Health inspection·April 11, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on record review and staff interview, the facility failed to issue the correct liability notices, when Medicare Part A Services were terminated to two residents. This affected two (Residents #12 and #36) of three reviewed for liability notices. The facility census was 51. Residents Affected - Some Findings include: 1. Review of Resident #12's medical record revealed a readmission date of 02/10/19 with a Medicare Part A skilled services episode start date of 02/10/19 and a last covered date of 03/28/19. On 03/28/19, Resident #12 was at her maximum potential for therapy services and was discharged from Medicare Part A services and remained in the facility. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed Resident #12 did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when she was discharged from Medicare Part A Services as she was noted to have not received non-covered services and went back to private pay but remained in the facility. 2. Review of Resident #36's medical record revealed an admission date of 11/29/18 with a Medicare Part A skilled services episode start date of 11/29/18 and a last covered date of 01/18/19. Further review of the medical record revealed Resident #36 was at her maximum potential for therapy services and was discharged from Medicare Part A services on 01/18/19 and remained in the facility. Review of the SNF Beneficiary Protection Notification Review revealed Resident #36 did not receive a SNF ABN when she was discharged from Medicare Part A Services as she was noted to have remained in the facility under Medicaid. During interview on 04/11/19 at 2:43 P.M., Business Office Manager #61 stated she was unaware the regulation required residents who were discharged from Part A services and remained in the facility were to have received the SNF ABN notice. 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: 365592 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 365592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continental Manor Nurs and Rehabilitation Center 820 East Center Street Blanchester, OH 45107 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)