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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to obtain a signed Notice of Medicare Non-Coverage
(NOMNC) in order for an opportunity to appeal an insurance denial for 1 of 3 residents (R1) reviewed for
Physical Therapy, in the sample of 3.
Residents Affected - Few
Findings include:
R1's Facesheet dated 3/8/2024 documents R1 was admitted to the facility on [DATE]. It further documents,
admission reason for stay: Short term skilled nursing and rehabilitation care.
R1's Critical Incident Form from R1's insurance provider, dated 3/11/2024 documents, Member admitted to
Greenville Nursing and Rehab for skilled care with intent to return home. Member admitted on [DATE] and
skilled care ended on 2/19/24 but therapy did not work on standing or walking. Member is not able to return
home and additional therapy is not approved. Member was provided with phone number for Ombudsman.
Member stated to this nurse that she was not notified that her therapy was ending. Member was provided
with phone number for Ombudsman.
On 3/8/2024 at 9:15 AM, R1 stated, I've talked to (V5, Insurance Case Worker) maybe twice. They said they
didn't give me a paper to sign. They weren't standing me up because the doctor (surgeon) hadn't released
me. I'm going home today-my ride just walked in. I never had a meeting with anyone about it.
On 3/8/2024 at 10:45 AM, V1 Administrator, stated, We have a NOMNC (Notice of Medicare
Non-Coverage) but it is not signed. Looks like we received it in the mail, which sometimes we don't get
them until after the date that services will end.
On 3/8/2024 at 11:27 AM, V1 stated, (R1) was on a managed Medicaid/Medicare plan. Initially (R1) was not
progressing because the doctor put her on restrictions. When she saw the doctor again and he lifted the
restrictions, she was already off Med 'A' (skilled nursing care). I wonder why they didn't fax it. They sent it by
mail (postal). I do not know who opened the letter. (V3) is supposed to. I think medical records may have
opened it and not known (it needed to be signed/addressed with R1), but I honestly can't say that's what
happened. Since the NOMNC wasn't signed, she was not able to appeal to get back on 'Med A.
On 3/8/2024 at 12:41 PM, V3, Business Office Manager (BOM) stated, If the resident is coherent, I talk to
them, and they sign it (NOMNC and ABN) to show that they understand. I do not know why it wasn't signed.
It should have a confirmation cover sheet to show that it got sent back to the insurance
(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:
145909
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
145909
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/14/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenville Nursing & Rehab
400 East Hillview Avenue
Greenville, IL 62246
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
company. I have done so many of these I can't always remember. I do not have any documentation to show
proof of her receiving the notice.
On 3/11/2024 at 9:45 AM, V5, Insurance Case Worker, stated, (R1) was getting physical therapy but she
couldn't even stand. Our Utilization Management Department does the authorizations and they told me she
(R1) should have contested the denial of coverage when the NOMNC was given to her.
On 3/14/2024 at 8:45 AM, V1 verified that they did not have a NOMNC signed by R1.
The Facility's Medicare Beneficiary Notice Policy, undated, documents, Notice of Medicare Non-Coverage
(NOMNC) Advanced written notice to enrollees must be provided before termination of services in a Skilled
Nursing Facility (SNF). If an enrollee files a Feature Focus appeal, then the plan must deliver a detailed
explanation of why services should end. The two notices used for this purpose are:
Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123-NOMNC, and
Detailed Explanation of Non-Coverage (DENC) Form CMS-10124-DENC.
A Notice of Medicare Non-Coverage (NOMNC) to Medicare health plan enrollees is required when their
Medicare covered service(s) are ending. The NOMNC informs enrollees on how to request an expedited
determination from their Quality Improvement Organization (QIO) and gives enrollees the opportunity to
request an expedited determination from a QIO.
The Facility's Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) documents, The
provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate
that the beneficiary or representative received the notice and understands that the termination decision can
be disputed. Use of assistive devices may be used to obtain a signature.
Signature line: The beneficiary/enrollee or the representative must sign this line.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145909
If continuation sheet
Page 2 of 2
