Inspection·April 3, 2025

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately bill and issue a refund for an overpayment to a resident in a timely manner for 1 of 3 residents (R1) reviewed for billing in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE]. On 1/1/2023 R1's payer source changed to hospice medicaid which it remained until the time of her passing on 7/3/2024. On 4/3/25 at 10:20 AM, V3 (Senior [NAME] President of Business Office) said she became involved a few weeks in the issue with R1's bill. V3 said that its very time consuming and she will have to go back over every single payment that was made and everything billed for R1 since 2023 but the best she can tell is that R1 did have an overpayment and was due a refund back in 2023. She believes the reason was that R1's spouse {V10} had a financial change and as a result the amount medicaid paid and the amount he was liable for R1's bill had changed so a former business office employee identified as V5 should have followed a process and send a 1156 form to medicaid and then completed a form to send to the senior vice president and a refund should have been issued. V3 said she could see where V5 made a notation in R1's Electronic Medical Record (EMR) that she had started that process but no notation was made that it was ever followed up on and no refund had been issues to R1's Power of Attorney (V10). V3 said 2 years is to long for this to take to get resolved, it should have taken about 6 weeks. V5 was attempted to be contacted by this surveyor on 4/3/25 with no return call. On 4/3/25 at 10:45 AM, V4 (Assistant Business Manager) went over R1's billing inquiry with this surveyor. V4 said based on the statements anything in parenthesis is a refund to the payee. There are various different totals in for R1 from 1/1/23-12/1/23 with the average being about $1,143.00 V4 said she was new to this role so she doesn't totally know everything yet but based on the information there was an overpayment in 2023 and R1 was due a refund. A Transaction report for R1's bill in her EMR shows a note completed by V5 on 9/20/2023 at 2:31 PM that states, income book has been incorrect. Income was not diverted to the spouse in the community. 1156 will be completed to reflect PL change. Spoke with the husband and he is aware there is a process that needs to be taken before he receives the refund. An account generation note on the same report shows on 12/6/23 the identified amount of the refund due for R1 was $9,290.10. On 4/3/25 at 11:10 AM, V9 (R1's son) was contacted at the request of V10 (R1's spouse). V9 explained that his dad (V10) had a financial change in 2023 and due to that his amount due for R1's bill had become less however the facility continued to bill him the same amount for R1's care. V9 said they (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: 145460 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 145460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thrive of Lake County 850 E US Highway 45 Mundelein, IL 60060 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)