Health inspection·August 28, 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 Based on medical record review and staff interview, the facility failed to ensure residents received a Skilled Nursing Facility Advanced Beneficiary Notice of NON-coverage (SNF/ABN) when cut from Medicare Part A services as required. This affected three residents (#11, #29 and #38) of three reviewed for Notice of Medicare Non-coverage (NOMNC). The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 06/04/17 with diagnoses including cognitive communication deficit, Alzheimer's Disease, and major depressive disorder. Review of notification of discharge from therapy form dated 05/29/19 documented Resident #11 would be discharged for Medicare Part A services on 05/31/19 due to the resident meeting their maximum potential. Review of NOMNC dated 05/31/19 documented a copy was mailed to the Resident #11 representative with no return signature. The review also revealed the resident was not given a SNF/ABN when the resident remained in the facility after being discharged from Medicare Part A services. 2. Review of medical record for Resident #29 revealed an admission date of 02/13/19 with diagnoses including muscle weakness, hypocalcemia, repeated falls, hydrocephalus and malignant neoplasm of the brain. Review of notification of discharge from therapy form dated 05/08/19 documented Resident #29 would be discharged for Medicare Part A services on 05/11/19 due to the resident meeting their maximum potential. Review of NOMNC dated 05/11/19 documented a copy was mailed to the Resident #29 representative with no return signature. The review also revealed the resident was not given a SNF/ABN when the resident remained in the facility after being discharged from Medicare Part A services. 3. Review of medical record for Resident #38 medical record documented an admission date of 12/22/16 with diagnoses including muscle weakness, constipation, bipolar disorder, insomnia, anxiety disorder, hypertension, major depressive disorder, muscle spasms and chronic pain. Review of notification of discharge from therapy form dated 04/08/19 documented Resident #38 would be discharged for Medicare Part A services on 04/12/19 due to the resident meeting their maximum potential. (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 4 Event ID: 365566 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 365566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Minster 24 North Hamilton Street Minster, OH 45865 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)