F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed for one of three sampled residents (Resident 1), to
inform about Medicare co pay upon admission.
Residents Affected - Few
This deficient practice caused the Resident 1's representative (RR) to be surprised by a bill and violated
their right to be informed.
Findings:
A review of Resident 1's admission record indicated the facility admitted Resident 1 on 1/8/2025 with
diagnoses including pneumonia (an infection/inflammation in the lungs), adult failure to thrive (FTT- a
decline caused by chronic diseases and functional impairments which can cause weight loss, decreased
appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities) and
anxiety (condition of chronic worry and fear).
A review of Resident 1's Minimum Data Set (MDS- a resident assessment) dated 1/15/2025 indicated
Resident 1's cognition was not intact. Resident 1 required maximal assist (helper does more than half the
effort to complete the activity) with toileting, bathing, dressing.
A review of Resident 1's physician order dated 1/24/2025 indicated Resident 1 may be transferred from
facility A to facility B.
On 1/31/2025 The California Department of Public Health (CDPH) received a complaint alleging the facility
sent a bill for Resident 1's Medicare co pay with no warning.
During a concurrent interview and record review on 2/12/2025 at 10:31 a.m. with the RR, Resident 1's
statement dated 1/24/2025 was reviewed. Resident 1's statement indicated from 1/8/2025-1/23/2025 the
facility billed the amount of $209.50 per day for Medicare Co-insurance and the total amount due was
$3,352.00. The RR stated this bill was received by mail from the facility after Resident 1 had been
transferred to facility B. The RR stated, I went to the facility to sign admission papers about three or four
days after Resident 1 was admitted and no one informed me of this copayment. The RR stated, I was under
the impression Resident 1's stay was covered. I did not find out about this co payment until I got the bill in
the mail after Resident 1 was transferred to facility B .
During a concurrent interview and record review on 2/12/2025 at 11:31 a.m. with the business office
manager (BOM), Resident 1's Medicare eligibility response dated 1/8/2025 was reviewed. Resident 1's
Medicare eligibility response indicated Resident 1used 79/100 days for skilled nursing stay. Resident 1 had
21 days of coverage left with a co pay of $209.50. The BOM stated, Upon admission I run the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055157
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055157
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Virgil Rehabilitation & Skilled Nursing Center
975 North Virgil Avenue
Los Angeles, CA 90029
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0582
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
eligibility report to verify their insurance then we have an interdisciplinary team (IDT) meeting and inform
the Resident of their copay and if their insurance will cover their stay . The BOM stated, I did not inform the
RR of the Medicare co pay at admission I just sent the bill out after Resident 1 was transferred to facility B.
During an interview on 2/12/2025 at 12:34 p.m. with the social services assistant (SSA), The SSA stated, I
attended the IDT meeting with the RR (who attended via phone) and the BOM was not a part of this
meeting . The SSA stated, During the meeting we talked about the cost for Resident 1, the BOM informed
Resident 1 had approximately 21 days of Medicare coverage remaining, so it was my understanding that
Resident 1's stay here was completely covered . The SSA further stated, When the RR came into the facility
to sign the admission paperwork, we discussed her cots again that her stay would be covered, we did not
discuss Resident 1's Medicare co pay nor did we discuss the cost of Resident 1 would have stayed past the
21 days .
A review of the facility's policy and procedures titled, admission to the Facility , revised 1/2023, the P&P
indicated: Our admission policies apply to all residents admitted to the facility regardless of race, color,
creed, national origin, age, sex, religion, handicap, ancestry, marital or veteran status, and/or payment
source.
4. The objectives of our admissions policies are to:
a. Provide uniform guidelines for admitting residents to the facility;
b. Admit residents who can be adequately cared for by the facility;
c. Address concerns of residents and families during the admission process;
d. Review with the resident, and/or his/her representative (sponsor), the facility's policies and procedures
relating to resident rights, resident care, financial obligations, visiting hours, etc.; and
e. Assure that the facility receives appropriate medical and financial records prior to or upon the resident's
admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055157
If continuation sheet
Page 2 of 2
