Community Care Center

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, staff interviews, and policy review, the facility failed to inform residents of an option to appeal

a discharge from Medicare Part A Skilled Services for 1 of 4 residents (#1). The facility reported a census of 49 residents.Findings include:The Minimum Data Set (MDS) for Resident #1 dated 6/27/25 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of anemia, hypertension, renal failure, malnutrition, and metabolic encephalopathy (improper brain functions due to a metabolism disorder). It revealed the resident was admitted on [DATE REDACTED] and received Occupational Therapy (OT) and Physical Therapy (PT) services.The Physical Therapy Treatment Encounter Note(s) dated 6/30/25 indicated the resident received skilled rehabilitation services from 6/20/25 to 6/30/25. It also indicated she was ready to discharge to her daughter's home the next day.The Progress Notes dated 7/01/25 at 10:45 AM indicated the resident discharged home with her daughter who received and understood the discharge instructions.The Notice of Medicare Non-Coverage (NOMNC) document dated 6/26/25 indicated Staff B, Human Resources and Financial Services (HR and Fin) contacted the resident's Power of Attorney (POA) at 10:07 AM. The document lacked a resident or POA signature which indicated receipt and understanding of the resident's right to appeal the discharge.On 10/13/25 at 3:08 PM, Staff B stated when she contacts the resident's representative or POA, she discusses the resident's end-of-skilled care date, the resident's discharge date if they're going home, and the last date the discharge can be appealed. On 10/14/25 at 1:36 PM, Staff B stated she was not aware Resident #1's NOMNC was not signed. On 10/14/25 at 1:48 PM, the Director of Nursing (DON) stated the facility did not know a signature was required if a call to the POA or representative was documented.A document titled SNF Notices of Non-Coverage - ABN/NOMNC revised 11/15/23 indicated the ABN (Advance Beneficiary Notice) must be reviewed with the beneficiary, or his/her representative and any questions raised during that review must be answered before it is signed. It also indicated ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Community Care Center

325 Southwest Seventh Street Stuart, IA 50250

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the resident was educated to manage the care needs for himself and allow others to assist his wife who will return home in 1-2 weeks.4. The MDS for Resident #5 dated 7/25/25 indicated Resident #5 had a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart failure, chronic kidney disease, and right shoulder replacement surgery. It revealed the resident began Medicare Occupational Therapy (OT) and Physical Therapy (PT) services on 7/18/25.The Physical Therapy Treatment Encounter Note(s) dated 7/28/25 indicated the resident was a fall risk and oxygen dependent but decided to return home against PT recommendations. It also indicated she would benefit from continued services to improve her strength and balance.The Transfer/Discharge Report dated 7/28/25 indicated the resident required a one-person assist with a gait belt for ambulation, was continent of bowel and bladder, and was able to feed herself. It also indicated she met her level of functioning but did not include a summary of her OT or PT services.The Progress Notes dated 7/29/25 at 11:30 AM indicated the resident discharged from

the facility but did not include documentation of discharge instructions.The resident's Medical Record lacked a Discharge Summary and Plan of Care.On 10/14/25 at 9:31 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated the facility does not send a Discharge Summary or Plan of Care home with residents at the time of discharge. They stated the details of therapy and the residents' care are discussed with each resident and/or Power of Attorney (POA) throughout the resident's stay. They also stated rehabilitation notes are not included in the discharge paperwork given to the resident or resident representative.A document titled Discharge Summary revised 9/27/17 included the following:Responsibility: DON Social Worker Food Service Supervisor Activity Director Licensed Practicing Nurse (LPN) or Registered Nurse (RN) Purpose: To provide information regarding the care needed after discharge To document education completed upon discharge To summarize the course of the resident's stay at the facility When the facility anticipates discharge, a resident must have a discharge summery that includes: Equipment: A recapitulation of the resident's stay A final summary of the resident's status to include items

in the following list, at the time of the discharge that is available for release to the consent of the resident or legal representative Medically defined condition and prior medical history Medical status measurement Functional status Sensory and physical impairments Nutritional status and requirements Special treatments Psychosocial status Discharge potential Dental condition Activities potential Rehabilitation potential Cognitive status Drug therapy A post-discharge plan of care that developed with the participation of the resident and his/her family, which will assist the resident to adjust to his/her new living environment GUIDELINE: A post discharge plan of care is not required for residents discharged to the hospital. It applies to a resident discharged to a private residence, to another nursing facility or skilled facility, or residential facility such as a board and care home or intermediate care facility for MR individuals. The post discharge plan describes the resident's and family's preferences for care, how they will access and pay for these services, and how care should be coordinated if continuing treatment involves multiple caregivers. It identifies specific resident needs after discharge such as personal care, sterile dressings, and physical therapy, and describes resident/caregiver education needs to prepare the resident for discharge.

Event ID:

Facility ID:

If continuation sheet