Kaiser Foundation Hospital Valley Continuing Care

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Comprehensive Assessment of Patients was met as follows: 1. The HHA failed to ensure four of seventeen sampled patients (Patient 5, Patient 6, Patient 10 and Patient 14) had a completed initial nursing assessment that determined their immediate care status within 5 days of admission. This deficient practice had the potential to result in decline in health status by not assessing the patient’s needs, which will cause a delay in care. (Refer to G520). 2. IJ (Refer to G528) 3. The HHA) failed to review and document all the medications the patient is currently using for six of seventeen sampled patients (Patient 1, Patient 6, Patient 11, Patient 13, Patient 15, and Patient 17). This deficient practice placed patients at risk of drug-to- drug interaction and harm by not knowing which medications were being taking. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services. The HHA failed to ensure the comprehensive assessment accurately identified the physical needs of the patients, to assist in developing the plan of care for 6 of 17 sampled patients. (Patient 6, Patient 11, Patient 13, Patient 14, Patient 16, and Patient 17). For Patient 6, the facility failed to assess an existing lymphedema (an abnormal collection of lymphatic [vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] fluid in the tissues just beneath the skin) on bilateral (both) lower extremities (legs). This deficient practice had the potential for Patient 6 to experience worsening of the lymphedema on both lower extremities that could lead to infection, sepsis and hospitalization. For Patient 13, for the recertification period from 5/3/2025 to 7/1/2025, the HHA did not assess Patient 13’s sacral (tailbone) wound and left leg wound on the home visit dated 5/5/2025, 5/7/2025, 5/10/2025, 5/15/20205, 5/17/2025, 5/19/2025. Patient 13 did not receive wound care treatment on 5/19/2025 and 5/23/2025. The sacral wound increased in size and the measurements on 5/26/2025 were: 3.97 cm (centimeters, unit of measurement) in length, 5.03 cm in width, and 1.5 cm depth. The sacrum wound measurements on 6/16/2025 were with measurements of 4 cm (cm-centimeters, unit of measurement) length, 5.5 cm (width), 2 cm (depth), undermining (measurement under the appearance of the wound) at 10 to12 o’clock measuring 2.5 cm. The HHA failed to identify and assess new existing wound to right horizontal gluteal fold. For Patient 11, the HHA failed to assess Patient 11’s Stage 4 pressure ulcer (the most severe stage of a pressure injury, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle) to left ankle and did not identify and assess the presence of wound to sacrum/buttocks. For Patient 14, the HHA did not conduct a complete assessment during the home visit on 6/12/2025, of the new open wounds to right elbow, right hand, and left buttock. For Patient 16, HHA did not assess the right knee incision site. For Patient 17, the HHA did not complete an assessment for pressure ulcer to sacral region. As a result of non-compliance: Patient 6 did not receive an assessment to promote healing of existing lymphedema on bilateral lower extremities and had the potential to experience worsening of the lymphedema on both lower extremities that could lead to infection, sepsis and hospitalization. Patient 13 experienced worsening of the sacral wound, placing Patient 13 at risk of infection, which could lead to hospitalization and/or death. Patient 11, Patient 14, Patient 16, and Patient 17 were placed at risk for hospitalization and/or death due to not identifying needs for further wound treatment to prevent complications of worsening wounds. These failures had the potential to result in delay in identifying significant needs and provision of services that could lead to hospitalization and death. (Refer to L528). The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (decided and controlled by law) mandated compliance with federal regulation for care planning, coordination of services, and quality of care to ensure care and services were provided to the patients.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Care planning, coordination of services, and quality of care of Patients was met as follows: The HHA failed to ensure five of seventeen sampled patients (Patient 1, Patient 11, Patient 13, Patient 15 and Patient 16) plans of care were followed as ordered. This deficient practice resulted in the physician not being aware of the missed services to the patient by the HHA and the patients not receiving their ordered treatments. (Refer to G572). 2. The HHA failed to include information required in the Plan of Care (POC - an individualized written program for a patient that is developed by health care professionals) for ten of seventeen sample patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 10, Patient 11, Patient 13, Patient 14, Patient 15, and Patient 17). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G574). 3. The HHA failed to ensure the plan of care was updated to reflect new orders for one of seventeen sampled patients (Patient 1). This deficient practice had the potential to result in confusion on the most current treatment plan. (Refer to G576) 4. IJ - G580 The HHA failed to ensure three of 17 sampled patients (Patient 6, Patient 13, and Patient 16) physician orders were carried out as ordered. For Patient 13, the HHA failed to provide wound care treatment to stage 4 pressure ulcer to sacrum, and stage 4 wound to left leg with wound vac (is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess wound exudate and to promote healing). For Patient 16, the HHA did not provide care and treatment to Patient 16’s right knee incision. For Patient 6, the HHA did not provide care and treatment to Patient 6’s Lymphedema (a condition where lymphatic [circulatory system] fluid builds up in soft tissues, causing swelling, most commonly in the arms or legs). (Refer to L580). 5. The HHA failed to ensure the physician was made aware two of seventeen sampled patients (Patient 6, Patient 14) had change of conditions. This failure had the potential to result in the physician not being aware the patients are not receiving HHA services, which can result in a delay in care and possibly a decline in their health status. (Refer to G590). 6. The Home Health Agency (HHA) failed to coordinate the services needed for one of seventeen sampled patients (Patient 10). This deficient practice resulted in delay of care and health goals. (Refer to G606). 7. The HHA failed to provide patient and family/caregiver education for three of seventeen sample patients (Patient 13, Patient 15, and Patient 17. This deficient practice had the potential to result in patients and their family/caregiver not knowing their treatment. (Refer to G610). 8. The HHA failed to ensure written information regarding the visit schedule was provided to one of seventeen sampled patients (Patient 13). This deficient practice resulted in confusion about the plan of care. (Refer to G614). 