dated 1/22/2024, read, This year's rate is $204.00 per day. We have verified your Medicare Supplement Insurance benefits and will bill this copay to your insurance as a courtesy after Medicare has paid their portion. Your insurance company has stated that they will pay the below percentage of this copay until your benefits are exhausted. Your portion will be billed to you on a weekly basis and will be due upon receipt. Please note, if we have not received payment from your insurance company within 45 days of billing, payment in full will be expected from you or your loved one. Date Copay Begins: 01/22/2024 . Days of Copay: 9. Review of Resident #1's Activity Report showed financial statements generated on 2/6/2024 with a balance of $1,224.00, on 2/16/2024 with a balance of $3,264.00, and on 2/23/2024 with a balance of $4,488.00. (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: 105571 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 105571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607 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)