Saad Healthcare

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on medical record (MR) review, observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure agency policy for infection prevention was followed. This deficient practice affected one of seven home visit (HV) patients including HV # 7 and had the potential to affect all patients receiving wound care. Findings include: Agency Policy: Hand Washing Indications Policy Number: 11160.20 Revised: 2/2022 Section 1: Purpose/Objective 1.1 To prevent nosocomial infections... ...4.6 Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated with virulent or infections microorganisms... 1. HV # 7 was admitted on 2/3/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type 1 Diabetes Mellitus with Chronic Kidney Disease. A HV was conducted on 4/1/25 at 9:45 AM to observe wound care provided by Employee Identifier (EI) # 8, Registered Nurse. EI # 8 performed hand hygiene, donned gloves, retrieved measuring tape, cotton swab, and marking pen from clean barrier, then dropped the marking pen onto the floor. EI # 8 picked up the marking pen with a gloved hand then continued to measure the open wound with the measuring tape and cotton swap. EI # 8 failed to remove gloves and perform hand hygiene after touching contaminated surface. An interview was conducted on 4/3/25 at 10:30 AM with EI # 1, Director of Nursing, who confirmed the agency failed to ensure the agency policy for infection prevention was followed.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on review of medical records (MR), observations, agency policy, and interviews with staff, patients and caregivers, it was determined the agency failed to ensure the medications were reconciled per agency policy to include all current medications. This deficient practice did affect five of seven Home Visit (HV) patients including HV # 1, HV # 2, HV # 5. HV # 7, and HV # 6, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Profile Process Policy Number: Not Listed Revised: 2/2025 Purpose/Objective: 1.1 To provide a source of information for all patients/clients receiving drug therapy. Policy: 2.1 A Plan of Care with Medication Profile will be completed on every patient upon admission to the agency and verified with physician for accuracy. All disciplines with the exception of Home Health Aides (CNA), will reconcile medication every visit and as needed for medication changes and updates... 4. HV # 7 was admitted on 2/23/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type One Diabetes Mellitus with Diabetic Chronic Kidney Disease. A HV was conducted on 4/1/25 at 9:45 AM to observe wound care provided by EI # 8, Registered Nurse (RN). A review of the medications in the home was conducted with EI # 8 and HV # 7’s cg and compared to the CMR dated 4/1/25. The following is a list of the medication discrepancies observed: a. Amitriptyline 100 mg take one and one-half tablets at bedtime, prescription dated 1/28/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication each night. b. Methocarbamol 500 mg take one tablet twice a day as needed, prescription dated 1/30/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication daily for pain. c. Ramelteon 8 mg, take one tablet at bedtime, prescription dated 3/4/25, was in the home but not listed on the CMR. The cg stated HV # 7 currently takes the medication each night for rest. d. Hydralazine 25 mg, take one three times a day as needed, prescription dated 3/8/25, was in the home but not listed on the CMR. The cg stated HV # 7 is currently taking the medication daily as needed. An interview was conducted on 4/3/25 at 11:05 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 5. HV # 6 was admitted on 3/10/25 with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Repeated Falls. A HV was conducted on 4/1/25 at 1:00 PM to observe care provided by EI # 7, Physical Therapist Assistant (PTA), A review of the medications in the home was conducted with HV # 6 and compared to the CMR dated 4/1/25. The following medication discrepancies were observed: a. Montelukast 10 mg take one daily, prescription dated 1/3/25, was in the home but not listed on the CMR. HV # 6 confirmed he/she was currently taking the Montelukast daily. b. Collagen + C (brand name) 2,500 mg over the counter (OTC) bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin daily for over a year. c. Quercetin 500 mg OTC bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin daily for over a year. d. Vitamin D 3 (brand name) 200 mg OTC bottle was in the home but not listed on the CMR. HV # 6 stated he/she had been taking the vitamin for over a year. An interview was conducted on 4/3/25 at 11:05 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 2. HV # 2 was admitted on 12/4/2024 and recertified on 2/2/2025 to 4/2/2025 with diagnoses including Parkinsonism Unspecified and Dysphagia, Oropharyngeal Phase. A HV was conducted on 4/1/25 at 11:20 AM to observe care provided by EI # 3, Occupational Therapist. A review of the medications in the home was conducted with HV # 2’s cg and compared to the CMR dated 4/1/25. T3 (Liothyronine) 30 mcg (micrograms) / T4 (Levothyroxine) 76 mcg (Methocel) E4M caps with instructions to take one cap each morning. Filled date 3/17/25. The CG reported HV # 2 has been taking the medication for a very long time. There was no documentation of the T3/T4 caps on the agency CMR. An interview was conducted on 4/3/25 at 10:31 AM with EI # 1 who confirmed the agency failed to ensure the medications were reconciled per agency policy. 