Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
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
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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