F0582

C

Failure to Use Correct CMS SNF ABN Form for Medicare Beneficiary Notices

Topeka, Kansas Survey Completed on 03-31-2026

Penalty

No penalty information released

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.