Inspection·March 28, 2024

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 ensure all required notices were provided to residents when skilled services were discontinued. This affected two (#2 and #11) of three residents review for beneficiary notices. The facility census was 41. Residents Affected - Few Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anemia, chronic kidney disease, and dislocation of the right knee. Further review of the medical record revealed Resident #2 was discharged from skilled services while using her Medicare Part A benefit on 10/02/23 and chose to remain in the facility. Review of the notices given to Resident #2 revealed the resident received a Notice of Medicare Non-Coverage (NOMNC) as required; however, the additional required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) was not given to Resident #2. 2. Review of Resident #11's medical record revealed the resident was admitted to the facility 10/23/23. Diagnoses included chronic obstructive pulmonary disorder, anxiety disorder, and epilepsy. Further review of the medical revealed Resident #11 was discharged from skilled services on 12/19/23 and chose to remain in the facility. Review of the notices given to Resident #11 revealed the resident received a NOMNC as required; however, the additional required SNF ABN was not given to Resident #11. Interview with Social Service Director #450 on 03/27/24 at 8:15 A.M. verified no SNF ABN was given to Resident #2 and Resident #11 as required. 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: 366118 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 366118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elms Retirement Village Inc 136 S Main St Wellington, OH 44090 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)