Health inspection·August 8, 2024

F 0582 Level of Harm - Minimal harm or potential for actual harm a copy of the NOMNC as required. AC/LPN #107 stated if a resident representative was not available and the resident was unable to sign the NOMNC due to cognitive status as was the case with Resident #86, they would notify the resident representative by telephone of the information contained in the NOMNC and the right to appeal. AC/LPN #107 stated a copy of the NOMNC had to be mailed out to obtain a signature if the resident representative was not present to sign it which she confirmed was not done for Resident #86. Residents Affected - Few Interview on 08/08/24 at 2:35 P.M. with the Director of Nursing (DON) revealed she was familiar with the facility's NOMNC policy as she gave them at times herself and there was a list of what had to be read to the resident representative over the phone if the NOMNC information was provided in that way. The DON confirmed the NOMNC notice still had to be sent to the resident representative certified receipt request to obtain a signature if it was not signed in-house. Review of the policy, Issuance of the Notice of Medicare Non-Coverage/The Generic Letter (aka Cut Letter) and the Skilled Nursing Facility (SNF)/ Advanced Beneficiary Notice (ABN) revised January 2024 revealed the facility was to issue the SNF/ABN to residents/beneficiaries prior to providing care that Medicare covered but may not pay because the care was not medically reasonable and necessary or was considered custodial. The notice was to be delivered to the beneficiary however if this was not possible the notice was to be delivered to an authorized representative no later than two days before the termination of services. Facility policy was to begin the notification process three to five or more days prior to termination of services. This gave ample time for the facility to be in compliance in case they were unable to get the notice signed in person or reach the beneficiary/authorized representative prior to the two days in the advance deadline. The following two steps were to be taken if the beneficiary/authorized representative was unable to sign for the receipt of the notice in person: a telephone call was to be made to the authorized representative and the designee was to speak to the person voice-to-voice. If an answering machine or voicemail was reached the designee was to keep trying and send out the written notification the same day. Leaving a message was not acknowledged as a valid notification. For a telephone notification to be considered valid the designee had to read the entire notice to the person being contacted .The beneficiary/authorized representative was to be informed of need for signature on notice of non-coverage either in person or upon receipt of same via certified mail. The deficient practice was corrected on 05/31/24 when the facility implemented the following corrective actions: • On 04/09/24, the facility's corporation noticed non-compliance regarding NOMNC issuance and explanation of right to appeal. • On 04/18/24, the Administrator met with AC/LPN #107, the DON, BOM #103 and Medical Records (MR) #111 to educate them regarding the NOMNC process including the facility's policy on NOMNC issuance. • From 04/26/24 to 05/31/24, the Administrator completed a minimum of two audits per week to ensure NOMNCs were being mailed out (if not signed in-house) with return receipt requested. The audits (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366281 If continuation sheet Page 2 of 3 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 366281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483 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)

F 0582 Level of Harm - Minimal harm or potential for actual harm consisted of review of timeliness of issuance, complete information regarding why services were being cut and how to file an appeal. The audit also reviewed documentation that the responsible party was notified and verbalized understanding of the NOMNC issuance. If the responsible party was issued the NOMNC via phone the review included correct documentation of who was notified, the date and time of notification and ensuring the NOMNC was sent certified mail, return receipt to the responsible party. Residents Affected - Few • Starting on 04/26/24, a new facility process began including keeping a copy of the mailed NOMNCs in a separate folder and uploading them to Point Click Care (electronic medical record system) once received signed from the responsible party. • On 06/26/24, the facility brought their NOMNC auditing to their Quality Assurance (QA) meeting for discussion and review. No additional concerns or issues were noted. • The Administrator would complete random audits on an ongoing basis to confirm continued compliance. This deficiency represents noncompliance investigated under Complaint Number OH00154026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366281 If continuation sheet Page 3 of 3