9. The HHA failed to ensure written information regarding the patient’s medication regime was present for one of seventeen sampled patients (Patient 15). This deficient practice had the potential to result in a medication error which can lead to injury or hospitalization. (Refer to G616). The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily (decided and controlled by law) mandated compliance with federal regulation for care planning, coordination of services, and quality of care to ensure quality patient care was provided to the patients.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Clinical Records was met as follows: 1.The HHA failed to ensure clinical records included records needed to accurately reflect the care for three of seventeen sampled patients (Patient 1, Patient 3, and Patient 4). This failure resulted in an incomplete clinical record. (Refer to G1012). 2.The HHA failed to include information required in the medical record to reflect the care for one of seventeen sampled patients (Patient 14). The HHA failed to document Patient 14’s Stage I pressure ulcer of the left buttocks. This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G1014). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation to ensure the provision of a quality health care in a safe environment.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) HHA failed to ensure five of seventeen sampled patients (Patient 1, Patient 11, Patient 13, Patient 15 and Patient 16) plan of care were followed as ordered. This deficient practice resulted in the physician not being aware of the missed services to the patient by the HHA and the patients not receiving their ordered treatments. 1. During a record review of Patient 1’s electronic medical record indicated Patient 1with a start of care (SOC) of 3/6/2025, with an admission diagnosis of unspecified open wound of left foot. During a record review of Patient 1’s Plan of Care, for certification period 3/6/2025 to 5/4/2025 indicated doctors order for skilled nurse visit frequency of; once a week for one week, twice a week for one week, then twice a week for two weeks, then twice a week for four weeks for wound care. During a concurrent interview and record review on 6/11/2025 at 3:58 pm with QA LVN 1of Patient 1’s Skilled Nurse (SN) SN visit note dated 3/13/2025, there were no photos or measurements included in the visit note. QA LVN 1 stated, “per our policy wound photos and measurements are supposed to be taken weekly. For the visit note on 3/13/2025 for Patient 1, there is no photo or wound measurements available in the system. This is important to measure wound progress and healing or monitor for deterioration.” During a concurrent interview and record review on 6/11/2025 at 4:25 p.m. with QA LVN 1 of Patient 1’s SN visit note dated 5/13/2025, and 5/16/2025 there were no measurements included in the visit notes for this visit. QA LVN 1 stated, “Per our policy wound measurements are supposed to be done weekly. In Patient 1’s visit notes for the week 5/11/2025 to 5/17/2025 there were no wound measurements including in either of the SN visit notes for this week.” During a concurrent interview and record review on 6/11/2025 at 2:28 p.m. with QA LVN 1of Patient 1’s SN visit note dated 5/20/2025, and 5/24/2025 there were no measurements included in the visit notes for this visit. QA LVN 1 stated, “Per our policy wound measurements are supposed to be done weekly. In Patient 1’s visit notes for the week 5/18/2025 to 5/24/2025 there were no wound measurements including in either of the SN visit notes for this week.” During a concurrent interview and record review on 6/11/2025 at 4:35 p.m. with QA LVN 1 of Patient 1’s SN visit note dated 5/27/2025, and 5/30/2025 there were no photo or measurements of the wound included in the visit notes for this visit. QA LVN 1 stated, “Per our policy wound measurements and photos are supposed to be done weekly. In Patient 1’s visit notes for the week 5/25/2025 to 5/31/2025 there were no wound measurements including in either of the SN visit notes for this week.” During an interview on 6/16/2025 at 2:51 p.m. with DPCS, DPCS stated, “per our policy when a patient has wounds, the skilled nurses are supposed to measure and take photos of the wound weekly. They are supposed to check the doctor’s orders and follow the doctor’s orders, and document the wound care provided. If pertinent information is missing this can lead to deterioration of the wound.” 2. A record review of Patient 11’s documents indicated an SOC of 11/10/2024, with a primary diagnosis of Pressure Ulcer of Left Ankle Stage 4 (wound extending to bone and muscle). A record review of Patient 11’s Plan of Care, for certification period 5/9/2025 to 7/7/2025 indicated doctors order for wound treatment to the left ankle twice a week and as needed. THe POC also indicated the skilled nurse/caregiver was to perform wound care on the sacrum (tail bone) and both buttocks. During an interview on 6/11/2025, at 3:32 p.m., Registered Nurse 3 (RN 3) stated the minimum requirements was to measure the wound every week and assess it every visit. During a concurrent interview and record review on 6/11/2025, at 3:36 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/14/2025. RN 3 stated the left ankle wound was assessed but no measurements was documented. RN 3 stated wound measurements were significant to the wound assessment as these help determine to see if the wound is improving or worsening. During a concurrent interview and record review on 6/11/2025, at 3:46 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/20/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. RN 3 stated the lack of assessment was a concern because an accurate assessment was needed to have an accurate plan of care and optimization of quality of care. During a concurrent interview and record review on 6/11/2025, at 3:50 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/25/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 3:54 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/27/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 3:55 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 6/3/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 3:56 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 6/6/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 4:00 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 6/10/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During an interview at the home visit on 6/12/25, at 12:46 p.m., Caregiver 2 (CGV 2) stated Patient 11 had sores on her buttocks that he had been treating at home. During a concurrent observation and interview on 6/12/25, at 1:00 p.m., RN 2 provided wound treatment to the left lateral ankle. RN 2 stated the wound look closed and would notify the wound nurse to see if a different treatment was needed. During a concurrent interview and record review on 6/13/25, at 11:05 a.m., RN 3 reviewed Patient 11’s POC dated 5/9/2025 to 7/7/2025. The POC indicated, “SN to perform wound care on Sacrum and bilateral (both) buttocks…” RN 3 stated the wounds should have been identified to monitor and to prevent further deterioration. RN 3 stated she reviewed all the home care visit notes for the current certification of 5/9/2025 to 7/7/2025 and determined there was no documentation that the nurses had monitored the wound on the buttocks. 