Failure to Notify Medicaid Residents of Trust Fund Balances Near SSI Limit
Summary
The deficiency involves the facility’s failure to notify Medicaid residents or their representatives when resident trust fund balances approached the Supplemental Security Income (SSI) resource limit. Surveyors reviewed medical records, resident fund account statements, and conducted staff interviews, and determined that six of seven sampled residents with Medicaid payor sources did not receive required notifications when their account balances reached $200 less than the SSI resource limit. There was no documentation of such notifications in the records for these residents, despite quarterly fund statements showing balances at or above the threshold. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs; this resident’s account balance during one quarter ranged from $2270.97 to $1888.16 without any documented notification. Another resident with type 2 diabetes mellitus, PTSD, and osteoarthritis, who was cognitively intact but required ADL assistance, had a quarterly account balance that increased from $1750.26 to $7395.49, again with no documentation of notification when the balance reached the required threshold. A third resident with type 2 diabetes mellitus, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and needed ADL assistance, had a quarterly balance that decreased from $2193.82 to $1618.38, with no evidence of notification at the appropriate point. Additional residents with epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, type 2 diabetes mellitus, Alzheimer’s disease, and congestive heart failure were also affected. These residents ranged from cognitively intact to severely cognitively impaired and all required assistance with ADLs. Their quarterly resident fund statements showed balances between approximately $1600 and nearly $5000 over multiple quarters, yet there was no documentation that they or their representatives were notified when their balances reached $200 less than the SSI resource limit. In an interview, the Administrator confirmed that the facility had not provided the required notifications for these residents when their resident fund accounts reached the specified threshold.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify Designated Representatives About Resident Funds Balances: The facility did not document notifying, or attempting to notify, designated representatives when two cognitively impaired residents’ personal funds accounts reached or exceeded the SSI resource limit. One resident had dementia, epilepsy, and DM2 with severe cognitive impairment and lacked decision-making capacity; the other had Alzheimer’s disease, schizophrenia, and severe CKD with severe cognitive impairment. Both residents’ ledgers showed balances over $2,000, and their representatives reported they had not been contacted about the accounts.
A facility failed to notify a cognitively intact resident when the resident trust account exceeded the SSI resource limit and failed to document notice about the resulting spend-down requirement. The resident stated no letters or discussions were received about the account balance or money to be taken for services, while records showed large disability back-pay deposits, a balance over the limit, and a DHS notice requiring an $8,525 spend-down for nursing facility costs.
The facility failed to close resident personal funds accounts within 30 days of discharge for two residents. One resident’s funds were not returned for about 60 days, and another resident’s Social Security checks were received after discharge while the account remained open. The Corporate Senior Business Office Manager stated there was no written policy for closing accounts and that errors occurred under the previous BSM.
Failure to return a resident’s personal funds after discharge. The resident had a credit balance and a separate trust account balance remaining, but the BOM confirmed no refund had been issued and said she had not been instructed to send one. The resident had HTN, macular degeneration, depression, and pain, and was cognitively intact with a BIMS of 15.
Failure to provide timely spend down notices for resident funds. Two residents with dementia and psychotic disturbance, both on Ohio Medicaid, had personal fund balances well above the $2,000 limit, with quarterly statements showing balances over $4,000 and $5,000. Although spend down notices were documented, the BOM confirmed the last notices were provided in April, and the facility did not provide the required notices when the accounts reached the threshold.
Failure to convey resident trust funds after death. The facility did not refund or account for personal funds within the required timeframe for three expired residents. Records showed each resident had trust account balances with deposits, interest, and later checks issued to Heritage Hills, while the admin stated they did not know the disposition of the funds or why one resident's funds were used months after death.
Failure to Notify Designated Representatives About Resident Funds Balances
Penalty
Summary
The facility failed to ensure designated representatives of cognitively impaired residents were notified when resident personal funds accounts approached or exceeded the Supplemental Security Income resource limit. The facility’s policy stated that Medicaid residents were to be notified when their personal funds account balance reached $200 less than the SSI resource limit, and the SSI resource standard for 2026 was $2,000 per individual. Survey review found that for two residents, documentation was not available showing that designated representatives were notified, or that attempts were made to notify them, when the residents’ personal funds balances reached or exceeded that limit. Resident #101 had diagnoses including dementia, epilepsy, and Type 2 diabetes. The MDS documented severe cognitive impairment and that family involvement in care discussions was very important to the resident, and a psychiatry evaluation documented lack of decision-making capacity. The resident’s funds ledgers showed balances over $2,000 for multiple quarters, but there was no documentation that the designated representative was notified; the representative stated they were unaware the facility managed the resident’s personal funds and had never been contacted. Resident #74 had diagnoses including Alzheimer’s disease, schizophrenia, and severe chronic kidney disease, and the MDS documented severe cognitive impairment and inability to report preferences related to clothing choice, family involvement in care discussions, and personal belongings. The resident’s funds ledgers also showed balances over $2,000 for multiple quarters, but there was no documented evidence of notification or attempted notification to the designated representative, who stated they expected financial information from the facility and had not received communications about the account.