3. HV # 5 was admitted on 2/14/25 with the diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputee and Type Two Diabetes with Diabetic Peripheral Angiopathy with Gangrene. A HV was conducted on 4/1/25 at 2:02 PM to observe care provided by EI # 6, Health Aide. A review of the medications in the home was conducted with HV # 5 and the cg and compared to the CMR dated 4/1/25. The following medications were on the CMR, but not in the home: a. Aspirin 81 mg tablet, delayed release, one tablet daily. HV # 5 stated, I should be taking aspirin, but never started the medication. b. Farxiga 10 mg tablet one tablet daily. HV # 5 and the cg reported they were unaware of the medication. c. Miralax 17 gram dose oral powder twice daily. HV # 5 and the cg reported they were unaware of the medication. An interview was conducted on 4/3/25 at 10:25 AM with EI # 1, who confirmed the agency failed to ensure the medications were reconciled per agency policy. 1. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. A HV was conducted on 4/1/25 at 11:26 AM to observe wound care provided by Employee Identifier (EI) # 2, Speech Therapist. A review of the medications in the home was conducted with EI # 2 and HV # 1’s caregiver (cg) and compared to the Client Medication Report (CMR). The following is a list of the medication discrepancies observed: a. Atorvastatin 40 milligram (mg) one tablet daily, prescription dated 3/14/25, was in the home. The cg verbalized the patient had been taking the 40 mg dose since returning home on 3/6/25. Atorvastatin 10 mg one tablet at bedtime was on the agency CMR. b. Miralax 17 grams daily was on the agency CMR. The cg verbalized Miralax was discontinued three weeks prior. c. Omega 3-6-9 1200 mg daily was on the agency CMR. The cg verbalized Omega 3-6-9 was discontinued prior to the patient returning home on 3/6/25. An interview was conducted on 4/3/25 at 10:49 AM with EI # 1, Director of Nursing, who confirmed the agency failed to ensure the medications were reconciled per agency policy.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on medical record (MR) review, agency policy, and interview with staff, it was determined the agency failed to ensure physician’s orders were followed. This deficient practice affected one of four diabetic patients reviewed including MR # 7 and had the potential to affect all diabetic patients admitted to this agency. Findings include: Agency Policy: Physician Notification and Physician Orders Policy Number: Not Listed Revised: 2/2025 Section 1: Purpose/Objective 1.1 To ensure that the physician is notified of all changes in patient status... 1.2 To ensure that all disciplines follow all orders, to include the 485/487 and Physician Change Orders... 1. MR # 7 was admitted on 8/16/24 with diagnoses including Dysphagia Following Cerebral Infarction, Peripheral Vascular Disease, and Type 2 Diabetes Mellitus. Review of the Resumption of Care (ROC) dated 8/28/24 revealed physician’s orders for Skilled Nurse (SN) one visit per week for seven weeks. SN to perform blood glucose analysis every visit and report blood glucose levels greater than 250 milligrams (mg)/deciliter(dl) and less than 70 mg/dl. Review of the SN Visit Note Report dated 9/10/24 revealed no documentation the SN obtained the blood glucose level. Review of the SN Visit Note Report dated 9/12/24 revealed the SN documented the blood glucose was 45 mg/dl and MR # 7 was taken to the Emergency Room. An interview was conducted on 4/3/25 at 11:04 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure the staff followed physician orders for performing blood glucose analysis every visit.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the physician was notified of significant changes. This deficient practice did affect two of seven Home Visit (HV) patients including HV # 7 and HV # 6, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Physician Notification and Physician Orders Policy Number: Not Listed Revised: 2/2025 Section 1: Purpose/Objective 1.1 To ensure that the physician is notified of all changes in patient status ... Section 4: Procedure ...4.2 Reasons to obtain a new order, or provider physician notification, will include but are not limited to the following: ...e. Change in patient status and/or need for additional services. ...g. Any parameters outside those listed above... 