Failure to Provide Monthly Spend-Down Letters
Summary
The facility failed to provide monthly spend-down letters to residents who were approaching or over the resource limit, affecting three residents. Resident #13, diagnosed with cerebral infarction, dementia, adjustment disorder, and schizoaffective disorder, had financial balances exceeding the resource limit from April to June 2024, but only received a spend-down letter in July 2024. Similarly, Resident #32, with diagnoses including psychotic disorder, dementia, and schizoaffective disorder, had balances over the limit during the same period and received letters only in January, March, and July 2024. Resident #33, diagnosed with osteoarthritis, anemia, and other conditions, also had balances over the limit in May and June 2024, but only received a letter in July 2024. Interviews with the Business Office Manager (BOM) and Sister Facility Business Office Manager (SFBOM) revealed that the BOM was unaware of the requirement to send monthly spend-down letters when residents were approaching or over the resource limit. The facility's policy, revised in April 2018, mandates that residents be informed when their personal funds account reaches $200 less than the SSI resource limit to prevent loss of Medicaid or SSI eligibility. The BOM confirmed the absence of spend-down letters for the affected months during the interview.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s credit balance and trust fund balance were not returned after discharge. Billing records showed Social Security payments were received after the resident left, creating a $2,120 credit, and an additional trust fund balance of $120.22 remained with no documentation that it was transferred to the resident’s representative or estate. The BOM confirmed the check request was delayed and that no steps had been taken to release the remaining funds.
The facility failed to provide written Medicaid benefits notification to two residents when their resident fund balances approached the resource limit threshold. One resident had intact cognition and decision-making capacity, while the other had moderate cognitive impairment and lacked capacity to make decisions. The BOM acknowledged the facility did not follow its resident trust funds policy, and both residents had balances above $4,000.
Failure to Return Resident Trust Funds After Discharge: A resident was discharged with personal belongings and medications reviewed, but the record did not show that his trust funds were returned at discharge. The trust account still showed a remaining balance of $35.04 after discharge, and the NHA confirmed the facility did not convey the resident's funds and close the account within the required 30 days.
The facility failed to notify residents or their responsible parties when personal fund accounts exceeded the Medicaid resource limit. Four residents reviewed had balances above the $2,000 limit, and there was no documentation that spend-down notices were sent. The BOM acknowledged the high balances, stated no staff were assigned to prepare notices, and said the facility lacked a process to help residents manage excess funds.
Failure to convey resident funds after discharge. A resident with cerebral infarction, adult failure to thrive, OA, HTN, CKD, dementia with agitation, and anxiety disorder was severely cognitively impaired and had a POA-authorized resident funds account. The account remained open after discharge and was not closed until months later, when the remaining balance was issued to the Treasurer of the State; the BOM confirmed the funds were not conveyed within 30 days.
A facility failed to notify residents or their representatives about excessive resident trust account balances for 7 sampled residents whose funds exceeded the $2,000 Medicaid asset limit. Records showed balances ranging from $2,547.70 to $18,955.25 for residents with diagnoses including DM, COPD, dementia, CVA, depression, anxiety, respiratory failure, and HTN. The BOM and Administrator both acknowledged the $2,000 limit and confirmed that notification had not been provided.
Failure to Return Resident Funds After Discharge
Penalty
Summary
The facility failed to return a resident’s credit balance and trust fund balance after discharge. The resident’s census documents show billing stopped on 10/20/25, and the record identifies Medicaid as the payor source. The resident’s family stated that at least two Social Security monthly benefits were remitted after the resident discharged, first to the hospital and then to another skilled nursing facility, and that the subsequent nursing facility billed the resident’s estate. The resident’s statements showed a credit of $2,120 from two payments of $1,060 made in November and December 2025, and a check request form dated 5/20/26 requested reimbursement of that amount to the facility where the resident resided after hospitalization. The resident’s statement dated 3/2/26-5/1/26 also showed a balance of $120.22 as of 5/1/26, and there was no documentation that this balance was transferred to the resident’s family representative or estate. The Business Office Manager reviewed the billing and trust fund statements and confirmed the resident had an active trust fund balance. The Business Office Manager stated the check request was not submitted timely, that there were no prior check request forms, and that no steps had been taken to release the remaining trust fund balance to the resident’s representative or estate.
