Health inspection·February 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 review and interview, the facility failed to ensure the resident or resident representative received the refund due the resident within 30 days from the resident's date of discharge from the facility for 1 of 3 residents sampled for financial status review, Resident #1. Residents Affected - Few Findings include: Review of Resident #1's admission record showed the resident was initially admitted to the facility on [DATE]. Review of Resident #1's physician order dated 10/13/2023 showed the resident will be discharged to an assisted living facility on 10/16/2023. Review of Resident #1's financial statement dated 2/21/2024 showed the resident has made a payment of $1,614.00 on 10/3/2023. The statement showed the resident was due $1,093.35 on 1/17/2024. During an interview on 2/21/2024 at 8:49 AM, Resident #1's Daughter stated that the resident had moved out on October 16, 2023, and she had not received a refund from the facility for unused days. During an interview on 2/21/2024 at 11:00 AM, the Business Office Manager (BOM) stated, [Resident #1's name] discharged to hospital on [DATE]. I sent refund status to [Third Party [NAME] Company's Staff] on 1/17/24 at 1:26 PM. I called third party billing company on 2/1/24 and asked the status of account for [Resident #1's name]. She told a prior employee left with no access to email with ledger for $1,093.35 due to a liability payment. Payment refund will be sent to [Resident #1's name] daughter. It was signed as accepted status on 1/17/24. During an interview on 2/21/2024 at 12:11 PM, Third Party [NAME] Company's Staff stated, [Resident #1's Name] refund has not been processed due to several employees quitting with no notice and no access to her email. It has been approved, processed and will be mailed today. Review of the facility contract signed by Resident #1 on 3/21/2023 reads, 13. Refunds payable shall be confirmed by audit by the Center's accounting office. All refunds due to the resident: a) shall be made regardless of the reason for the resident leaving.c) refunds will be made for any prepaid room and board services for which payment has been received. The refund of the unused portion of prepaid fees and charges will be made within 30 days following resident's death, refunds will be made in accordance with state and federal law) in cases where third party coverage is involved (Medicare, Medicaid, Insurance) refunds may be delayed until formal determination and documentation of a (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: 105597 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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)