Failure to Bill Medicare Part A and Timely Refund Resident Overpayment
Summary
The facility failed to appropriately bill the resident's Medicare plan during the stay and failed to reimburse the resident within 30 days after discharge for an overpayment involving Resident #5. The resident was admitted on 12/23/25 and discharged on 04/03/26. The discharge MDS documented discharge from the facility with return not anticipated. An eligibility report dated 01/02/26 showed the resident's Medicare advantage plan had terminated on 12/31/25, the resident had Medicare Part A effective 11/01/2017, and the plan benefits were Medicare Part A first bill effective 01/01/26. Review of billing statements showed the facility did not bill Medicare Part A for the resident's stay. Facility records included an email from the Regional Field Controller dated 05/28/26 stating the resident overpaid $9,266.97 for the stay. During interviews, the BOM stated the resident had moved from out of state, had been private pay after the out-of-network advantage plan was canceled, and qualified for a skilled stay as of 01/01/26, but the facility failed to complete the skilled notes and documentation needed for Medicare payment. The BOM also stated Medicare A was not billed for the stay and did not know why staff did not complete the required documentation. The Administrator stated the resident was admitted with out-of-network insurance, was not sure how the facility missed that the resident qualified for a skilled stay under Medicare Part A as of 01/01/26, and believed the BOM should have realized the resident qualified for skilled care. The Administrator and BOM were aware in mid-May that the family was upset about the billing issue and that the resident had qualified for Medicare coverage, but the resident had not yet been reimbursed. The DON also stated the resident's family came to the facility in May upset about the billing issue, corporate said a refund was owed, and the resident had not been reimbursed.
Penalty
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Failure to provide discharge planning and Medicare exhaustion notice for a resident. The resident’s record had no documentation of discharge planning, and facility leaders stated the resident was billed at the self-pay rate after Medicare days were exhausted without receiving a letter or other notice. The DON said she was not involved in the admission care plan process, and the Administrator stated the facility does not give residents documentation when Medicare days end and does not have a discharge policy.
Failure to document NOMNC delivery to a resident representative. For one resident sampled for beneficiary notification, Social Services completed the NOMNC verbally by phone, but the form had only one facility signature and there was no record that the notice was mailed to the representative. The DOSS confirmed the lack of documentation and stated the facility does not use certified mail.
The facility failed to provide SNF ABNs to two residents when Medicare Part A coverage ended, and their representatives were not given written notice of possible financial liability for non-covered skilled services. One resident had Alzheimer’s disease and was unable to make decisions, and the representative reported receiving bills without prior written notice. The BOM acknowledged the notices were not provided, and the ADM stated she was not clear on ABN policy and regulations.
A resident with a Medicare Part A episode was not provided the SNF-ABN and NOMNC, and the resident was too confused to sign the forms. Staff reported the resident had no DPOA, the brother signed admission paperwork, and an admin staff member stated the paperwork needs to be signed for the NOMNC and SNF-ABN.
A resident's MPOA did not receive timely NOMNC notice of the end of Medicare-covered skilled services. Facility policy required notice at least 2 days before the last covered day, but the phone notification was made after coverage had already ended, and the Social Services Designee confirmed the MPOA was not notified in advance.
The facility failed to provide a timely NOMNC to a resident with intact cognition. Record review showed Medicare Part A coverage ended before the NOMNC was signed, and the administrator confirmed there was no evidence the notice was given at least two calendar days before coverage ended. The resident stated she did not recall the form being reviewed with her, though she was okay with therapy ending.
Failure to Provide Medicare Exhaustion Notice and Discharge Planning
Penalty
Summary
The facility failed to provide discharge planning and a letter stating when Medicare days would be exhausted for one resident who was sampled for discharge rights. The resident’s face sheet showed an initial admission to the facility, and review of the electronic medical record, including progress notes from 2/2026 through 3/2026, found no documentation of discharge planning. During interview, the Social Services Director stated she began working at the facility in March 2026, after the resident’s admission, and described that discharge planning was discussed at an initial care plan meeting and at weekly Medicare meetings, though she had only attended one or two of those meetings. The Business Office Manager stated the resident’s 100th Medicare day was on 3/18/2026, that discharge paperwork was given on 3/24/2026, and that the resident was billed at the self-pay rate from 3/19/2026 through 3/25/2026. She confirmed the resident was not aware her Medicare days were exhausted during that time. The DON stated she was new to the facility and was not involved in the 72-hour admission care plan meeting, and the Administrator stated the facility does not give residents any documentation or letter when Medicare days are exhausted and does not have a discharge policy.
