Health inspection·July 11, 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 Based on record review and staff interview, the facility failed to notify a resident of possible financial liability when Medicare services were discontinued. This affected one (#43) resident of three reviewed for Medicare Part A services and had the potential to affect any residents with Medicare Part A coverage. The facility identified three residents currently on Part A services. Residents Affected - Few Findings include: Review of Resident #43's medical record revealed an admit date of 01/31/19 with diagnoses included diabetes mellitus and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment, dated 02/07/19, revealed the resident's cognition was severely impaired. Review of social worker progress note, dated 02/15/19, revealed a Medicare Notice of Non-coverage was signed 02/15/19 with a last covered day of 02/18/19. Review of the medical record failed to reveal any documentation of a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was provided to the resident's representative. Interview with Social Worker (SW) #12 on 07/08/19 at 3:44 P.M. stated a SNFABN was not provided to Resident #43 since he remained in the facility and was treated with part B 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 4 Event ID: 366421 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 366421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florentine Gardens 409 Wards Corner Road Loveland, OH 45140 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)