1. HV # 7 was admitted on 2/3/25 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, and Type 1 Diabetes Mellitus with Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/23/25 revealed physician’s orders for Skilled Nurse (SN) three visits per week for one week then two visits per week for seven weeks. SN to assess/evaluate co-morbid conditions including ... Diabetes Mellitus... Further review of the HHC and POC dated 2/23/25 revealed physician’s orders for SN to perform blood sugar analysis every visit and to report to the physician blood glucose levels greater than 250 milligrams (mg)/decaliter (dl) or less than 70 mg/dl. Review of the SN Visit Note Report dated 3/4/25 revealed the SN documented the blood sugar reading was 435 mg/dl, patient asymptomatic. There was no documentation the physician was notified. An interview was conducted on 4/3/25 at 10:30 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure the physician was notified. 2. HV # 6 was admitted on 3/10/25 with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Repeated Falls. Review of the HHC and POC dated 3/10/25 revealed physician’s orders for Physical Therapist (PT) two visits per week for four weeks. Review of the PTA Visit Note Report dated 4/1/25 revealed the patient’s last bowel movement was on 3/27/25, which was greater than 3 days. Instructions under the Gastrointestinal section was to notify the Nurse Supervisor if greater than three days. Further review of the PTA Visit Note Report dated 4/1/25 revealed no documentation the physician was notified of the no bowel movement of greater than three days. An interview was conducted on 4/1/25 at 1:05 PM with EI # 1, who confirmed the agency failed to ensure the physician was notified of no bowel movement greater than three days.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on medical record (MR) review, agency policies and procedures, and interviews it was determined the agency failed to ensure: 1. Negative Pressure Wound Therapy (NPWT) black foam number removed and/or inserted into the wound was documented per policy. 2. Soiled wound VAC dressing was removed and a wound assessment completed in response to an unresolved on-call problem. 3. Blood draws from a PICC (peripherally inserted central catheter) were documented per the agency policy. 4. Wounds were measured per policy. This deficient practice affected five of 17 MRs reviewed including MR # 1, MR # 5, Home Visit (HV) # 1, HV # 3, HV # 4, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: NPWT Policy Number: Not documented Revised: 2/25 Section 1: Purpose and objective 1.1 To standardize the management of wounds where NPWT is indicated. 1.2 To ensure all patients are receiving treatment that is in keeping with best practice guidelines for wound care. ...Section 4: Procedure ...4.3 The removal of NPWT: ...Check that the number of gauze and foam pieces removed from the wound is the same as the number that was originally placed in the wound... 4.4 The application of NPWT: ...The number of pieces of foam inserted into the wound must be documented in the coordination note... Section 5: Documentation 5.1 Record application of NPWT in wound care record and coordination note. Include: ...Type and number of foam pieces removed/inserted/applied... Agency Policy: On Call Procedure Policy Number: Not documented Revised: 2/25 Section 1: Purpose/Objective 1.1 To implement, maintain, and promote Home Health...patient after hours regarding all patient related issues... Section 4: Procedure 4.1... On-call personnel will be notified for follow up on the patient to attempt to resolve the issue by phone and follow up or direct if a visit is warranted based on report and signs and symptoms. Office personnel will place an order for a scheduled visit if needed after hours to resolve any issues... Agency Policy: Wound Care Policy Number: Not documented Revised: 4/18 Section 1: Purpose and Objective 1.1 To provide and environment conductive to wound healing. 1.2 To prevent infection. 1.3 To effectively treat and document wound healing performance. Section 2: Policy 2.1 Wound measurement and photos are done on Admission...on a weekly basis... Section 5: Documentation 5.1 Document...length, width, and depth of wound... Agency Policy: PICC Line Irrigation or Blood Draw Policy Number: Not documented Revised: 2/25 Section 1: Purpose/Objective...To maintain the patency of the catheter. Section 2: Policy and Criteria. 2.1... Agency protocol is as follows: A. With 10 cc (cubic centimeter) Saline...prior to blood sampling. B. Withdrawal of blood - 10 cc and discard. C. With 20 cc Saline...after blood sample withdrawal. ...Section 4: Procedure Document procedure performed... 