3. A record review of Patient 13’s document indicated an SOC of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle). A record review of Patient 13’s Plan of Care, for certification period 5/3/2025 to 7/1/2025 indicated doctors order for wound treatment to the sacrum and left leg. There was a wound treatment order to a stage 4 sacrum wound with a frequency of twice a week. The other wound treatment order was for a stage 4 wound on the left leg with a frequency of daily wound by the SN (skilled nurse)/caregiver. During a concurrent interview and record review on 6/13/2025, at 12:51 p.m., RN 3 reviewed Patient 13’s doctor order dated 5/5/2025. RN 3 stated Patient 13 was supposed to be visited three times a week for 8 weeks from 5/4/2025 to 6/28/2025 for wound vac change. During a concurrent interview and record review on 6/13/2025 from 4:07 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/17/2025. The document indicated, “SN change dressing to both lower leg wound and change wound vac dressing to sacrum. Wounds not heal.” RN 3 stated there was no documented evidence the nurse provided wound treatment to the sacrum and left leg. RN 3 stated the risk of not assessing the wounds were: not knowing the progress, not knowing if there are signs and symptoms of infection, not knowing if the wound is improving or worsening.” During a concurrent interview and record review on 6/13/2025 from 4:10 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/19/2025. The record indicated, “wound care and wound vac completed as ordered.” RN 3 stated the record did not specify the wound treatment provided, to the specific location. During a concurrent interview and record review on 6/13/2025, at 4:15 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/19/2025 and 5/23/2025). RN 3 stated there was no documentation to explain what happened. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. During a concurrent observation and interview at the home visit on 6/16/2025, at 11:30 a.m., RN 4 proceeded to do wound care on the left lateral leg. CGV 3 stated some parts of the wound on the left leg were getting better, while other parts of the wound were opening again. CGV 3 stated the wound nurse visited on 5/29/2025 and changed the wound treatment frequency on the left leg from 2 times a week to 1 time a week. CGV 3 stated she was doing wound care to the left leg once a week. During an interview at the home visit on 6/16/2025, at 12:00 p.m., CGV 3 stated was concerned with the wound on the left leg. CGV 3 stated Patient 13 was not getting better. A record review of Patient 13’s doctor order, dated 5/29/2025, indicated a change to the wound treatment to the left leg frequency to 2 times a week. During a concurrent interview and record review on 6/16/2025, at 2:50 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/26/2025 and 5/29/2025). RN 3 stated there was no documentation to explain what happened, or any attempts to reschedule the visit. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. RN 3 stated whenever there is a missed visit, the doctor was supposed to be notified on why the visit was missed and there should have been an attempt to reschedule the visit the same week so that a visit is not missed. During a concurrent interview and record review on 6/16/2025, at 3:00 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 5/26/2025. The record indicated, “As per PCG (primary care giver) wound vac stays for 1 day and then start leaking due to urine incontinent.” RN 3 stated there was no mention that another visit was made to check and assess the status of the wound vac. RN 3 stated another visit was needed to make sure the wound vac is working well, and to make sure the wound care treatment is being done correctly. RN 3 stated one of the characteristics to determine if a wound was getting better was the size of the wound: the wound would get smaller. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:22p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/2/2025. RN 3 stated there was no wound treatment and measurement for the left leg. During a concurrent interview and record review on 6/16/2025, at 3:29 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/4/2025. RN 3 stated there was no wound treatment to the left leg. During a concurrent interview and record review on 6/16/2025, at 3:31 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/6/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. RN 3 stated she did not know if the wounds on the sacrum and left leg were improving or worsening because there was no information to review. During a concurrent interview and record review on 6/16/2025, at 3:36 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/9/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. During a concurrent interview and record review on 6/17/2025 at 9:44 a.m., RN 3 reviewed Patient 13’s Home Care Visits, dated 5/26/25, 5/29/25, and 6/16/25. RN 3 stated the visit note for 5/26/25 did not have a complete wound assessment of the sacrum, to determine if the wound was improving or worsening. RN 3 reviewed the wound assessment measurements of 5/26/2025, as these were the most recent measurements prior to 6/16/2025. The sacrum wound measurements on 5/26/2025 were: 3.97 cm x 5.03 cm x 1.5 cm. The sacrum wound measurements on 6/16/2025 were 4 cm x 5.5 cm x 2 cm., with undermining at 2.5 cm. RN 3 stated the sacrum wound assessment on 6/16/2025 indicated an increase in size compared to 5/26/2025. RN 3 stated the sacrum wound was not progressing towards the desired goal of healing. When the wound is not progressing, the wound might worsen. The patient might need more interventions such as checking nutritional status to optimize wound healing. If there was signs and symptoms of infection, all these can lead to wound infection and hospitalization. The worse case scenario is that the patient can get sepsis (blood infection that affect the entire body), which can lead to death. During a concurrent interview and record review on 6/17/2025, at 10:00 a.m., RN 3 reviewed Patient 13’s Home Care Visits, dated 5/5/25 and 6/16/25. RN 3 stated the last completed wound assessment with measurements was on 5/5/2025. RN 3 stated the wound measurements to the left leg on 5/5/2025 indicated the wound was 4.25 cm x 1.35 cm x 0.2 cm, with no undermining. The wound measurements to the left leg on 6/16/2025, indicated the wound was 4 cm x 1.0 cm x 0.5 cm, no undermining. RN 3 stated it was hard to determine if the wound was improving or worsening because the size was decreasing, but the depth of the wound was increasing. RN 3 stated an additional wound assessment would be needed to determine if the wound on the left leg was improving or worsening. 