Failure to Provide Timely NOMNC and Consistent Discharge Notice for a Cognitively Impaired, Non‑English‑Speaking Resident
Summary
The deficiency involves the facility’s failure to provide a timely Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s representative in accordance with federal requirements and the facility’s own NOMNC policy. The resident was admitted with significant neurologic and functional impairments, including hemiplegia and hemiparesis following a cerebral infarction, dysphagia, metabolic encephalopathy, type 2 diabetes, and gait abnormalities. Early assessments documented that the resident’s preferred language was not English, that staff were unable to determine if an interpreter was needed, and that the resident had slurred, sometimes understandable speech and severe cognitive impairment as evidenced by very low BIMS scores. A baseline care plan identified an alteration in communication, a language barrier, and aphasic, disorganized, and slurred speech, but did not include checked interventions such as a communication board, written communication, or translation applications. Throughout the stay, multiple therapy and nursing notes documented the resident’s limited cooperation, refusals of care and therapy, falls, and behavioral symptoms, often in the context of a language barrier and confusion. Nursing and therapy documentation repeatedly showed that staff attempted to communicate verbally or with a language board but were unable to verify understanding due to the language barrier, and there was no evidence of attempts to use an interpreter or translator application. The resident experienced several unwitnessed falls, episodes of combative behavior, refusal of medications, blood glucose checks, and care, and was at times described as barricading herself in her room. A psychiatric consult was ordered but there was no evidence in the clinical record that a psychiatric evaluation was ever completed before discharge. The care plan for behavioral symptoms did not include specific interventions addressing the resident’s primary non‑English language or use of interpreter services. As the stay progressed, therapy records showed that the resident participated in some OT, PT, and ST sessions but also refused multiple sessions, with therapy staff documenting refusals and minimal progress. Despite speech therapy documentation on one day recommending continuation of the plan of care, PT and ST discharge summaries were later completed indicating dates of service over a short period and noting minimal progress or refusal. Nursing and administrative notes indicated that staff communicated with the resident’s son about concerns for the resident’s safety at night and the need for a caregiver or private sitter, and the son ultimately arranged and paid for a private sitter overnight and then took the resident home. The discharge planning note stated that the NOMNC was signed by the son on a specific date and that discharge home was discussed, but the NOMNC form itself showed Medicare coverage ending on that same date and was actually signed by the son the following day, the day of discharge. There was no documentation that the NOMNC timeframe was waived, that appeal information was provided at the time of the initial notification, or that the discharge was resident‑ or family‑driven or due to the facility’s inability to meet needs as documented by a physician. Interviews with staff and the resident’s son confirmed that the son was informed of discharge plans only shortly before discharge, that he did not receive 48‑hour advance notice or appeal information, and that the facility’s own policy required the NOMNC to be delivered at least two days before Medicare‑covered services ended, which did not occur for this resident. Additionally, discharge documentation contained conflicting information about the reason and timing of discharge. The Discharge Instructions and Summary listed the reason for discharge as completion of skilled services and stated that the resident participated in therapy as tolerated, while the Notice of Transfer or Discharge cited that the resident’s needs could not be met in the facility and included appeal and Ombudsman information. The notice of transfer or discharge also contained inconsistent dates for when the notice was given. The clinical record lacked a physician note stating that the resident was unsafe to remain in the facility or that her needs could not be met there. Interviews with the LPN discharge nurse, DON, administrator, and other staff showed inconsistent explanations regarding whether the resident met therapy goals, whether she refused therapy, whether the discharge was rushed due to safety concerns, and whether 48‑hour advance notice of Medicare coverage termination and discharge was provided. The facility’s NOMNC policy required delivery of the NOMNC at least two days before Medicare‑covered services end, with proper documentation of communication and appeal rights, but the record for this resident did not show that these requirements were met.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to complete NOMNC forms with the required QIO name and toll-free number for three residents, leaving generic template language and missing Medicare service details on the notices. For one resident, staff used an expired ABN instead of the correct SNFABN, and the DON/Administrator acknowledged the incorrect form was used and that the generic NOMNC template should have been completed before being given to residents.
Failure to issue NOMNC forms for two residents before Medicare skilled coverage ended. The BOM stated they were responsible for the notices and none could be found for the residents, and the Admin stated Medicare-insured residents were supposed to receive advance NOMNC notice.
Improper NOMNC Signatures and Notification: Two residents with intact cognition and capacity to make decisions were not appropriately notified of Medicare coverage changes. One resident denied seeing or signing the NOMNC, while the BOM acknowledged she signed both NOMNC forms even though she was not the resident or representative. The DON stated only the resident or representative should sign, and the facility policy required timely Medicare notices to the resident and/or representative.
A resident admitted with Medicare Part A benefits remained in the facility after Part A coverage ended, but the facility did not provide the required SNF ABN to notify the resident of potential financial liability for continued services. Staff confirmed the SNF ABN was not completed, and the Administrator acknowledged the omission.
Failure to Provide SNF-ABN for Medicare Non-Coverage: The facility did not provide SNF-ABN forms to two residents when Medicare Part-A coverage ended. One resident had hypothyroidism, MDD, dysphagia, and hyperlipidemia and remained in the facility for LTC after a NOMNC was issued; another resident had muscle weakness, arthritis, and anxiety disorder and also received a NOMNC, but the record did not show review or issuance of an SNF-ABN. The NHA confirmed the omission.
