Failure to Notify Residents and Families of Conversion From Medi-Cal to Private Pay
Summary
The deficiency involves the facility’s failure to notify four residents and/or their responsible parties of changes in their primary payor status from Medi-Cal IEHP to private pay, as required by resident rights and the facility’s own policy. Record review showed that each of the four residents had Medi-Cal IEHP as the primary payor prior to January 1, 2026, and that their primary payor was changed to private pay effective January 1, 2026, in the PointClickCare (PCC) census records. The facility’s policy titled “Pay Source Conversion” states that Social Services is responsible for notifying the family of non-coverage and anticipated payment, and that the resident and/or responsible party must be informed of their financial obligations when there is a conversion from one primary pay source to another. Resident 2 was admitted with a history of transient ischemic attack and was documented as self-responsible, with an MDS indicating intact cognition. Resident 3 was admitted with dementia, also documented as self-responsible, and had an MDS indicating intact cognition. Resident 4 was admitted with dementia, had a responsible family member, and an MDS showing she was rarely/never understood with moderately impaired cognition. Resident 5 was admitted with metabolic encephalopathy and had an MDS indicating moderately impaired cognition. Despite these documented conditions and responsible party designations, interviews with Residents 2, 3, and 5 revealed that they were unaware they were currently paying privately for their stays, did not know the cost, and reported that no one had discussed these financial changes with them. Resident 4 was non-responsive at the time of attempted interview, and later her responsible party reported not receiving any notification of the payor change or information about the cost. Interviews with staff confirmed that required notifications were not provided. The Business Office Manager (BOM) stated that her department is responsible for notifying residents and responsible parties of payor changes via a notice of insurance change letter, but reported that the Director of Finance (DOF) at the corporate office initiated the payor changes on December 31, 2025, without informing her. The Accounts Receivable Director stated that the BOM, Administrator (ADM), or Social Services Director (SSD) should inform residents about becoming private pay. The Social Service Assistant stated that the BOM is responsible for payor changes and that she had never dealt with payor changes. The ADM stated the BOM is supposed to give notice of payor status changes to residents and report such changes in stand-up meetings, but he was not aware of the corporate-initiated changes and the BOM did not report any payor changes. The DOF stated that BOM, SSD, and sometimes ADM should explain payor changes and document their actions, and later clarified that no written Medi-Cal recommendation was received and that the decision to change the four residents to private pay was made at the facility level. These actions and inactions resulted in residents and responsible parties not being notified of the change from Medi-Cal to private pay and their resulting financial obligations.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
A resident who had prepaid for services was discharged with a credit balance of $7,582.31 due back after copays were applied, but the facility did not refund the full amount within the required 30 days. The business office confirmed the resident had prepaid $11,067.31 and acknowledged that the facility’s refund turnaround time was about 30–60 days. Documentation showed two partial refund checks totaling $5,123.31 were sent, leaving $2,459.00 still owed to the resident beyond the 30-day timeframe, contrary to federal requirements and the facility’s own policy.
The facility failed to follow its own policy and federal requirements to return personal funds within 30 days after a resident’s death or discharge. One deceased resident’s representative reported making multiple in‑person visits and numerous phone calls over several weeks to recover more than $1,800 from the resident’s account, with the refund not issued until months later. In addition, two discharged residents had remaining account balances that were not refunded within the expected 30‑day period, and one resident’s balance continued to accrue without any refund being processed. The Regional Director of Business Office Services and the Administrator both acknowledged that refunds were not completed within the required timeframe.
Surveyors found that two residents who had been discharged and later died had credits in their patient liability accounts indicating refunds were due, but these refunds were not issued within the required timeframe. One resident’s representative reported not receiving a refund despite a documented credit balance, and the NHA confirmed no refund had been made. For the second resident, the BOM stated that a refund request had been sent to corporate accounts payable, yet the refund still had not been issued. Both residents were beyond 30 days post-discharge, and review of the facility’s refund policy showed that overpayments and personal funds are to be refunded or made available to the resident’s representative within specified 30–60 day timeframes.