4. During a record review of Patient 15’s medical record form titled “Home Health 60-day Summary” dated 3/22/2025, indicated Patient 15 had a PICC (peripherally inserted central catheter – a thin flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest) line inserted on 4/1/2025 for daily Bumex (medication to treat water retention – edema) infusion. During a record review of Patient 15’s medical record form titled “Progress Notes” dated 5/13/2025, indicated Patient 15’s Bumex was changed to 4 mg (milligrams – unit of measure) IV (intravenous – injected into a vein) every other day, “per MD”. During a record review of Patient 15’s medical record form titled “SN (skilled nurse) OASIS Recertification” dated 5/21/2025, indicated Patient 15’s blood pressure was to be checked before, during and after Bumex administration. The SN OASIS Recertification form indicated there was one blood pressure reading for Patient 15, 130/80. During a record review of Patient 15’s medical record form titled “Home Health Plan of Care – Recertification” dated from 5/22/2025 to 7/20/2025, indicated Patient 15’s blood pressure was to be checked before, during and after Bumex administration. During a record review of Patient 15’s medical record form titled “Active Medication” date reviewed 5/21/2025 and printed for review on 6/11/2025, indicated Bumex – give 16 mL intravenously daily with no special instructions documented. During a record review of Patient 15’s medical record form titled “SN Home Visit” dated 6/6/2025, indicated Patient 15’s blood pressure was to be checked before, during and after Bumex administration. The SN Home Visit form indicated there was one recorded blood pressure for Patient 15, 128/80. During a record review of Patient 15’s medical record form titled “SN Home Visit” dated 6/8/2025, did not indicate to assess Patient 15’s blood pressure before, during and after Bumex administration. The SN Home Visit form indicated there was one recorded blood pressure for Patient 15, 120/76. During a record review of Patient 15’s medical record form titled “SN Home Visit” dated 6/10/2025, indicated Patient 15’s blood pressure was to be checked before, during and after Bumex administration. The SN Home Visit form indicated there was one recorded blood pressure for Patient 15, 129/98. During a record review of Patient 15’s medical record form titled “Home Health Summary/Plans for Next Visit” dated 5/15/2025, indicated Registered Nurse 11 (RN11) conducted Patient 15’s follow-up visit on 5/15/2025. The Home Health Summary/Plans for Next Visit form also indicated “BP checked before, during, and after Bumex admin and documented.” Lastly the Home Health Summary/Plans for Next Visit form did not have a documented blood pressure reading for Patient 15. During a record review of Patient 15’s medical record form titled “Vital Signs” undated, indicated Patient 15’s blood pressure readings dated June 2, 4, 6, 8, 10, and 12; May 23, 25, 27, and 29; and March 22, 2025. During a concurrent observation and interview on 6/12/2025 at 10:25 a.m. with Registered Nurse 7 (RN7) and Registered Nurse 12 (RN12) at Patient 15’s home, Patient 15 stated he takes Bumex 2 tabs on the days he does not receives it through the PICC line. RN5 stated Patient 15 takes 2 tablets of Bumex by mouth, but that she (RN5) does not recall the milligrams of the tablets. RN5 was observed checking Patient 15’s blood pressure once before administering Bumex, with a reading of 149/82. The RN5 was observed placing the pulse oximeter (device to monitor respiratory status) on Patient 15’s finger while administering Bumex. During an interview on 6/12/2025 at 10:25 a.m. with Patient 15, Patient 15 stated that he (Patient 15) receives IV Bumex every other day through his (Patient 15) PICC line. During a concurrent interview and record review on 6/16/2025 at 3:45 p.m. Registered Nurse 9 (RN9) of Patient 15’s EMR, RN9 stated that visiting nurses should be assessing Patient 15’s blood pressure before, during and after Bumex administration to assess for hypotension (low blood pressure) which can cause dizziness, sweating, and fainting. The RN9 stated that Patient 15’s EMR has one set of blood pressure reading for each home visit. 5. During a record review of Patient 16’s medical record form titled “Home Health Plan of Care” dated from 5/22/2025 to 7/20/2025, indicated a start of care date of 5/22/2025 with a primary diagnosis of aftercare following joint replacement surgery, encounter for change or removal of surgical wound dressing. During a record review of Patient 16’s medical record form titled “Order” dated 4/29/2025, indicated Patient 16 was referred to home health services for aftercare right total knee arthroplasty on 4/29/2025. The form also indicated under order comments, “Please remove Mepilex dressing at 7-10 days post-op… surgery date 5/21/2025.” Lastly, the form indicated under “Total Joint Care – edema management and surgical site observation.” During a record review of Patient 16’s medical record form titled “PT OASIS Start of Care” dated 5/22/2025, indicated PT1 conducted the visit. The form also indicated under “active wound – wound incision 5/21/25 right knee – surgical incision with dressing.” The form also indicated Patient 16’s primary diagnosis was aftercare following join replacement surgery – encounter for change or removal of surgical wound dressing. Lastly, the form indicated PT1 documented Patient 16’s incision appearance as “R KNEE incision covered by non-removal dressing (Mepilex) which presents as clean and intact.” During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/23/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/27/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/29/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 6/3/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT OASIS Discharge” date 6/5/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact”. During a record review of Patient 16’s Electronic Medical Record (EMR), the EMR did not indicate Patient 16’s right knee incision dressing was removed and assessed/ evaluated by PT1. During a concurrent interview and record review on 6/17/2025 at 9:45 a.m. with RN9 of Patient 16’s EMR, the RN9 stated the main reason Patient 16 was referred to HH services was for the surgical site observation. The RN9 stated she (RN9) was unable to find any documentation Patient 16’s right knee incision site was assessed or observed while receiving home health services. The RN9 stated it was important that Patient 16’s incision site to be assessed to prevent infection, delay in recovery and healing, or complications. A record review of the HHA’s document titled, Care Planning Process, revised on 8/2017, indicated, “4. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. 5. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs...16. Missed visit frequency requires a physician verbal order.” During a review of the HHA’s document titled, “Rover/Tissue Analytics Wound Photo and Assessment Documentation,” revised on 12/2023, the “Rover/Tissue Analytics Wound Photo and Assessment Documentation” indicated the Tissue Analytics Photo would be used once a week on the first visit of the week. The record indicated all wound assessment and treatment documentation must be entered with every dressing change. Continued review of the record indicated “Confirm photo and wound LDA (a comprehensive wound/skin assessment and treatment flow shared across all SCAL (southern California) and Hawaii care setting to improve timely and accurate communication between physician and bedside/field clinicians” documentation is accurate and complete. This serves as your comprehensive wound assessment/wound check.