Failure to Notify Resident of Trust Fund Balance and Spend-Down Requirement
Penalty
Summary
The facility failed to notify a resident when the resident trust account balance reached the SSI resource limit and failed to document notice that the resident may lose eligibility for Medicaid or SSI. The facility policy dated April 2021 states the business office representative will notify the resident when the personal funds account reaches $200 less than the SSI resource limit and when the account, along with other non-exempt resources, reaches the SSI resource limit for one person. In interview on 6/17/26, the cognitively intact resident stated no letters were ever received about the trust account balance or any spend-down money the facility would take for services, and stated no one had discussed this with the resident. The resident’s profile identified the resident as the responsible party for the account. Record review showed the resident’s trust accounting ledger included deposits of $14,753.78 and $16,061.09, with a balance of $31,878.46, and the resident statement later showed a balance of $30,753.72. A DHS Notice of Decision stated the resident’s medical benefits would change because resources were over the limit and that the resident must meet a spend-down deductible, with the nursing facility cost of care identified as $8,525.00. The business office manager stated the resident recently received a large back pay from disability income, DHS sent a notice requiring a spend-down of about $8,500, and the resident was spoken to about the spend-down within the last 30 days, but there was no documentation of that discussion.
Resident Personal Funds Accounts Not Closed Timely After Discharge
Penalty
Summary
The facility failed to ensure Resident Personal Funds Accounts were closed within 30 days of discharge and that remaining balances were returned at that time for 2 of 3 residents reviewed for management of resident funds, Residents F and J. During confidential interviews, concerns were raised that a resident’s personal funds account was not closed within 30 days of discharge, and both the resident and the new facility contacted the facility without receiving assistance in obtaining the remaining funds within that timeframe. The funds were returned after approximately 60 days, and the resident did not have access to the money during that period. Record review showed Resident F was discharged on 3/24/26, but the resident’s Social Security check was received by the facility on 5/4/26, 41 days after discharge, and was deposited into the still-open personal funds account. A check for the deposit amount plus one cent interest was not processed to be mailed until 5/22/26, and the account was recorded as closed on 5/21/26, 59 days after discharge. Resident J was discharged on 4/3/26, yet two Social Security checks were received after discharge and the account was not closed until a check was sent on 5/12/26, 40 days after discharge. The Corporate Senior Business Office Manager stated the facility did not have a written policy or procedure for closing resident personal funds accounts and that errors occurred under the previous Business Office Manager.
Failure to Return Resident Funds After Discharge
Penalty
Summary
The facility failed to ensure that personal funds deposited with the facility were returned within 30 days of discharge for one resident. Record review showed the resident had a credit balance of $580.07 on the facility transaction report and a trust account opening balance of $178.00, with a $21.00 debit for shampoo, cut, and style, leaving a closing trust balance of $157.00. The resident’s admission record showed diagnoses including hypertension, macular degeneration, depression, and pain, and the discharge MDS indicated a BIMS score of 15, showing the resident was cognitively intact. During interview, the Administrator stated the resident was cared for by the facility from 11/14/25 through 11/30/25 at no charge, and that in January 2026 the resident paid $3,173.92 when she should have paid $3,343.97. She explained that the resident’s account was charged $119.42 for eight days of stay, leaving a credit balance of $573 due to the resident that had not been paid, along with the $157.00 remaining in the trust account. The BOM confirmed that she had not issued payment for the remaining trust fund balance and that $157.00 was due to the resident since discharge, and stated she had not been instructed to issue any refund. The complainant also stated he believed the facility owed the resident money from her trust fund account and a refund of the money left on her account.
Failure to Provide Timely Spend Down Notices for Resident Funds
Penalty
Summary
The facility failed to provide spend down notices when resident personal funds accounts reached $200 less than the Social Security Insurance resource limit. This deficiency involved two residents, both of whom had diagnoses including dementia and psychotic disturbance, and both were unable to complete an interview to assess mental status on their MDS assessments. Review of the facility records showed that both residents had Ohio Medicaid as their primary payer and had resident fund balances in excess of $4,500, with quarterly statements showing balances of $4,234.16 and $5,162.44 on 03/31/26. Record review showed spend down notices dated 04/23/26 stating that each resident’s fund balance was within $200 of, or exceeding, what is allowable under Medical Assistance. However, interview with the BOM confirmed that the Medicaid spend down limit in Ohio was $2,000, and further interview confirmed that the last documented spend down notice provided to each resident was in April 2026. The report identified this as non-compliance investigated under Complaint 2579178.
Failure to Convey Resident Trust Funds After Death
Penalty
Summary
The facility failed to convey resident funds to next of kin within 30 days of death for 3 expired residents whose trust fund accounts were reviewed. A facility policy titled Refunds stated that within 30 days of a resident's discharge or death, the facility would refund the resident's personal funds and provide a final accounting to the resident, the resident's representative, or the resident's estate, as applicable. Record review showed that Resident #8 expired in the facility and had a trust fund balance that included deposits, interest, and a later check made out to Heritage Hills for $300.36, leaving a balance of $0.02. The administrator stated they were initially told the resident still owed the facility for services rendered, but after review determined the resident did not owe the facility and was due a refund of $300.38. Resident #9 also expired in the facility and had a trust fund balance that reflected social security funds and interest, with the ledger showing a remaining balance of $831.81. Resident #10 expired in the facility and had a trust fund balance that included a refund from Heritage Hills and interest, with the ledger later showing a check made out to Heritage Hills for $1613.79 and a remaining balance of $0.08. During interview, the administrator stated they were not the administrator when Residents #8 and #9 expired and did not know the disposition of funds from the trust account was part of their responsibilities. For Resident #10, the administrator stated they handled the monthly disposition of funds to each resident, but the facility owner kept the accounting books and determined what was owed by or due to the facility from each resident, and they did not know why the owner wrote a check out to Heritage Hills for $1613.79 of Resident #10's funds six months after the resident expired.
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