ABN forms were not provided for two residents when Medicare Part A skilled coverage ended. One resident had profound/severe cognitive impairment with dependence for ADLs, and the other had severe cognitive impairment and could not make medical decisions. The BOM stated both residents remained in the facility after their last covered day and received a NOMNC, but not an ABN, even though the forms were needed to explain which services Medicare would cover and which costs could become the resident's responsibility.
Failure to Provide Medicare NOMNC and Appeal Notice: Two residents did not receive required notice when Medicare Part A skilled services were ending. One cognitively intact resident signed the NOMNC on the same day services ended, with no documentation of the required advance notice, and another resident’s representative received only verbal notice, with no written NOMNC, cost information, or appeal rights documentation.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
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
Failure to Timely Refund Full Balance Owed After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to refund the full amount of funds owed to a discharged resident within 30 days, as required by 42 CFR 483.10(g)(17)-(18) and the facility’s own policy. The facility policy stated that when a credit balance exists on a resident’s private account, and all insurance, Medicaid, and third-party payers are paid with no remaining deductibles or copays, a refund will be issued by check within 30 days of confirmation. Record review showed that one resident was discharged with a credit balance of $7,582.31 from prepaid charges after applicable copays were paid. The Business Office Manager confirmed that the resident had prepaid $11,067.31 and that $7,582.31 was due back to the resident upon discharge as an overpayment. The Business Office Manager also stated that the typical turnaround time for issuing a refund from the facility is about 30–60 days, which exceeds the 30-day requirement. Documentation provided showed that the facility issued one refund check for $4,011.31 and a second refund check for $1,112.00 to the resident, but as of the survey date, the facility still owed a remaining refund amount of $2,459.00, which had not been returned within 30 days of discharge.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F582 Medicaid/ Medicare Coverage / Liability Notice (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? By , Resident #3 refund was sent. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review of residents discharged in the previous 30 days to ensure refunds were provided in a timely manner. Any concerns noted were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. On4/2/2026, Business Office Manager were educated by the NHA/designee on ensuring refunds are provided in a timely manner. Newly hired Business Office Managers will be educated to ensure refunds are provided in a timely manner by the NHA/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. NHA/Designee to conduct audits of 5 random discharged residents to ensure refunds are provided in a timely manner weekly for 4 weeks then monthly for 2 months.The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Timely Refund Resident Personal Funds After Death or Discharge
Penalty
Summary
The deficiency involves the facility’s failure to return residents’ personal funds within 30 days of death or discharge, as required by its own policy and federal requirements. The facility’s “Refund of Overpayments” policy states that within 30 days of a resident’s death, the resident’s personal funds and a final accounting will be made available to the resident’s representative or probate. For one deceased resident, the clinical record showed an admission and subsequent death, with a documented account balance of $1,826.15 at the time of death. The resident’s Power of Attorney reported that while the resident was in the facility she had about $1,800 or more in her account, and that after her death he went to the facility multiple times and called about 20 times seeking the refund, but no one would talk to him. He stated he did not receive the refund until several months later. The Regional Director of Business Office Services confirmed the balance at the time of death, acknowledged there was no documentation that the facility contacted the family about the refund, and confirmed the refund was not issued until well beyond the 30‑day timeframe. The deficiency also involved two discharged residents whose personal funds were not refunded within 30 days of discharge. For one discharged resident, the facility’s Resident Fund Statement showed an ending balance of $116.46 as of a specific date, and the Regional Director of Business Office Services verified the discharge date and that the refund had not yet been issued. For another discharged resident, the Resident Fund Statement showed an ending balance of $221.18 as of a specific date, and the Regional Director verified the discharge date and that the resident’s account balance had increased to $381.36 as of the survey date, with no refund yet issued. In interviews, the Regional Director of Business Office Services and the Administrator both stated that the facility’s expectation is that refunds for deceased or discharged residents are completed within 30 days, confirming that this did not occur for these three residents.