Failure to Provide NOMNCs to Two Residents Two residents whose Medicare Part A skilled services were ending while they remained in the facility did not receive the required NOMNC. The SWD stated he was unaware the notices were needed, and the SWC said her quarterly review with him focused on discharge planning and did not include when NOMNCs should be issued.
Incomplete Medicare Non-Coverage Notices and Use of an Expired ABN
Penalty
Summary
The facility failed to ensure that the CMS Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was completed with the required Quality Improvement Organization (QIO) name and toll-free telephone number before it was issued to three residents reviewed for beneficiary notifications. For each of the three residents, the NOMNC forms retained generic template language, including the placeholder for the type of Medicare-covered services, and did not include the facility’s QIO name or toll-free contact number. The forms were signed by the residents, and the notices stated that Medicare-covered services would end after the listed date, but the required specific information was not entered on the forms. The facility also failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form CMS-10055, for one resident. Instead, an expired ABN, Form CMS-R-131, was signed by that resident even though the form had been retired from use by CMS before the signature date. During interview, the Administrator acknowledged that the resident should have received the correct form and stated there was no knowledge that staff attempted to correct the error or provide the appropriate form. The Administrator also acknowledged that the facility used a generic CMS-10123 template and that it should have been completed with the correct information before residents received it.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue Notification of Medicare Non-Coverage (NOMNC) forms at least two calendar days before Medicare skilled coverage ended for 2 of 3 sampled residents reviewed for beneficiary notices. Resident 27 was admitted to the facility and later discharged on 04/27/2026 to an adult family home, and the record showed no NOMNC form was provided before discharge. Resident 161 was admitted to the facility and later discharged on 12/02/2025 to home, and the record also showed no NOMNC form was provided before discharge. During interview, the Business Office Manager stated they were responsible for issuing the notices and that none could be found for Residents 27 and 161, and the Administrator stated Medicare-insured residents were supposed to receive NOMNC notice in advance and that the lack of notices for these residents did not meet expectations.
Improper NOMNC Signatures and Notification
Penalty
Summary
The facility failed to ensure that two sampled residents, Resident 33 and Resident 88, were appropriately notified of changes in their Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form. Resident 33 was admitted with diagnoses including HTN and DM, and the MDS indicated intact cognition, maximal assistance with ADLs, and the H&P stated the resident had the capacity to understand and make decisions. Resident 88 was admitted with diagnoses including depression and severe chronic kidney disease, and the MDS indicated intact cognition with supervision needed for ADLs; the H&P also stated the resident had the capacity to understand and make decisions. During an interview on 5/28/2026, Resident 33 denied that the signature on the NOMNC form was his and denied having seen or ever being presented with the form. In a concurrent interview and record review, the BOM stated she had signed the NOMNC forms for Residents 33 and 88, but acknowledged she should not have signed them because she was not the resident or the resident representative. The BOM stated signing the forms without the residents' consent or knowledge could cause a loss of trust and affect their rights. The DON stated the NOMNC forms should only be signed by the resident or resident representative, not the BOM. The facility policy stated it is the facility's responsibility to ensure Medicare notice forms are completed as per Medicare guidelines and given to the resident and/or representative timely.
Failure to Provide SNF ABN After Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to 1 of 3 sampled residents reviewed for beneficiary notification. Resident 13 was admitted in 12/2025 with Medicare Part A benefits, and the facility’s SNF Beneficiary Notification Review form showed the resident’s last covered day for Medicare Part A services was 2/18/26 while the resident remained in the facility. Despite the termination of Part A coverage and the resident’s continued stay, the resident was not given a SNF ABN to notify them of potential financial liability for services received. Staff 19 confirmed that residents whose Part A services end and who remain in the facility should receive a SNF ABN in addition to a Notice of Medicare Non-Coverage, and stated that the SNF ABN was not completed for Resident 13. Staff 1 acknowledged the facility failed to complete the required SNF ABN for Resident 13.
Failure to Provide SNF-ABN for Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) to inform residents when items and services were no longer eligible for Medicare Part-A coverage for two sampled residents. Resident R4 was admitted to the facility and had an MDS dated 3/2/26 showing diagnoses that included hypothyroidism, major depressive disorder, dysphagia, and hyperlipidemia. A clinical social services note dated 3/16/26 indicated that R4 was issued a NOMNC with a last covered day of 3/18/26, and the resident remained in the facility for long-term care, but the record did not include evidence that an SNF-ABN was provided. Resident R57 was admitted and later readmitted to the facility, and her MDS documented diagnoses including muscle weakness, arthritis, and anxiety disorder. Her clinical record showed that she was issued a NOMNC on 5/11/26, but clinical nurse notes and social services notes did not indicate a review of the NOMNC form provided to her. Facility documentation did not include evidence that SNF-ABN forms were provided to either resident, and during an interview on 5/20/26 at 10:28 a.m., the NHA confirmed that the facility failed to provide the SNF-ABN form as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The provider failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was given to two sampled residents whose Medicare-covered skilled services were ending while they still had remaining Medicare benefit days and remained in the facility. Resident 19’s CMS SNF Beneficiary Notification Review form showed a Medicare Part A skilled services episode start date of 10/28/25 and a last covered day of 12/31/25, but he was not given the NOMNC. Resident 21’s CMS SNF Beneficiary Notification Review form showed a Medicare Part A skilled services episode start date of 12/9/25 and a last covered day of 1/15/26, but she was also not given the NOMNC. During interview, the social worker designee stated he was unaware that residents 19 and 21 should have received the NOMNC, and the social worker consultant stated she met quarterly with him to review resident items but did not discuss when NOMNC forms should be provided.
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