Inspection·August 1, 2019

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 medical record review, review of facility policy, staff interview and review of the Notice of Medicare Non-Coverage instructions, the facility failed to ensure residents and resident representatives were provided with advance notice of non-coverage of Medicare Part A skilled services. This affected three (#24, #112, #113) of four residents reviewed for beneficiary notices. The facility identified five residents discharged from skilled services in the last six months. The facility census was 62. Residents Affected - Few Findings include: 1. Review of the closed medical record for Resident #113 revealed the resident was admitted to the facility on [DATE]. Diagnosis included congested heart failure. Further review of the medical record revealed the resident was discharged from the facility on 06/07/19. Review of a Skilled Nursing Facility (SNF) Protection Notification Review revealed Resident #113's skilled services started on 05/07/19 and the last covered day of skilled services was 06/05/19. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. It revealed a Skilled Nursing Facility Advanced beneficiary notice (SNFABN) was completed and a Notice of Medicare Non-coverage letter was provided. Review of the Notice of Medicare Non-Coverage form revealed skilled services were to end on 06/05/19. Telephonic notification on 06/03/19 at 1:30 P.M. revealed Case Manager #125 explained the notice of non-coverage to the family and informed them of their right to appeal. The form was un-signed by the resident or family. Review of the SNFABN form revealed dated 06/03/19 revealed Case Manager #125 informed the resident's family of the skilled services being discontinued and of the need for out of pocket payments if they chose to continue with skilled services and provided them the options available to them. The form was unsigned by the resident or family. Interview with Case Manager #125 on 07/29/19 at 3:30 P.M. verified she had provided information regarding Medicare skilled services being completed but did not send the SNFABN or the Notice of Medicare Non-Coverage to the family to be signed. 2. Review of the closed medical record for Resident #112 revealed the resident was admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary disease. Further review of the (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 3 Event ID: 365246 Printed: 05/15/2026 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 365246 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Wert Manor 160 Fox Rd Van Wert, OH 45891 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)