Failure to Notify Residents of Medicaid Resource Limit Threshold
Penalty
Summary
The facility failed to provide written Medicaid benefits notification to two residents when the amount in their resident fund accounts reached $200 less than the resource limit for one person. Resident 22 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and gout. A review of the MDS dated 2/23/2026 showed Resident 22's cognition was intact, and the H&P dated 10/10/2025 stated the resident had capacity to understand and make own decisions. During interview on 5/18/2026, Resident 22 stated the facility had not provided quarterly financial statements for several months. The resident fund statement for 1/1/2026 to 3/31/2026 showed a balance of $4,851.02. Resident 54 was originally admitted and later readmitted with diagnoses including sequelae following unspecified cerebrovascular disease, obstructive hydrocephalus, and presence of a cerebrospinal fluid drainage device. The MDS indicated Resident 54's cognition was moderately impaired, and the H&P dated 4/6/2026 stated the resident did not have the capacity to understand and make decisions. The resident fund statement for 1/1/2026 to 3/31/2026 showed a balance of $4,423.84. During a concurrent interview and record review, the Business Office Manager stated the facility did not follow its policy to provide notification to Resident 22 and Resident 54 when their resource limits were approaching $2000, and stated the residents could be at risk of losing Medicaid benefits.
Failure to Return Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to convey resident funds and close a resident trust account within 30 days after discharge for one closed resident record, CR66. The facility policy stated that upon discharge, eviction, or death of a resident with personal funds deposited with the facility, the resident's funds and a final account of those funds would be conveyed within 30 days. Review of CR66's record showed he was admitted to the facility and later discharged on 2/6/26, with clinical nurse notes indicating that all personal belongings were taken with him and that medications were reviewed with him and a home nurse. Review of CR66's record did not show evidence that his monies were provided at discharge. A review of the facility trust fund account dated 5/20/26 showed CR66 still had a remaining balance of $35.04. During interview, the Regional Business Office Manager stated that money from the resident trust fund is ideally provided in real time but may take up to 30 days to refund to a resident. The Nursing Home Administrator later confirmed that the facility failed to convey resident funds and close the account upon discharge within 30 days for CR66.
Failure to Notify Residents of Excess Personal Fund Balances
Penalty
Summary
The facility failed to notify residents or their responsible parties when resident personal fund accounts reached within $200 of the Medicaid resource limit, as required by regulation. Record review showed that four of six residents reviewed for personal funds had balances above the $2,000 Medicaid resource limit, including balances of $20,702.70, $6,007.89, $24,237.64, and $4,280.00, and there was no documentation that the residents or responsible parties were notified of the need to spend down the funds. During interview, the Business Office Manager acknowledged awareness of the high balances and stated the facility did not have a social worker to prepare and send spend-down letters, no other staff were assigned to this task, no spend-down notifications were issued, and the facility lacked a process to assist residents in managing excess funds.
Failure to Convey Resident Funds After Discharge
Penalty
Summary
The facility failed to ensure resident funds were conveyed within 30 days of discharge from the facility. This affected one resident, who had diagnoses including cerebral infarction, adult failure to thrive, osteoarthritis, hypertension, chronic kidney disease, dementia with agitation, and anxiety disorder. The resident was severely cognitively impaired on the quarterly MDS assessment, and the resident’s POA had authorized a resident funds account at the facility. Review of the resident funds account showed a beginning balance of $69.14 and an ending balance of $49.14 on the quarterly statement covering 07/01/25 to 09/30/25. The resident discharged from the facility on 10/13/25, but the account was not closed until 01/14/26, when a debit of $49.14 was posted to close the account and a check for $49.14 was issued to the Treasurer of the State. The BOM verified in interview that the resident’s funds account was not conveyed within 30 days of discharge. The facility policy stated resident trust accounts would be closed and refunded per regulatory guidelines.
Failure to Notify Residents of Excess Trust Account Balances
Penalty
Summary
The facility failed to notify residents or their representatives of excessive resident trust account balances for 7 of 58 sampled residents, despite the Tennessee Medicaid asset limit for a single nursing home applicant being $2,000.00. Review of the Resident Statement Landscape dated 4/29/2026 showed Resident #3 had a balance of $18,955.25, Resident #6 had $4,799.11, Resident #19 had $2,547.70, Resident #38 had $8,119.00, Resident #67 had $12,755.29, Resident #81 had $4,810.16, and Resident #93 had $10,121.71, all above the limit. The report states these balances were over the allowable amount by amounts ranging from $547.70 to $16,955.25. The medical record review identified each resident’s admission and diagnoses, including diabetes mellitus, malnutrition, hypotension, cerebral infarction, anxiety, hemiplegia, depression, chronic obstructive pulmonary disease, dementia, respiratory failure, and hypertension. During interview, the BOM stated the trust account limit was $2,000.00 and acknowledged that residents or representatives had not been notified regarding the excessive balances or the risk of losing Medicaid benefits. The Administrator also stated the trust account limit was $2,000.00 and that the resident or representative should have been informed of the risk of losing Medicaid benefits.
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