Failure to Include Estimated Costs on SNF/ABN Forms
Summary
The facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) by omitting the estimated cost of services for two residents. Resident #286 was admitted to the facility and began receiving Medicare Part A services on December 27, 2023. A Notice of Medicare Non-Coverage (NOMNC) was issued to Resident #286's representative on March 11, 2024, indicating that Medicare coverage would end on March 13, 2024. However, the SNF/ABN form dated March 11, 2024, did not include the estimated cost of services. Similarly, Resident #287, who began Medicare Part A services on June 14, 2024, received a NOMNC on August 12, 2024, stating that coverage would end on August 16, 2024. The SNF/ABN form for Resident #287, dated August 12, 2024, also lacked the estimated cost of services. Interviews with facility staff revealed a lack of awareness regarding the requirement to include estimated costs on the SNF/ABN forms. Nurse #2, responsible for completing the forms for both residents, stated she was unaware of the need to include estimated costs and would do so in the future. The Administrator in Training acknowledged that if estimated costs were required, they should have been included for both residents. The Administrator was also unaware that the estimated costs had not been completed for the residents and agreed that they should have been included.
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.
Surveyors determined that the facility did not use the correct CMS-10055 SNF Advance Beneficiary Notice of Non-Coverage (SNF ABN) when notifying two residents or their representatives that Medicare-covered services were ending. For each resident, a NOMNC was issued with the appropriate end date of covered services, but the accompanying ABN was an outdated version lacking the proper CMS identification number. A social services staff member reported relying on the facility’s master forms list and, at times, insurance company forms, and was unaware the ABN was incorrect. The administrator was not aware the wrong ABN had been used, and the facility did not have a policy on beneficiary notice.
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.
Facility staff did not provide required Notices of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare Part A services for two Medicare beneficiaries. In one case, the resident’s representative received the NOMNC by email only one day before rehab services ended. In the other case, a resident signed the NOMNC on the last covered day of Part A services. During interview, the social worker confirmed that NOMNCs for these residents were not issued 48 hours in advance of the termination of covered services.
Surveyors found that when a resident’s Medicare Part A coverage ended and the resident remained in the facility, staff issued an outdated or incorrect ABN form instead of the required CMS-10055 notice. Record review confirmed the last covered day under Medicare Part A and showed that the wrong form (CMS-20052) was used. In interviews, administrative and social services staff acknowledged that the correct SNF ABN form was not provided, despite the facility having a policy referencing the proper CMS-10055 form.
The facility failed to issue required CMS-10055 SNF Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Review of electronic medical records showed that both residents had defined Medicare Part A episodes followed by continued custodial stays, but there was no documentation that ABNs were provided. The facility’s own Advance Beneficiary Notice policy required timely notification of Medicare eligibility, coverage, and potential liability for payment before providing items or services that may not be covered, such as custodial care. An interview with social services staff revealed unawareness of the need to complete and issue the ABN, and the facility could not produce evidence that the CMS-10055 form was given to either resident.
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 Use Correct CMS SNF ABN Form for Medicare Beneficiary Notices
Penalty
Summary
Surveyors found that the facility failed to provide the correct CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two Medicare beneficiaries, identified as R56 and R57, or their representatives. Record review showed that for R56, the facility issued a Notice of Medicare Non-Coverage (NOMNC) indicating covered services would end on 11/19/25, with the NOMNC and ABN received on 11/17/25; however, the ABN used was not the most current version of the CMS-10055 form. Similarly, for R57, the facility issued a NOMNC documenting that covered services would end on 11/04/25, with the NOMNC and ABN received on 11/02/25, but again the ABN provided was not the current CMS-10055 version. During interviews, the social services staff member responsible for issuing the notices stated she obtained and used ABN forms from the facility’s master list of forms and sometimes used ABN forms supplied by insurance companies, and she was unaware that the ABN form she used lacked an identification number. The administrator reported not being aware that the incorrect ABN form had been issued. The facility was unable to provide a policy on beneficiary notice, and the census at the time of survey was 54 residents, with 14 residents sampled and four reviewed for beneficiary notification.
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 Timely NOMNC Prior to End of Medicare-Covered Services
Penalty
Summary
Facility staff failed to provide required Notices of Medicare Non-Coverage (NOMNC), Form CMS-10123, at least two days before the end of Medicare-covered services for two Medicare beneficiaries. Record review on 03/24/2026 at approximately 4:35 PM showed that for one resident, the skilled services episode began on 09/04/2025 with the last covered day of Part A services on 09/25/2025. An email exchange in the clinical record dated 09/24/2025 at 10:14 AM between the social worker (Employee #5) and the resident’s representative included an attached notice stating that the resident’s rehab services were ending the next day under that version of Medicare. The NOMNC documentation showed the representative acknowledged the notice via email on 09/24/2025 at 12:52 PM, confirming that the notice was not provided at least two days before the end of covered services. For a second resident, record review showed a skilled services episode start date of 08/29/2025 and a last covered day of Part A services of 09/22/2025. The NOMNC form for this resident contained the resident’s printed full name and a date of 09/22/2025 on the signature line, indicating the notice was given on the last covered day rather than at least two days in advance. During a face-to-face interview on 03/24/2026 at approximately 4:35 PM, the social worker (Employee #5) confirmed that the NOMNCs for both residents were not sent 48 hours before the end of covered services, acknowledging that the facility did not provide timely notification of changes to Medicare-covered items and services for these residents.
Failure to Use Correct ABN Form When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the correct Medicare Advance Beneficiary Notice of Non-Coverage (ABN) to a resident whose Medicare Part A skilled coverage ended while the resident remained in the facility. The facility census was 162 residents, with three residents reviewed for beneficiary notifications, and documentation showed that one resident’s Medicare Part A last covered day was 10/31/25. Instead of using the required ABN Form CMS-10055, the facility issued Form CMS-20052 (11/2017). During interviews, an administrative staff member and a social services staff member both confirmed that the correct ABN Form CMS-10055 was not provided to this resident. The facility had an undated policy titled “Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 (2024),” but it was not followed in this case. This deficiency was identified through record review and staff interviews, which established that the resident did not receive the appropriate standardized notice of Medicare non-coverage at the time their Part A coverage ended, despite the facility having a policy referencing the correct ABN form.
Failure to Issue Required ABNs When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide required CMS-10055 Skilled Nursing Facility (SNF) Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs for continued services, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Record review showed that one resident had a Medicare Part A episode from 09/18/25 to 10/20/25 and then remained in the facility for custodial care, but the electronic medical record contained no evidence that an ABN was issued. Another resident had a Medicare Part A episode from 10/25/25 to 12/24/25 and also remained for custodial care, with no documentation in the electronic medical record that an ABN was provided. The facility’s policy on Advance Beneficiary Notices, reviewed 05/07/25, required timely notices regarding Medicare eligibility and coverage and informing beneficiaries of potential liability for payment, including issuing a liability notice upon admission or during the stay before providing items or services that may not be covered because they are not medically reasonable and necessary or are custodial care. Interviews confirmed that the responsible social services staff member was not aware of the requirement to complete and issue the ABN, and the facility was unable to produce evidence that the CMS-10055 form was given to either resident.
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