Health inspection·February 4, 2021

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send quarterly personal fund account balance statements to resident's responsible party for 1 of 3 sampled residents reviewed for personal funds, (#2). Findings: Resident #2 was admitted to the facility on [DATE] for long term care. His diagnoses included Alzheimer's disease dementia with behavioral disturbances. A review of the face sheet revealed Medicaid was his payer source. A review of the medical record revealed his most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status could not be completed because the resident was never/rarely understood, had both long term and short term memory problems, and had severely impaired cognitive skills for daily decision making. On 2/2/21 at 2:18 PM, a phone interview was conducted with resident #2's designated responsible party and durable Power of Attorney (DPOA). She acknowledged the resident was a Medicaid recipient. She said he had a trust fund with the facility's business office but she had not received statements of his account balance from the facility' business office for the last few years. The address of resident #2's responsible party/POA was documented on the information page in the resident's electronic medical record (EMR). The address in the EMR was confirmed by the responsible party as her correct current address. On 2/3/21 at 5:30 PM, interview with the Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and the Regional Business Office Director (RBOD) acknowledged that resident #2 had Medicaid as his payor source. They acknowledged that he had a personal trust fund account with the facility. They also acknowledged the resident was confused and had a responsible party/financial and medical POA family member. Review of resident #2's business office record revealed the POA paperwork had been signed by the family member and the resident as of 4/21/16. The responsible party/POA had signed a Resident Trust Account Agreement and Beneficiary Form on 11/3/17. The facility directly received the resident's monthly Social Security checks for direct payment. A review of the form read that the responsible party's address was in a different state. Review of resident #2's 2020 quarterly trust fund statements revealed that they had been sent to an address in a different state. The BOM, ABOM, and RBOD acknowledged that they were unaware of the responsible party's address change and the business office electronic system and the medical records electronic system did not automatically synchronize address changes. They said address changes had to be manually input in the business Page 1 of 6 106029 106029 02/04/2021 Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few office's electronic program. They said the interdisciplinary team had not communicated the change of address to them. They noted the updated address information should have been relayed to the business office. The ABOM said that according to their documentation, the last time they had called and spoken to the resident's responsible party was on 6/26/2018. Review of the facility's policy and procedure, Resident Trust Fund, included that balance statements were to be mailed to the resident and/or responsible party on a quarterly basis. 106029 Page 2 of 6 106029 02/04/2021 Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the designated responsible party when a resident's Medicaid trust fund monies were within $200.00 of the Social Security Income limit for 1 of 3 sampled residents reviewed for personal funds, (#2). Residents Affected - Few Findings: Resident #2 was admitted to the facility on [DATE] for long term care. His diagnoses included Alzheimer's disease dementia with behavioral disturbances. A review of the face sheet revealed Medicaid was his payer source. A review of the medical record revealed his most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status could not be completed because the resident was never/rarely understood, had both long term and short term memory problems, and had severely impaired cognitive skills for daily decision making. On 2/2/21 at 2:18 PM, a phone interview was conducted with resident #2's designated responsible party and durable Power of Attorney (DPOA). She acknowledged the resident was a Medicaid recipient. She said he had a trust fund with the facility's business office but she had not received statements of his account balance from the facility' business office for the last few years. The address of resident #2's responsible party/POA was documented on the information page in the resident's electronic medical record (EMR). The address in the EMR was confirmed by the responsible party as her correct current address. Review of resident #2's 2020 quarterly trust fund statements revealed they had been sent to the incorrect address. On 2/3/21 at 5:30 PM, interview with the Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and the Regional Business Office Director (RBOD) acknowledged they were unaware of the responsible party's address change. They said the business office's electronic system and the medical records electronic system did not automatically communicate address changes to each other. They added that the interdisciplinary team had not communicated the address change to them and they did not know who currently lived at the address where the resident's statements were being delivered. Review of resident #2's personal fund balance as of 2/3/21 was $4,231.00. They said that he received $130.00 monthly from his Social Security check. The remaining monthly balance was used for care and services received at the facility. On 2/3/21 at 6 PM, the BOM and RBOD said $1800.00 of the $4,231.00 dollars came from two federal Corona Virus Disease 2019 (COVID-19) stimulus checks, received on 7/29/2020 for $1200.00 and on 1/22/21 for $600.00. She said the $1800.00 was not required to be spent down for