Health inspection·October 9, 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 interviews and record reviews, the facility failed to adhere to its Medicare denial process policy when it did not promptly notify one of three sampled residents (Resident 1) about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS -10055) This document provides information to the patient so they can decide whether or not to get the care that may not be paid for Medicare. Additionally, Resident 1 did not receive timely notification about the Notice of Medicare Non-Coverage (NOMC)which is a notice that a Medicare provider or health plan must give to beneficiaries at least two days before covered services end, along with information on how to request an expedited appeal, as the coverage was coming to an end. Residents Affected - Few This failure resulted in Resident 1 ' s representative not being promptly informed of her appeal rights and financial liability for services no longer covered by Medicare. Findings: During a review of the facility-provided document tiled Notice of Medicare Non-Coverage, it was noted that the effective date of coverage for skilled nursing services will end on 8/31/2024. Additionally, the document indicated that the responsible party for the resident signed the document on 9/18/2024. During a review of the facility-provided document titled Activity Report, it was noted that there was no indication of whether Resident 1 ' s responsible party was informed about SNF ABN prior to the resident termination of Resident 1 ' s Medicare insurance coverage. Additionally, the document did not specify whether Resident 1 ' s responsible party was informed about the appeal process at least two days prior to the end of the Medicare insurance coverage. During a telephone interview on 10/09/2024 at 8:46 a.m. with the Business Office Director (Director)1, Director 1 confirmed that the responsible party for Resident 1 was offered the opportunity to sign both the SNF ABN and NOMC form. However, the responsible party for Resident 1only signed the NOMC form on 9/18/2024, which was 18 days after the expiration of Resident 1 ' s Medicare insurance coverage. When asked whether the SNF ABN form should have been offered at least 2 days prior to the end of the Medicare insurance coverage, Director 1 concurred. During a review of the facility ' s policy and procedure (P&P) titled, Medicare Denial Process, dated October 8, 2018, the P&P indicated, Medicare beneficiaries will be properly notified when it is determined that they do not meet the requirements for covered services under the Medicare program. Page 1 of 2 555162 555162 10/09/2024 Mountain View Post Acute 27555 Rimrock Rd Barstow, CA 92311

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for two of three sampled residents (Residents 1 & 2). Residents Affected - Few This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1 & 2) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted on [DATE], with a diagnosis that included abnormalities of gait and mobility (a change in walking pattern that can be caused by injury, disease, or neurological issues), shortness of breath (the feeling of unable to breathe normally or feeling suffocated). During interview and observation with Resident 1 on September 24, 2024, at 10:14 a.m. Resident 1 stated the staff does not respond to call lights promptly and has to wait for half an hour at times. During the review of Resident 2 ' s admission record, the document indicated Resident 2 was admitted to the facility on was admitted to the facility on [DATE], with a diagnosis that included generalized muscle weakness (a decrease in muscle strength that can make it difficult to move arms, legs, or other body parts), and repeated falls (two or more falls in a year or over a given timeframes). During an interview and observation with Resident 2 on September 24, 2024, at 10:18 a.m. Resident 2 stated half the time, the staff don ' t respond when she asks for help. Resident 2 also mentioned that it seems to take forever for them to respond when she uses her call lights. During an interview on September 24, 2024, at 11:21 a.m. with the registered nurse supervisor (RN) 1, regarding the appropriate response time to call light. RN 1 stated it should be answered as soon as physically possible. During an interview on September 24, 2024, at 11:39 a.m. with the facility administrator (ADM)1, ADM 1, did not provide a specific response when discussing Residents 1 & 2 concerns about call light not being responded to promptly. During a review of the facility ' s policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised December 19, 2022, indicated, Staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 555162 Page 2 of 2