4. HV # 3 was admitted to the agency on 3/30/25 with a diagnose of Disruption of External Operation (surgical) Wound. Review of the HHC and POC dated 3/30/25 to 5/28/25 revealed an order for a SN frequency twice weekly for one week, and once weekly for eight weeks to perform/teach wound care to left lower back, cleanse with Normal Saline, pat dry, and leave open to air using clean/aseptic technique. Derma bond in place. Review of the SN visit note dated 3/30/25 revealed no documentation of weekly wound measurements for wound # 2, Left Mid-Back Surgical Incision (SI), and wound # 3, Medium Mid-Back SI per the agency policy. An interview was conducted on 4/3/25 at 11:15 AM with EI # 1 who confirmed wound measurements were not performed on admission per agency policy. 5. HV # 4 was admitted to the agency on 3/14/25 with a diagnosis of Encounter for Surgical Aftercare Following Surgery on the Nervous System. Review of the HHC and POC dated 3/14/25 to 5/12/25 revealed an order for SN frequency of once weekly for one week, and twice weekly for eight weeks. Review of the physician order dated 3/21/25 revealed an order for the SN to cleanse # 2 Left Axillary Surgical incision with wound cleanser/normal saline, pat dry, then leave open to air daily. Review of SN visit note dated 3/24/25 and 3/28/25 revealed no documentation of wound measurements for wound # 2, Left Axillary, Surgical Incision the week of 3/23/25 per agency policy. An interview was conducted on 4/3/25 with EI # 1 who confirmed there were no wound measurements performed weekly per agency policy. 1. MR # 1 was admitted to the agency on 3/5/25 with diagnoses including Sepsis, Unspecified Organism and Pressure Ulcer of Sacral Region, Stage 4. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/5/25 to 5/3/25 revealed an order for a skilled nurse (SN) frequency twice weekly for one week, once weekly for one week, then twice weekly for seven weeks to cleanse stage IV to sacral, pat dry, cut to fit and fill wound cavity with black foam, cover with transparent drape, apply trac pad (part of the NPWT dressing) then NPWT at 125 mmHg (millimeter of mercury) continuously on Tuesday and Friday. SN to instruct as needed NPWT protocol for malfunction including to clean with normal saline, pat dry, pack wound with Dakin’s moistened gauze, cover with dry gauze, and secure with tape. Review of the two nursing notes dated 3/7/25 and 3/27/25 revealed no documentation of the number of black foam pieces removed from and placed in the sacral wound. Review of the two nursing notes dated 3/14/25 and 3/19/25 revealed no documentation of the number of black foam pieces removed from the sacral wound. Review of the On Call note dated 3/18/25 revealed the caregiver called to report the patient had a large bowel movement and the area around the NPWT and the wound was filled with stool. The cg reported there remained stool under the NPWT and the wound area after the cg had cleaned the stool off of the patient. There was no documentation the patient and/or caregiver had been educated and was able to remove the NPWT dressing, the NPWT dressing had been removed, or the agency offered an after hours SN visit to change the NPWT dressing and assessment the wound due to stool remaining under the NPWT and wound area per the caregivers report. An interview was conducted on 4/3/25 at 11:24 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to document the black foam number removed and/or inserted into the wound per policy. EI # 1 confirmed there was no documentation the NPWT dressing was removed or a SN visit was offered on 3/18/25. EI # 1 verbalized a nursing visit would have been expected by the agency with the unresolved problem of stool remaining under and around the NPWT dressing per the caregiver. 2. MR # 5 was admitted to the agency on 3/7/25 with diagnoses including Osteomyelitis of Vertebra, Lumbar Region and Intraspinal Abscess and Granuloma. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for eight weeks then twice weekly for one week to perform venipuncture or use PICC line to obtain a complete blood count with differential (CBC), a comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), and c-reactive protein test (CRP) weekly. Review of the SN visits dated 3/10/25, 3/17/25, 3/24/25, and 3/31/25 revealed the nurse obtained the CBC, CMP, ESR, and CRP via the patient PICC line. There was no documentation the PICC line was flushed prior to or following the blood draw and 10 cc’s of blood was withdrawn and discarded. An interview was conducted on 4/3/25 at 10:47 AM with EI # 1 who confirmed the agency failed to document blood draws from a PICC per the agency policy. 3. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for one week, twice weekly for two weeks, then once weekly for six weeks to perform/teach wound care to the left hand skin tear cleanse with wound cleanser, pat dry, apply silver alginate to wound bed, cover with dry gauze, wrap with rolled gauze, and secure with coban every other day. Review of two of two nursing notes for the week of 3/9/25 to 3/15/25 revealed no documentation of a wound measurement for the left hand skin tear. An interview was conducted on 4/3/25 at 10:51 AM with EI # 1 who confirmed the wound was not measured per the agency policy.