Health inspection·March 9, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure notices of Medicare non-coverage (NOMNC) contained all required information. This affected two of two residents (Residents #133 and #134) reviewed for beneficiary notices. The facility census was 30. Residents Affected - Some Findings Include: Medical record review revealed Resident #133 was admitted to the facility [DATE] with diagnoses that included heart failure and high blood pressure. Resident #133 discharged home [DATE]. Review of the NOMNC given to Resident #133 on [DATE] prior to his discharge revealed the notice stated Your Medicare provider and/or health plan have determined that Medicare with not pay for your current {insert type} services after the effective date indicated above. Medical record review revealed Resident #134 was admitted to the facility on [DATE] with diagnoses that included left femur fracture, anxiety disorder and depression. Resident #134 expired at the facility on [DATE]. Review of the NOMNC given to Resident #134 on [DATE] prior to ending skilled services and electing hospice services revealed the notice stated Your Medicare provider and/or health plan have determined that Medicare with not pay for your current {insert type} services after the effective date indicated above. Interview with Social Worker (SW) #998 on [DATE] at 3:30 P.M. verified the notices given to Residents #133 and #134 did not contain what service type was ending. 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 5 Event ID: 365533 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 365533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joshua Tree Care Center 27500 Mill Rd North Olmsted, OH 44070 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)