Health inspection·January 4, 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 Based on resident, family, and staff interviews and record review, the facility failed to provide the resident and the resident's representative in a timely manner for a daily room rate increase. This affected one resident (Resident #52) of three residents reviewed for billing practices. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #52 revealed an admission date of 03/22/23. Medical diagnoses included metabolic encephalopathy, chronic respiratory with hypoxia, and diabetes mellitus. The resident was private pay status as of 06/10/23. The resident resided as the sole occupant in a semi-private room from 06/10/23 until 01/03/24 when he was moved to a private room. Resident #52 was listed as his own responsible party with his daughter, Family Member #200, was listed as his resident representative. Review of the facility's daily room rates and included services dated October 2023 revealed the facility semi-private room rate was $248 per day and the private room rate was $270 per day. Review of Resident #52's admission agreement revealed the facility agreed to provide room, board, laundry and housekeeping services, nursing care, and personal assistance to the resident. The agreement indicated the resident would be given thirty days advanced notice of changes in the facility's charges. Review of Resident #52's monthly invoice dated 11/03/23 revealed he was charged a daily rate of $270 per day. Review of a letter addressed to Resident #52 dated 11/15/23 revealed the facility issued a 30 day notice that the resident's daily rate will increase on 12/15/23 to $496 per day. Review of Resident #52's monthly invoice dated 12/26/23 revealed the resident was charged $270 per day for 12/01/23 to 12/14/23. On 12/15/23, the resident's daily rate at the facility was increased to $496 per day for 12/15/23 to 12/31/23. The invoice additionally included January 2023 charges to include $496 per day for 31 days. An interview on 01/04/24 at 8:40 A.M. with Resident #52 revealed he resided in a private room. Resident #52 stated he was moved on the afternoon of 01/03/24 from a semi-private room into his current private room. Resident #52 stated he was happy with the room change. Resident #52 stated he preferred his daughter to handle all of his banking and financial affairs. Page 1 of 2 366194 366194 01/04/2024 Bennington Glen Nursing & Rehabilitation Center 825 State Route 61 Marengo, OH 43334

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 01/04/24 at 12:45 P.M. with the Administrator revealed Resident #52 had been given a 30 day notice that his daily rate would be increased on 12/15/23. Neither Resident #52 nor his daughter, Family Member #200 had signed a document agreeing to or which indicated they received the notice of rate change. The Administrator stated a copy was possibly left in Resident #52's room but verified it was not documented in the resident's medical record. A copy of the letter was mailed to Resident #52's representative, Family Member #200, by certified mail, but was returned to the facility sender. The Administrator provided the original letter and notice sent and verified it returned unopened to the facility. The Administrator stated the resident's representative was informed verbally of the change in rate when present in the facility towards the end of November 2023. The Administrator stated the change in rate was prompted by Resident #52 continuing to occupy a semi-private room when he stated he would never allow a roommate to share his semi-private room. The Administrator verified the facility's daily room rates did not indicate a rate for a single resident occupying a semi-private room. The Administrator stated no other residents had been charged a double rate for occupying a semi-private room that she could recall. Furthermore, the Administrator indicated the facility had capped admissions due to available staffing levels and indicated the facility had not in recent months been at full capacity. An interview on 01/04/24 at 1:32 P.M. with Family Member #200 revealed she never received a certified letter in the mail nor did she refuse the receipt of a certified letter to indicate the daily rate would be changed. Family Member #200 stated while visiting Resident #52 at the facility on 11/27/23, she was informed by a staff member that the daily rate would be increased on 12/15/23. A follow up interview on 01/04/24 at 3:25 P.M. with the Administrator verified the letter sent to Family Member #200 regarding Resident #52's daily rate change stated that the change was for a private room, not single-occupancy in a semi-private room. The Administrator verified the facility's admission agreement stated a 30 day notice was required for changes in daily rate, and did not realize the regulatory requirement was sixty days notice in writing. The Administrator stated Resident #52's January bill would be revised to reflect the transfer to a true private room on 01/03/24. 366194 Page 2 of 2