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on review of medical records (MRs), agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure patient education and return demonstration was provided for all medications and treatments. This deficient practice did affect four of 17 MR reviewed including MR # 6, Home Visit (HV) # 3, MR # 9, and HV # 1 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient/Family Education Process for Medications Policy Number: Not Listed Revised 10/2018 Section 1: Purpose/Objective 1.1 To provide a systematic and coordinated methodology for teaching and documenting medication instructions... Section 4: Procedure 4.1 On admission and throughout the care stay, medication teaching will be incorporated with each assessment and care of the patient. 4.2 Patient teaching will also include assessment of learning needs and evaluations of emotional barriers to learning... 4. HV # 1 was admitted to the agency on 3/7/25 with diagnoses including Cerebral Infarction due to Embolism of Bilateral Carotid Arteries and Nonrheumatic Aortic (Valve) Stenosis. Review of the HHC and POC dated 3/7/25 to 5/5/25 revealed an order for a SN frequency once weekly for one week, twice weekly for two weeks, then once weekly for six weeks to perform/teach wound care to the left hand skin tear cleanse with wound cleanser, pat dry, apply silver alginate to wound bed, cover with dry gauze, wrap with rolled gauze, and secure with Coban. Caregiver to perform wound care every other day and as needed when soiled between nurse visits. Review of five of five nursing notes from 3/7/25 to 3/20/25 revealed no documentation a return demonstration was obtained from the patient and/or caregiver to ensure competency in providing wound care. An interview was conducted on 4/3/25 at 10:51 AM with EI # 1 who confirmed there was no documentation a return demonstration was obtained from the patient and/or caregiver to ensure competency in providing wound care. 2. HV # 3 was admitted to the agency on 3/30/25 with a diagnose of Disruption of External Operation (surgical) Wound. Review of the HHC and POC dated 3/30/25 to 5/28/25 revealed a SN frequency twice weekly for one week, and once weekly for eight weeks to infuse Ertapenem 1 gram in 100ML via eclipse bulb every 24 hours via intravenous (IV) access to the right upper extremity (RUE) midline and SN to perform/teach wound care to left lower back, cleanse with Normal Saline, pat dry, and leave open to air using clean/aseptic technique. Derma bond in place. Caregiver to perform wound care daily and as needed when soiled between nurse visits. Review of the SN visit note dated 3/30/25 and 4/1/25 revealed no documentation of return demonstration of wound care or intravenous infusion. An interview was conducted on 4/3/25 at 11:15 AM with EI # 1 who confirmed the agency failed to ensure staff provided return demonstration of wound care or intravenous infusion. 3. MR # 9 was admitted to the agency on 10/5/24 with a diagnosis of Chronic Osteomyelitis with Draining Sinus, Left Ankle Foot. Review of the HHC and POC dated 10/5/24 revealed a SN frequency weekly for ten weeks to infuse Vancomycin 1 gram in 250 ML via eclipse bulb over 90 minutes every 12 hours via IV access to the right upper extremity peripherally inserted central catheter. Review of the SN visit note dated 10/5/24 to 12/3/24 revealed no documentation of return demonstration of intravenous infusion or SN visits to infuse the Vancomycin every 12 hours. An interview was conducted on 4/3/25 at 11:14 AM with EI # 1 who confirmed the agency failed to ensure staff provided return demonstration of intravenous infusion. 1. MR # 6 was admitted on 10/26/23 and recertified from 6/22/24 to 8/20/24 with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Chronic Diastolic (Congestive) Heart Failure, and Type 2 Diabetes Mellitus. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/22/24 revealed physician’s orders for Skilled Nurse (SN) one visit per week for eight weeks. SN for observation and assessment of pain, effectiveness of pain management and skilled teaching related to pain management. SN may instruct and reinforce medication teaching related to use of medications. Further review of the HHC and POC dated 6/22/24 revealed physician’s orders for Tramadol 50 milligrams (mg) every eight hours as needed for pain. Review of the SN Visit Note Reports from 6/22/24 through 7/31/24 revealed no documentation patient teaching for the medication Tramadol was provided. Review of the SN Visit Note Report, Transfer to Inpatient Facility, dated 8/6/24 revealed MR # 6 was transferred to an inpatient facility due to an overdose of Tramadol. An interview was conducted on 4/3/25 at 10:45 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure staff provided patient teaching for pain control medications.”