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure two of seventeen sampled patients (Patient 1 and Patient 13) receive visits as specified in the care plan. This deficient practice resulted in violation of patient’s rights. 1. During a record review of Patient 1’s electronic medical record indicated Patient 1with a start of care (SOC) of 3/6/2025, with an admission diagnosis of unspecified open wound of left foot. During a record review of Patient 1’s Plan of Care, for certification period 3/6/2025 to 5/4/2025 indicated doctors order for skilled nurse visit frequency of; once a week for one week, twice a week for one week, then twice a week for two weeks, then twice a week for four weeks. During a concurrent record review and interview on 6/11/2025 at 3:13 pm with Quality Analyst, Licensed Vocational Nurse 1 (QA LVN 1) of Patient 1 electronic record there was one skilled nurse visit documented for the week of 3/9/2025 to 3/15/2025, on 3/13/2025. There was no missed visit documented or any communication with the doctor of the missed visit. QA LVN 1 stated, there should have been a communication note documented to the MD at a minimum for the missed visit. There is no documentation at all for the missed visit for Patient 1 for the week of 3/09/2025 to 3/15/2025. 2. A record review of Patient 13’s document indicated an SOC of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle). A record review of Patient 13’s Plan of Care, for certification period 5/3/2025 to 7/1/2025 indicated doctors order for wound treatment to the sacrum and left leg. There was a wound treatment order to a stage 4 sacrum wound with a frequency of twice a week. The other wound treatment order was for a stage 4 wound on the left leg with a frequency of daily wound by the SN (skilled nurse)/caregiver. During a concurrent interview and record review on 6/13/2025, at 12:51 p.m., Registered Nurse 3 (RN 3) reviewed Patient 13’s doctor order dated 5/5/2025. RN 3 stated Patient 13 was supposed to be visited three times a week for 8 weeks from 5/4/2025 to 6/28/2025 for wound vac change. During an interview at the home visit on 6/16/2025, at 12:00 p.m., Caregiver 3 (CGV 3) stated was concerned with the wound on the left leg. CGV 3 stated Patient 13 was not getting wound care three times a week. During a concurrent interview and record review on 6/13/2025 from 4:07 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/17/2025. The document indicated, “SN change dressing to both lower legs wound and change wound vac dressing to sacrum. Wounds not heal.” RN 3 stated there was no documented evidence the nurse provided wound treatment to the sacrum and left leg. During a concurrent interview and record review on 6/13/2025 from 4:10 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/19/2025. The record indicated, “wound care and wound vac completed as ordered.” RN 3 stated the record did not specify the wound treatment provided, to the specific location. During a concurrent interview and record review on 6/13/2025, at 4:15 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/19/2025 and 5/23/2025). RN 3 stated there was no documentation to explain what happened. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. A record review of Patient 13’s doctor order, dated 5/29/2025, indicated a change to the wound treatment to the left leg frequency to 2 times a week. During a concurrent interview and record review on 6/16/2025, at 2:50 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/26/2025 and 5/29/2025). RN 3 stated there was no documentation to explain what happened, or any attempts to reschedule the visit. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. RN 3 stated whenever there is a missed visit, the doctor was supposed to be notified on why the visit was missed and there should have been an attempt to reschedule the visit the same week so that a visit is not missed. During a concurrent interview and record review on 6/16/2025, at 3:22p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/2/2025. RN 3 stated there was no wound treatment and measurement for the left leg. During a concurrent interview and record review on 6/16/2025, at 3:29 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/4/2025. RN 3 stated there was no wound treatment to the left leg. During a concurrent interview and record review on 6/16/2025, at 3:31 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/6/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. During a concurrent interview and record review on 6/16/2025, at 3:36 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/9/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. A record review of the HHA’s document titled, Rights/Responsibilities, revised on 11/2017, indicated, “Patients have the right to...9. Receive all services outlined in the plan of care.””

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure four of seventeen sampled patients (Patient 5, Patient 6, Patient 10 and Patient 14) had a completed initial nursing assessment that determined their immediate care status within 5 days of admission. This deficient practice had the potential to result in decline in health status by not assessing the patient’s needs, which will cause a delay in care. 1.During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 4/7/2022, with a diagnosis that included sacral Stage four pressure ulcer (severe deep wound that extend down to the muscle, tendon or bone and can include black tissue or puss). During a review of Patient 5’s Home Health Certification and POC for the certification period starting from 5/1/2025 to 7/19/2025, the POC included an order for the skilled nurse (SN) to visit once a week for nine weeks, to assess all body system with emphasis on the patient’s integumentary system (skin) on every visits. One of the nursing interventions was to provide wound care on sacral Stage four pressure ulcer as follows: cleanse/irrigate with Normal Saline, gently pat to dry, soak with moistened gauze antimicrobial cleanser (Vashe) for five minutes, apply Calmoseptine ointment, apply Cavillon ( barrier film) to periwound , pack wound with AMD rolled gauze, cover with ABD pads, secure with tape and Tegaderm daily. During a home visit observation, and interview on 6/12/2025, at 11 a.m., with License Vocational Nurse (LVN 3) , Patient 5 was observed lying in bed unable to move both lower extremities. LVN 3 stated Patient 5 had a Stage four sacral pressure sore with serosanguineous drainage without odor. A review of Patient 5’s Re-certification Comprehensive Adult Nursing Assessment (OASIS-to determine the need for nursing services) dated 5/1/2025, indicated under the Skin and Wound Assessment that there was no documented evidence of a skin assessment for the existing sacral Stage four pressure ulcer and it was not addressed. During an interview with RN 9 on 6/13/2025, at 1 p.m. RN 9 stated Patient 5’s OASIS Recertification Assessment dated 5/1/2025, did not indicate a wound assessment for the existing Stage four sacral pressure ulcer. RN 9 further stated a wound assessment would be needed to determine if the open wound was improving or worsening. 