Inspection·August 31, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to the resident or resident's representative for three of three records reviewed (Residents 100, 101, and 102). Residents Affected - Many Findings include: Review of form titled Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the form title Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs. Review of facility documentation revealed that Resident 100 was discontinued from Medicare Part A on April 3, 2023, with benefit days remaining. There was no documentable evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Review of facility documentation revealed that Resident 101 was discontinued from Medicare Part A on June 5, 2023, with benefit days remaining. There was no documented evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Review of facility documentation revealed that Resident 102 was discontinued from Medicare Part A on April 10, 2023, with benefit days remaining. There was no documentated evidence that the resident or resident's representative was provided the required NOMNC or SNF-ABN form. Interview with the Employee E3 on August 31, 2023, at 12:40 p.m. confirmed that there was no evidence that the NOMNC and SNF-ABN notices were provided to the above residents or their representative. 483.10(g)(18)(i) Medicaid/Medicare Coverage/liability notice (continued on next page) 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 5 Event ID: 395590 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 395590 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Lititz 125 South Broad Street Lititz, PA 17543 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)