Health inspection·March 20, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interviews, the facility failed to ensure a response to a billing grievance was responded to for one (Resident #1) of two residents reviewed for grievance process of thirteen sampled residents. Findings included: An interview was conducted on 03/19/2024 at 12:09 p.m. with a family member of Resident #1. The family member stated she was able to review the Medicaid Access Portal, which showed the resident's patient liability to be $1751.07 per month. The family member stated she overpaid, and she wanted a refund for the overpayment and the facility was sending her bills. The family member stated she called Business Office Manager (BOM) (former) about the billing error. The family member said she e-mailed a copy of the Notice of Case Action to (BOM/former), she stated the date on the e-mail was January 8th, 2024. Continuing, she stated I have not heard back, but I received another bill yesterday for $58.37. A record review of the business account for Resident #1, the Activity Report, documented on 01/08/2024, recd (received) call from [family member], she feels that we have the incorrect pt (patient) liab (liability); checked flmmis (Florida Medicaid Management Information System) and it matches our system, she is reaching out to DCF (Department of Children and Families.) An interview was conducted on 03/20/2024 at 4:45 p.m. with the Regional Business Office Manager (RBOM). She confirmed Resident #1 was currently being sent a bill for $58.37. The $58.37 was for one day in September 2023. Resident #1's bed had been held while he was in the hospital, Medicaid had been billed, and the last day of the bed hold was 09/02/2024. The RBOM confirmed the resident's family member had called in 01/2024 and by the notes in the account activity, the family member had questioned the patient liability. The RBOM confirmed the patient liability had changed from 08/2023 to 09/2023, but she did not know the reason for the change. When asked if the business office writes grievances for billing issues, the RBOM stated, maybe if the resident was current and he states he does not understand his bill, but, typically the concern is taken care of in the business office notes. The RBOM stated the former BOM took her vacation and left two weeks ago, and the RBOM confirmed she could tell from the business activity notes if the family member had been followed up with. A review of the facility's policy and procedure, Complaint/ Grievance, N-1042, last revised 10/24/2024, documented the policy: the Center will support each resident's right to voice a complaint/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and informed (sic) the resident of progress towards resolution. (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: 105587 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 105587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Countryside 3825 Countryside Blvd N Palm Harbor, FL 34684 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)