2. During a review of Patient 6’s document, the document indicated Patient 6’s start of care (SOC) date was 3/4/2022, with an admission diagnosis of lymphedema (an abnormal collection of lymphatics [vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] fluid in the tissues just beneath the skin). During an interview on 6/11/2025, at 3:36 p.m., with RN 3, RN 3 stated wound measurements (in general) were significant to the wound assessment as this help determine to see if the wound is improving or worsening. During a joint home visit, observation, and interview on 6/12/2025, at 1:30 p.m., with RN 5 at Patient 6’s home, RN 5 stated Patient 6 had a pitting edema plus (+) 3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower leg were swollen wrapped with compression wrap. RN 5 did not remove Patient 6’s compression wrap or assess the lymphedema for any signs and symptoms of any deterioration or skin complications. During an interview on 6/13/2025, at 11:15 a.m., with RN 3, RN 3 stated the purpose of the comprehensive assessment was to assess the entire body system to identify potential problems that required further interventions to help the patient heal and prevent complications. RN 3 stated we (care staff) cannot focus on just the task; we have to look at the whole picture. During an interview and review of Patient 6’s clinical records (in general) on 6/13/2025, at 1 p.m., with RN 9, RN 9 stated all of Patient 6’s OASIS Recertification Assessment, from the SOC of 3/4/2022 to 4/16/2025, did not indicate a wound assessment for the existing lymphedema on both lower extremities. RN 9 stated a wound assessment would be needed to determine if the lymphedema was improving or worsening. RN 9 stated, since the SOC on 3/4/2022, there was no evidence of assessment of skin, circumference (measurement) or photos for Patient 6’s bilaterial lower extremity lymphedema. During an interview on 6/13/2025, at 11:15 a.m., Registered Nurse 3 (RN 3) stated the purpose of the comprehensive assessment was to assess the entire body system to identify potential problems that required further interventions to help the patient heal and prevent complications. RN 3 stated we (care staff) cannot focus on just the task; we have to look at the whole picture. 3. A record review of Patient 10’s documents indicated an SOC of 6/8/2025, with a diagnosis of Acute Kidney Failure (a sudden loss of kidney function). During an interview at the home visit on 6/12/2025, at 11:10 p.m., Registered Nurse 2 (RN 2) stated Patient 10 was in the Advanced Medical Care at Home program, for patients who need more care and more monitoring, as these patients were at higher risk of hospitalization. During an interview at the home visit on 6/12/25, at 11:20 a.m. Patient 10 stated to RN 2 that she had been having diarrhea, abdominal swelling, and has Crohn’s disease. Patient 10 stated she had “really high” blood pressure when she was hospitalized and was concerned, she would have a stroke (brain attack). Patient 10 stated she also had history of UTI (an infection of the urinary tract) as well. RN 2 stated it sounded like she had more issues going on. During a concurrent interview and record review on 6/12/25, at 3:00 p.m., RN 3 reviewed Patient 10’s OASIS Assessment, dated 6/8/25. RN 3 stated the assessment did not clearly indicate Patient 10 was having intestinal issues and additional interventions were needed for the plan of care such as assessing her gastro-intestinal symptoms, and teaching signs and symptoms to report to the doctor (such as belly swelling, pain, discomfort). The assessment did not identify the interventions needed in the plan of care for Patient 10’s Acute Renal Failure (ARF-kidneys not working well). RN 3 stated Patient 10 needed interventions for her ARF such as monitoring her fluid intake and output, signs of dehydration, which conditions to report to the doctor (such as decreased urine output, thirst, mental status changes, fever) During an interview on 6/17/2025, at 1:55 p.m., Registered Nurse 9 (RN 9) stated Patient 10 was hospitalized on 6/17/2025 for chest pain. 4. During a record review of Patient 14’s medical record form titled “Referral Diagnoses” date 6/4/2025, indicated Patient 14 was referred to Home Health (HH) services for a left posterior thigh open wound on 6/4/2025. During a record review of Patient 14’s medical record form titled “Progress Notes” dated 6/6/2025, indicated Medical Doctor 1 (MD1) was Patient 14’s primary doctor and completed and filled the Progress Notes. MD1 documented that Patient 14 had the following skin issues: 1. Two wounds on coccyx, 2. Wound on left thigh, 3. Right elbow injury, and 4. Right hand nails had fallen off. During a record review of Patient 14’s medical record form titled “SN (skilled nurse) OASIS Start of Care” dated 6/7/2025, indicated Registered Nurse 1 (RN1) filled and signed the SN OASIS Start of Care form. The SN OASIS Start of Care form indicated Patient 14 had an unhealed pressure ulcer/injury at Stage 2 (open wound expanding into deeper layers of the skin) or higher. The SN OASIS Start of Care form indicated RN1 was unable to visualize Patient 14’s wounds. The form did not indicate the reason as to why Patient 14’s wounds were unable to be visualized by RN1. Lastly, the SN OASIS Start of Care form indicated Patient 14 had a primary diagnosis of pressure ulcer of unspecified site, unspecified stage. During a record review on 6/11/2025, of Patient 14’s Electronic Medical Record (EMR), the EMR did not indicate Patient 14 had a wound assessment. During a concurrent interview and record review on 6/11/2025 at 2:20 p.m. with the Senior Clinical Practice Nurse (RN9) of Patient 14’s EMR, the RN9 stated Patient 14’s wounds were not assessed on 6/11/2025 during the initial nursing assessment and does not know the reason why the wounds were not assessed. During a concurrent observation and interview on 6/12/2025 at 9 a.m. with Registered Nurse 5 (RN5) and Registered Nurse 12 (RN12) at Patient 14’s joint home visit, Patient 14 was noted laying supine on a hospital bed with a soiled dressing on her (Patient 14) right elbow and right hand. The RN 5 assessed Patient 14 with the assistance of Patient 14’s grandson (GS) and daughter (CVG6). Patient 14 was noted to have two red marks on her left buttocks. The RN5 stated Patient 14’s left hip wound was healed. Patient 14’s GS and caregiver (CGV8) requested RN5 to change the dressing on Patient 14’s right elbow and right hand. The RN5 stated that wound pictures or measurements were required when a wound was a Stage 2 or higher when asked why pictures or measurements weren’t taken. During a concurrent interview and record review on 6/12/2025 at 12:35 p.m. with Registered Nurse 12 (RN12) of Patient 14’s EMR, RN12 stated Patient 14’s EMR did not indicate there were any identified