one year, a deadline of July 1, 2021. They acknowledged the remaining $2,231.00 in resident #2's trust fund was $231.00 over the Medicaid allowed amount of $2000.00. They said their process was to send a letter to the responsible party when the resident's trust fund amount was within $200.00 of the state limit. They said a letter had been sent but to the incorrect address. They acknowledged the $231.00 should have been spent down by 1/31/21 but had not been as it was mailed to the wrong address. The RBOD acknowledged 106029 Page 3 of 6 106029 02/04/2021 Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident could lose Medicaid eligibility as the money had not been spent down prior to 1/31/21. When asked if they had attempted to contact the resident's POA by telephone, the ABOM said the last time they called and spoke to the resident's responsible party was 6/26/2018. Review of the Resident Fund Balance Notification letter dated 1/14/21 from the facility noted that it had been sent to the old address rather than the responsible party's current address. A phone interview on 2/4/21 at 11:03 AM with resident #2's responsible party/POA noted that she had not received the letter informing her of the surplus $231.00 which could potentially affect the resident's Medicaid eligibility. The resident's POA stated that she would have liked to use the money to purchase a burial plot with any monies that might have been in his personal account. Review of the facility's policy and procedure, Resident Trust Fund-Medicaid Resident Fund Balance within $200.00 of State Limit, BO-418 revision date 7/21/2020 included the following: The business office manager will notify the Medicaid resident/or responsible part when a Medicaid recipient's resident trust fund is within $200.00 of the State limit . The business office will review the Resident Trust Fund balance regularly for accounts that are within $200.00 of the State limit. The facility's director of social services must be notified when a Medicaid resident's account is within $200.00 of the State limit .A letter with a copy of the resident's trust fund account will be mailed to the resident or designated responsible party indicating that the resident's fund balance is approaching the resource limit allowed by Medicaid, and that Medicaid eligibility could be jeopardized if the trust fund balance exceeds the limited set by Medicaid . A copy of the letter and trust fund statement attached. The State limits as of June 2020: FL - $2,000 . . 106029 Page 4 of 6 106029 02/04/2021 Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746

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 fully inform residents of Medicare covered and non covered services for 2 of 3 sampled residents, (#24, #35). Residents Affected - Few Findings: Review of resident #24's Beneficiary Protection Notification revealed the last day of coverage for skilled services was 1/7/2021. A review of resident #35's Beneficiary Protection Notification revealed the last day of coverage for skilled services was 1/5/2021. On 02/04/21 at 12:08 PM, the Regional Business Office Director revealed that 2 residents (#24, #35) did not get the Notice of Medicare Non-Coverage (NOMNC). The Regional Director was unable to provide the documents and stated the NOMNC was not issued as the Assistant Social Service Director was new and was not educated on the Policy and Procedures (P&P) for the Skilled Nursing Facility Advance Beneficiary Notification and NOMNC. The Regional Director said the facility should have provided the NOMNC no later than two days (48 hours) before the end of Medicare coverage so the residents were informed of their options since services were being discontinued. She added that as the residents did not receive this notice, they were not provided the option of appealing it. Review of facility's P&P effective date 11/30/2014 read, Skilled Nursing Facilities must provide the Notice of Medicare Provider Non-Coverage .to Medicare beneficiaries no later than two days (48 hours) before the effective date of the end of the coverage that their Medicare coverage will be ending. 106029 Page 5 of 6 106029 02/04/2021 Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately reflect the bladder and bowel appliance status on the Minimum Data Set (MDS) assessment for 1 of 40 sampled residents, (#26). Residents Affected - Few Findings: Resident #26 was admitted to the facility on [DATE] for therapy and nursing services. His admission diagnoses included cerebral infarction with hemiparesis affecting the right dominant side, epilepsy, and dysphasia. Review of resident #26's most recent quarterly MDS assessment dated [DATE] revealed in Section H Bladder and Bowel (B/B) the resident had a bowel or bladder ostomy appliance. On 02/01/21 at 12:45 PM, resident #25 was observed in his room. There was no evidence of a urinary catheter, bladder ostomy, and/or bowel ostomy. Review of resident #26's physician orders from November 2020 through February 2020 revealed no orders related to an B/B ostomy and/or urinary catheter. Review of the resident's comprehensive care plans did not reveal any care plan that included a bowel and bladder ostomy appliance and/or urinary catheter. On 2/4/2020 at 11:58 AM, during a review of resident #26's orders and care plans with the MDS coordinators, they acknowledged the resident did not have urinary catheter and no B/B ostomy appliance. They stated resident #26's 11/24/2020 quarterly MDS was assessed in error for B/B ostomies. They added the error was not identified by the facility, so a Correction MDS had not been completed and submitted. Review of the Center's for Medicare and Medicaid (CMS) Resident Assessment Instrument Version 3.0 Manual included the following instructions to facility personnel who were responsible for the residents' MDS assessments: .If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected. 106029 Page 6 of 6