Health 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 and staff interview, the facility failed to provide Advanced Beneficiary Notices (ABN's) upon discharge from Skilled Medicare Part A Services to two residents (#4 and #34). This affected two (#4 and #34) of two residents reviewed for Beneficiary Notices. The facility census was 45. Residents Affected - Few Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Further review of the medical record revealed an ABN notice dated 01/29/19. Further review of the Beneficiary Notices revealed Resident #4 was cut from Medicare Part A Skilled Service on 04/18/19 and the resident remained in the facility. There was no further evidence Resident #4 was provided with an ABN notice when cut from Medicare Part A Service. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Further review of the medical record revealed an ABN notice dated 01/22/19. Resident #34 was cut from Medicare part A Skilled Service on 03/28/19 and the resident remained in the facility. There was no further evidence Resident #34 was provided with an ABN notice when cut from Medicare Part A Service. Interview with the Administrator on 07/31/19 at 2:29 PM confirmed ABN notices were provided to Resident #4 and Resident #34 upon admission and not upon end date of skilled services. 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: 366075 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 366075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Valley View 3363 Ragged Ridge Road Frankfort, OH 45628 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)