wounds. The RN12 stated that Patient 14’s primary reason for home health admission was her (Patient 14) wounds. The RN12 stated Patent 14’s wound should have been assessed with interventions and goals identified and documented. The RN12 stated that a comprehensive assessment includes assessing the patients from head to toe. The RN12 stated visiting notes should be documented in the patients EMR within 24 hours of the actual home visit. During a record review of Patient 14’s medical record form titled “SN Home Visit” dated 6/12/2025, did not indicated Patient 14’s two red marks on her (Patient 14) left buttocks were not mentioned. During a concurrent interview and record review on 6/13/2025 at 3 p.m. with RN12 of Patient 14’s EMR, RN12 stated Patient 14’s nursing visit note dated 6/12/2025 was reviewed. The RN12 stated that the nursing visit note dated 6/12/2025, did not indicate that Patient 14’s admitting wound, per referral, was healed. The RN12 stated that Patient 14’s wounds were not assessed during the home visit on 6/12/2025. The RN12 stated that it was important to do a complete wound assessment on each wound to determine if the wounds are improving or deteriorating. The RN12 stated that when a wound assessment is not done the possible outcomes could be deterioration which can lead to bone infection. During a concurrent interview and record review on 6/16/2025 at 3:30 p.m. with the RN9 of Patient 14’s EMR, the RN9 stated Patient 14 had a nursing comprehensive assessment on 6/12/2025. The RN9 stated Patient 14’s initial wound on the left posterior thigh open wound was resolved and three new skin issues were identified by Registered Nurse 7 (RN7), which included Patient 14’s right hand, right elbow, and left buttocks. The RN9 stated RN7’s wound assessment was not complete on 6/12/2025, because there were no measurements or pictures taken of the three new skin issues. The RN9 stated that it was important to perform a complete assessment to have a baseline and follow the progress or deterioration of the wounds. A record review of the HHA’s document titled, Initial and Comprehensive Assessment, revised on 9/2023, indicated, “A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care by the same clinician. The assessment will be patient-specific and comprehensive to include the patient’s need for home health care, rehabilitative care, social services, and discharge planning.””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure the comprehensive assessment accurately identified the physical needs of the patients, to assist in developing the plan of care for 6 of 17 sampled patients. (Patient 6, Patient 11, Patient 13, Patient 14, Patient 16, and Patient 17). For Patient 6, the facility failed to assess an existing lymphedema (an abnormal collection of lymphatic [vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] fluid in the tissues just beneath the skin) on bilateral (both) lower extremities (legs). This deficient practice had the potential for Patient 6 to experience worsening of the lymphedema on both lower extremities that could lead to infection, sepsis and hospitalization. For Patient 13, for the recertification period from 5/3/2025 to 7/1/2025, the HHA did not assess Patient 13’s sacral (tailbone) wound and left leg wound on the home visit dated 5/5/2025, 5/7/2025, 5/10/2025, 5/15/20205, 5/17/2025, 5/19/2025. Patient 13 did not receive wound care treatment on 5/19/2025 and 5/23/2025. The sacral wound increased in size and the measurements on 5/26/2025 were: 3.97 cm (centimeters, unit of measurement) in length, 5.03 cm in width, and 1.5 cm depth. The sacrum wound measurements on 6/16/2025 were with measurements of 4 cm (length), 5.5 cm (width), 2 cm (depth), undermining (measurement under the appearance of the wound) at 10 to12 o’clock measuring 2.5 cm. The HHA failed to identify and assess new existing wound to right horizontal gluteal fold. For Patient 11, the HHA failed to assess Patient 11’s Stage 4 pressure ulcer (the most severe stage of a pressure injury, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle) to left ankle and did not identify and assess the presence of wound to sacrum/buttocks. For Patient 14, the HHA did not conduct a complete assessment during the home visit on 6/12/2025, of the new open wounds to right elbow, right hand, and left buttock. For Patient 16, HHA did not assess the right knee incision site. For Patient 17, the HHA did not complete an assessment for pressure ulcer to sacral region. As a result of non-compliance: Patient 6 did not receive an assessment to promote healing of existing lymphedema on bilateral lower extremities and had the potential to experience worsening of the lymphedema on both lower extremities that could lead to infection, sepsis and hospitalization. Patient 13 experienced worsening of the sacral wound, placing Patient 13 at risk of infection, which could lead to hospitalization and/or death. Patient’s 10, Patient 11, Patient 14, Patient 16, and Patient 17 were placed at risk for hospitalization and/or death due to not identifying needs for further wound treatment to prevent complications of worsening wounds. These failures had the potential to result in delay in identifying significant needs and provision of services that could lead to hospitalization and death. On 6/17/2025 at 2:55 p.m., the Department called an immediate jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s staff, Nurse Leader, Senior Director 1, Senior Director 2, Administrator, Clinical Practice Nurse, DPCS, Improvement Advisor, and Clinical Supervisor, related to the HHA failure to ensure the comprehensive assessment accurately identified the needs of the patients, to assist in developing the plan of care for wound care and treatment for 7 of 17 sampled patients. (Patient 6, Patient 11, Patient 13, Patient 14, Patient 16, and Patient 17). On 6/18/2025 at 3 p.m., the survey team completed the survey task and conducted an exit conference in the presence of Nurse Leader, Senior Director 1, Senior Director 2, Administrator, Senior Clinical Practice Nurse, DPCS, Improvement Advisor, Clinical Supervisor, and Service Line Administrator, with the IJ not removed. During an interview on 6/11/2025, at 3:32 p.m., Registered Nurse 3 (RN 3) stated the minimum requirement for wound measurements were every week. Wound assessments were required every nurse visit. During an interview on 6/11/2025, at 3:36 p.m., RN 3 stated wound measurements were significant to the wound assessment as these help determine to see if the wound is improving or worsening. During an interview on 6/13/2025, at 11:15 a.m., RN 3 stated the purpose of the comprehensive assessment was to assess the entire body system to identify potential problems that required further interventions to help the patient heal and prevent complications. RN 3 stated we (care staff) cannot focus on just the task; we have to look at the whole picture. 