Failure to Timely Refund Resident Personal Funds After Discharge and Death
Penalty
Summary
Surveyors identified that the facility failed to refund personal funds owed to two discharged residents within the required timeframe. For one resident, the resident’s representative reported on 04/29/2026 that they had not received a refund. Record review showed this resident had been discharged to a hospital on 08/10/2025 and subsequently died on 09/01/2025. The resident’s financial transaction report, covering 05/01/2025 to 03/31/2026, showed a patient liability credit of $620.29, indicating a refund was due from monies paid. Despite this, the Nursing Home Administrator (NHA) confirmed that the refund had not been issued, and the resident was more than 30 days post-discharge. For a second resident, records showed admission on an unspecified date and death on 08/20/2026. The financial transaction report for 07/01/2025 to 03/31/2026 showed a patient liability credit of $804.81, also indicating a refund was due. During an interview on 04/29/2026, the Business Office Manager (BOM) stated that this resident had requested a refund, and that a request for $804.80 had been sent to the corporate accounts payable office on 03/30/2026, but the refund had not yet been sent. The BOM and NHA both confirmed that refunds for these two residents had not been issued and that both cases exceeded 30 days post-discharge. Review of the facility’s undated “Refund of Overpayments” policy showed that personnel are to promptly refund overpayments, that monies on deposit are to be refunded upon request or death, that overpayments should be refunded as soon as possible but not later than 60 days (30 days if an electronic adjustment is possible), and that personal funds are to be made available to a deceased resident’s representative within thirty days of death.
ABN Forms Not Provided When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to ensure Advance Beneficiary Notice (ABN) forms were provided when Medicare Part A coverage ended for two sampled residents, Resident 53 and Resident 58. Resident 53 was admitted and later readmitted to the facility, had diagnoses including dysphagia, Alzheimer's disease, and schizophrenia, and was documented in the H&P as having profound cognitive impairment. The MDS dated 1/22/2026 indicated severe cognitive impairment and dependence on staff for eating, toileting, hygiene, and bathing. Resident 53's SNF Beneficiary Notification Review form showed the last covered date for Medicare Part A skilled services was 2/6/2026, and that an ABN form was not provided. Resident 58 was admitted and later readmitted to the facility, with diagnoses including HTN, asthma, and dysphagia. The H&P dated 11/21/2025 stated the resident could make needs known but could not make medical decisions, and the MDS indicated severe cognitive impairment and substantial assistance needed for dressing, bathing, and toileting. Resident 58's SNF Beneficiary Notification Review form showed the last covered date for Medicare Part A skilled services was 1/23/2026, and that an ABN form was not provided. During interview, the BOM stated both residents remained in the facility after their last covered day of Medicare Part A services and were given a NOMNC, but not an ABN. The BOM and Administrator stated ABN forms should have been completed so the residents could be informed of which specific services would be covered by Medicare and which services they would be financially responsible for.
Failure to Provide Timely Medicare Skilled Service Termination Notices
Penalty
Summary
The facility failed to ensure that two residents were properly notified when Medicare Part A covered skilled services were ending and, in one case, failed to provide the resident’s representative with written notice and appeal information. Resident #35 had diagnoses including chronic respiratory failure with hypoxia, COPD, schizophrenia, dementia, and anxiety, and the 4/13/26 MDS showed the resident was cognitively intact with a BIMS score of 13 out of 15. Record review showed the resident was discharged from Medicare Part A skilled therapy services on 12/12/25, and the NOMNC was signed on the same day the services ended, with no documentation that the resident received at least two days’ notice before the end of skilled services. Resident #41 had diagnoses including schizophrenia, COPD, dementia with anxiety, and heart disease, and the 3/14/26 MDS indicated severe impairment in cognitive skills for daily decision making. Record review showed Medicare Part A skilled therapy services ended on 11/28/25, and the NOMNC documented verbal notification to the resident’s representative on 11/25/25. However, there was no documentation that the representative received the written NOMNC letter, the estimated cost of continuing services out of pocket, the reason skilled services were ending, or the information needed to appeal the decision.
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