Failure to Document NOMNC Delivery to Representative
Penalty
Summary
The facility failed to provide documentation that the Notice of Medicare Non-Coverage (NOMNC) was delivered to a resident representative for one of two residents sampled for beneficiary notification. For Resident #101, the NOMNC dated 11/26/25 indicated that Social Services called the resident representative on 11/24/25, but the form was signed by only one facility representative. During interview, the Director of Social Services confirmed that the NOMNC was completed verbally over the phone with only one staff signature, and stated that best practice is to have two signatures. She also stated she could not provide documentation that the NOMNC was mailed to the resident representative because the facility does not use certified mail and there was no documentation in the medical record showing that mailing occurred.
Failure to Provide SNF ABN for Medicare Coverage Changes
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two sampled residents, Resident 86 and Resident 92, and therefore did not give written notice of Medicare coverage ending or potential financial liability for services not covered. During a concurrent interview and record review, the Business Office Manager stated that Resident 86’s last covered day for Medicare Part A was 4/16/2026 and Resident 92’s was 6/11/2026, and acknowledged that SNF ABNs were not provided in writing to either resident or their representatives. The Business Office Manager stated she was responsible for notifying residents or their representatives of changes in Medicare coverage and possible share of cost, and stated that failure to do so could leave them facing financial difficulties without being informed of changes in benefits or allowed to appeal those decisions. Resident 86’s record showed admission on 2/6/2026 with diagnoses including Alzheimer’s Disease, generalized muscle weakness, and abnormalities of gait and mobility. The MDS indicated the resident was unable to make decisions for self. During interview, Resident 86’s representative stated they were not given any written notification of changes in Medicare coverage and were receiving bills from the facility. The Administrator stated she was not clear on Advanced Beneficiary Notice policies and regulations and acknowledged that if residents were not told their Medicare coverage was ending, they may be unaware of their potential financial responsibilities and share of costs. The facility policy stated that when Medicare may not pay for otherwise covered skilled services, the resident or representative is to be notified in writing of why the services may not be covered and of potential liability for payment.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (CMS-10055) and the Notification of Medicare Non-Coverage (CMS-10123) to Resident 18 or the resident’s representative. The resident’s EMR documented a Medicare Part A episode beginning 02/17/2026 and ending on 03/09/2026. On 06/22/2026, Administrative Staff B reported that Resident 18 was unable to sign the SNF-ABN and NOMNC because the resident was very confused. Administrative Staff B also reported that the resident did not have a DPOA and that the resident’s brother signed all admission paperwork. During an interview on 06/23/2026, Administrative Staff A stated that the paperwork needs to be signed for the NOMNC and SNF.
Late Notice of Medicare Non-Coverage to MPOA
Penalty
Summary
The facility failed to provide adequate notice of the last covered Medicare A days to Resident #127's Medical Power of Attorney (MPOA). The facility policy stated that the Notice of Medicare Non-Coverage (NOMNC) would be provided at least 2 days in advance of the last covered day to allow time to appeal if the beneficiary chose. For Resident #127, the NOMNC stated that Medicare coverage of current skilled services would end on 03/04/26, but the telephone notification to the MPOA was not made until 03/06/26 at 10:00 AM. During an interview, the Social Services Designee confirmed that the MPOA was not notified at least 2 days in advance of the end of Medicare-covered skilled services.
Late NOMNC Delivery
Penalty
Summary
The facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to one resident, R27, who had intact cognition on the quarterly MDS. Review of the resident’s SNF Beneficiary Protection Notification Review forms showed Medicare Part A coverage ending on 2/15/26 and again on 5/23/26, with NOMNC forms dated 6/15/26 and signed by the resident on that same date. During interview, R27 stated she did not recall anyone reviewing the form with her but said she was okay with her therapy services ending. The administrator later reviewed the record and confirmed there was no evidence the notice had been given at least two calendar days before the end of Medicare Part A coverage as required by the facility’s NOMNC policy.
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