Failure to Provide Medicare Non-Coverage Notices
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, for 3 residents reviewed for beneficiary notification. The Administrator stated the facility did not have a policy for beneficiary notification, and the facility’s Entrance Conference Worksheet identified 13 residents discharged home from Medicare Part A services with benefits remaining, including the 3 residents cited in the deficiency. For Resident #80, the record showed admission on 08/14/2025 and discharge on 09/06/2025; the admission MDS documented a BIMS score of 12, indicating moderate cognitive impairment, and the SNF Beneficiary Notification Review showed the NOMNC was not provided to the resident or representative before discharge. Resident #130 was admitted on 10/08/2025 and discharged on 11/15/2025. The discharge MDS documented a BIMS score of 14, indicating intact cognition, and showed the most recent Medicare stay ran from 10/08/2025 through 11/14/2025. Resident #131 was admitted on 10/06/2025 and discharged on 12/17/2025; the discharge MDS documented a BIMS score of 15, indicating intact cognition, and showed the most recent Medicare stay ran from 12/05/2025 through 12/16/2025. For both residents, the SNF Beneficiary Notification Review showed the NOMNC was not provided to the resident or representative before discharge. During interviews, the Administrator stated the letters were the responsibility of a previous social worker who was no longer employed and that current staff could not locate the letters.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
The facility failed to provide and accurately complete the Notice of Medicare Non-Coverage (NOMNC) for three Medicare Part A beneficiaries with intact cognition who were receiving skilled services for conditions including asthma with acute exacerbation, type II DM, morbid obesity, left femur fracture, acute embolism, and cerebral infarction with hemiplegia. For each resident, the medical record and Skilled Nursing Beneficiary Protection Notification Review documented Medicare Part A episode start dates and last covered days, but there was no documentation that a NOMNC was issued, and in one case the Medicare Part A start date was recorded incorrectly. The President of Clinical Operations confirmed that NOMNCs were not provided, despite a facility policy requiring issuance of the notice at least two days before Medicare benefits end.
The facility failed to issue timely refunds to two residents or their estate after discharge and death, respectively. One resident with multiple sclerosis and osteoporosis was discharged to another setting, but a refund of private pay funds was not issued until more than 90 days later, exceeding both regulatory and facility policy timeframes. Another resident with dementia died in the facility, and a substantial refund owed to the estate was also delayed beyond 90 days, with the responsible party reporting repeated, unanswered contacts to corporate staff. The receptionist, who handled petty cash and communicated with the off‑site business office, and the administrator both confirmed that the refunds were not processed within the required time limits.
Failure to provide SNF ABN when Medicare Part A ended. A resident with CHF and intact cognition remained in the facility after Medicare Part A services ended, but there was no documentation that the SNF ABN was given to the resident or legal guardian when benefit days were not exhausted.
The facility failed to provide two residents with Medicare beneficiary discontinuation notices that identified the actual service being discontinued. The notices reviewed only stated that skilled services were being cut, and an SS Director later verified that the letters were not specific to the service being discontinued.
A resident was not given the required Quality Improvement Organization (QIO) contact information on their Notice of Medicare Non-Coverage, preventing access to the appeal process for ending skilled services. Staff interviews confirmed the omission of the QIO name and phone number on the notice.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Failure to Provide and Accurately Complete NOMNC for Medicare Part A Discharges
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete and provide the Notice of Medicare Non-Coverage (NOMNC) to residents whose Medicare Part A skilled services were ending. For one resident with asthma with acute exacerbation, type II diabetes mellitus, and morbid obesity, records showed admission, transition to Medicare Part A, and discharge dates, as well as an MDS Discharge-Return Not Anticipated assessment indicating intact cognition. The facility’s Skilled Nursing Beneficiary Protection Notification Review documented a Medicare Part A skilled service episode start date and last covered day, but there was no documented evidence that a NOMNC was given to this resident. A second resident with a left femur fracture and type II diabetes mellitus had intact cognition per the MDS Discharge-Return Not Anticipated assessment and a documented Medicare Part A skilled service episode start date and last covered day, yet again there was no evidence a NOMNC was provided. A third resident with acute embolism and thrombosis of the right lower extremity and cerebral infarction with left hemiplegia/hemiparesis was admitted, transitioned to Medicare Part A, and later discharged, with intact cognition noted on the MDS Discharge-Return Not Anticipated assessment. The facility’s review listed an incorrect Medicare Part A skilled service episode start date and a last covered day, but there was no documented NOMNC for this resident. During interview, the President of Clinical Operations confirmed the facility failed to provide NOMNCs to these three residents, despite a policy stating that a NOMNC must be issued at least two calendar days before Medicare benefits end.
