Health inspection·March 4, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm 2) Review of Resident #1's medical record provided a request signed by Resident #1 dated 09/30/2024 for the disenrollment from the resident's current health insurance coverage to different health insurance coverage. The record did not provide documentation of an attestation signed by the facility staff that assisted with the change in enrollment for Resident #1 attesting that Resident #1 or the representative requested the change or that the beneficiary or representative received and understood the minimum required information. Residents Affected - Few During an interview on 3/4/2025 at 11:50 AM the Community Liaison stated, We do not have a sign attestation that we as a facility have reviewed all the information with the resident [Resident #1] and that the resident is the one requesting to dis-enroll and enroll into traditional Medicare. Based on interview and record review, the facility failed to ensure guidance was provided to 2 of 3 residents, Residents #1 and #2, of informed health status treatment and changes related to the enrollment/disenrollment from health plan coverage, and failed to develop a written policy and procedure regarding the process of assisting beneficiaries with changing their health care coverage. Findings include: 1) Review of the medical record for Resident #2 contained disenrollment paperwork signed by Resident #2 for the disenrollment from the resident's current health insurance coverage to different health insurance coverage. The record did not provide documentation of an attestation signed by the facility staff that assisted with the change in enrollment for Resident #2 attesting that Resident #2 or the representative requested the change or that the beneficiary or representative received and understood the minimum required information. The documentation was requested from the Community Liaison/Admissions Director. The Community Liaison/Admissions Directed stated, The facility staff did not sign an attestation. No additional documentation was provided. During an interview on 3/4/2025 at 12:00 PM, the Community Liaison/Admissions Director stated, Nursing, Therapy and MDS [Minimum Data Set] sit down and see what the residents' needs are and anticipate if a resident will need more than 100 days [in facility care and services]. If they are not progressing and need longer than 100 days, residents are provided with the option to disenroll from their insurance and go to regular Medicare, so they are not threatened to be cut off for therapy based on their insurance managed plan. There are weekly updates sent to the resident's insurance company and the insurance company usually gives us a heads up that they are only provided [the resident] a set number of days after the progress reports are received from us. We need to offer the option to dis-enroll prior to the first of the next month. We discuss the options of Medicare Part D, but [Name of Company] provides a zero deductible for all drugs that we provide here at this facility. We provide them the information to re-enroll. We do go over everything with them verbally, have the resident (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: 105649 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 105649 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Care Center 490 S Old Wire Rd Wildwood, FL 34785 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)