Failure to Timely Issue Resident Refunds After Discharge and Death
Penalty
Summary
The facility failed to ensure residents received refunds due within the regulatory timeframe of 30 days, and also failed to meet its own 90‑day refund policy. One resident with multiple sclerosis and osteoporosis was admitted and later discharged to an assisted living facility, with nursing documentation confirming the discharge. An invoice showed that this resident’s refund check for $1,565 was not issued until more than 90 days after discharge, exceeding both the facility’s policy and regulatory requirements. Another resident with dementia was admitted and later expired in the facility, with nursing notes documenting the death and notification of the physician, family, and hospice. An invoice indicated that a refund check for $6,440 to this resident’s estate was issued more than 90 days after the resident’s death. The responsible party reported not having received the refund despite multiple contacts with corporate staff. The receptionist, who managed petty cash and communicated with the corporate office, believed refunds should be issued within 90 days and acknowledged that the time elapsed for this refund exceeded that period. The administrator confirmed that refunds are processed by the corporate office, not on-site, and acknowledged that both residents’ refunds were issued later than 90 days after discharge or death and beyond the 30‑day regulatory requirement.
Failure to Provide SNF ABN When Medicare Part A Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to Resident #24 when Medicare Part A benefits ended and the resident remained in the facility. Resident #24 was admitted with diagnoses including congestive heart failure, and the MDS 3.0 assessment identified the resident as cognitively intact. Review of the Notice of Medicare Non-Coverage showed that Medicare Part A services ended on 12/15/25, but the facility initiated discharge from Medicare Part A services when benefit days were not exhausted and the resident continued to stay in the facility. There was no documentation that the SNF ABN was provided to the resident or legal guardian, and the Social Services Director confirmed the notice was not given when Medicare Part A services ended.
Medicare Beneficiary Notices Lacked Specific Service Information
Penalty
Summary
The facility failed to notify two residents of Medicare beneficiary discontinuation of services notices that were reviewed. For Resident #1, the Medicare beneficiary discontinuation of services letter showed the resident was notified on 08/05/25 that skilled services would be discontinued on 08/08/25, but the notice only stated that skilled services were being cut and did not identify the actual service. For Resident #49, the Medicare beneficiary discontinuation of services letter showed the resident was notified on 08/27/25 that skilled services would be discontinued on 08/29/25, but the notice likewise only stated that skilled services were being cut and did not identify the actual service. During an interview on 01/21/26 at 10:32 A.M., the Social Service Director verified that the Medicare beneficiary discontinuation of services letters for Residents #1 and #49 were not specific to the service being discontinued.
Failure to Provide QIO Information on Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide required information regarding the Quality Improvement Organization (QIO) on the Notice of Medicare Non-Coverage letter given to a resident whose skilled services and therapies were ending. Review of the resident's medical record showed that the notice, signed by the resident or their representative, did not include the QIO's name or phone number, which is necessary for the resident to request a timely appeal of the termination of services. This omission was confirmed during interviews with both the Social Service Coordinator and the Director of Nursing, who acknowledged that the notice lacked the required appeal information.
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