1. A record review of Patient 6’s documents indicated a start of care date (SOC) of 3/4/2022, with an admission diagnosis of Lymphedema (swelling mostly in arm or leg, caused by lymphatic system blockage). During a home visit observation, and interview on 6/12/2025, at 1:30 p.m., with Registered Nurse 5 (RN 5), RN 5 stated Patient 6 had a pitting edema +3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower leg were swollen wrapped with compression wrap. RN 5 did not remove the compression wrap or assess the lymphedema for any signs and symptoms of any deterioration or skin complications. During an interview and review of Patient 6’s clinical records on 6/13/2025, at 1 p.m. RN 9 stated all of Patient 6’s OASIS Recertification Assessment, from the SOC of 3/4/2022 to 4/16/2025, did not indicate a wound assessment for the existing lymphedema on both lower extremities. RN 9 also stated there were no documented evidence that the visiting nurse did a wound assessment of patient’s lymphedema on both lower extremities in their nursing visit notes. RN 9 further stated a wound assessment would be needed to determine if the lymphedema was improving or worsening. RN 9 stated, since SOC 3/4/2022 there is no documented evidence of any skin assessment, circumference or photos for Patient 6’s bilaterial lower extremity lymphedema. 2. A record review of Patient 13’s document indicated an SOC of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle): A. During a concurrent interview and record review on 6/13/2025, at 12:04 p.m., RN 3 stated Patient 13’s SN OASIS Recertification, dated 4/28/25, had no wound assessments documented; all the wounds were supposed to be identified in the recertification assessment. RN 3 stated the documentation showed a wound vac (a device that removes drainage from a wound, helps with healing) on the left heel, right leg, and left food, as indicated “Patient a wound Vac dressing change on buttock, Left Heal, Right leg and left foot.” RN 3 stated the document did not have a complete wound assessment. The SN OASIS Recertification was for certification period 5/3/2025 to 7/1/2025. During an interview on 6/13/2025, at 12:31 p.m. RN 3 stated she reviewed the visit note of 5/1/2024. The note indicated Patient 13 had two wounds: the sacrum and left leg. RN 3 referred to the SN OASIS Recertification and stated, “The question is what is on the right leg?” During an interview on 6/13/2025, at 12:51 p.m., RN 3 stated Patient 13 was supposed to be visited three times a week for 8 weeks from 5/4/2025 to 6/28/2025. During a concurrent interview and record review on 6/13/2025 from 3:14 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/5/2025. RN 3 stated the document indicated treatment provided to 2 wounds: the sacrum and left calf (leg). The document also indicated “new DTI (deep tissue injury) to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD (dry sterile dressing), secure with gauze roll and tape, daily and as needed.” RN 3 was asked if a wound was present on the right ankle. RN 3 stated, “I’m not sure if its still there or its resolved.” During a concurrent interview and record review on 6/13/2025 from 3:30 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/7/2025. RN 3 stated the document indicated treatment provided to 2 wounds: the sacrum and left calf (leg). The document also indicated “new DTI (deep tissue injury) to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD (dry sterile dressing), secure with gauze roll and tape, daily and as needed.” RN 3 was asked if a wound was present on the right ankle. RN 3 stated, “I’m not sure if is still there or its resolved.” During a concurrent interview and record review on 6/13/2025 from 3:38 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/10/2025. The document indicated, “…multiple wounds in the scrum (sacrum), upper leg, lower leg (stage 4 ulcers)…”. RN 3 stated this gave the impression that Patient 13 had 3 wounds, but only 2 were assessed. RN 3 stated there was partial assessments of the wound with no wound measurements for the sacrum and left leg. Continued review of the document indicated “new DTI to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD, secure with gauze rolls and tape, daily and as needed.” During a concurrent interview and record review on 6/13/2025 from 3:38 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/13/2025. RN 3 stated there was no wound assessment. RN 3 stated wound assessments were supposed to be done every visit for the purpose to see the progress of the wound, identify signs and symptoms of infection. Depending on the assessment, the doctor would have to be notified to see if a change of treatment was needed. During a concurrent interview and record review on 6/13/2025 from 3:55 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/15/2025. RN 3 stated there was no wound measurements for the sacrum and left calf (leg). The wound assessment for the sacrum was missing and the left leg wound was partially assessed. RN 3 stated pictures were supposed to be taken minimally once a week for the purpose to see the wound progress, determine if there were signs and symptoms of infection, and to determine if the doctor needed to be notified. RN 3 stated no pictures were taken of Patient 13’s wounds. Continued review of the document indicated “new DTI to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD, secure with gauze rolls and tape, daily and as needed.” During a concurrent interview and record review on 6/13/2025 from 4:07 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/17/2025. The document indicated, “SN change dressing to both lower leg wound and change wound vac dressing to sacrum. Wounds not heal.” RN 3 stated there was no documented evidence the nurse provided wound treatment to the sacrum and left leg. RN 3 stated there was no documented evidence the wounds to the sacrum and left leg were assessed. RN 3 stated the risk of not assessing the wounds were: not knowing the progress, not knowing if there are signs and symptoms of infection, not knowing if the wound is improving or worsening.” Continued review of the document indicated “new DTI to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD, secure with gauze rolls and tape, daily and as needed.” During a concurrent interview and record review on 6/13/2025 from 4:10 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/19/2025. The record indicated, “wound care and wound vac completed as ordered.” RN 3 stated the record did not specify the wound treatment provided, to the specific location. RN 3 stated there was no documented evidence the wounds to the sacrum and left leg were assessed. RN 3 stated the risk of not assessing the wounds were: not knowing the progress, not knowing if there are signs and symptoms of infection, not knowing if the wound is improving or worsening.” Continued review of the document indicated “new DTI to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD, secure with gauze rolls and tape, daily and as needed.” During a concurrent interview and record review on 6/13/2025, at 4:15 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/19/2025 and 5/23/2025). RN 3 stated there was no documentation to explain what happened. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. During an interview at the home visit on 6/16/2025, at 10:00 a.m., Registered Nurse 4 (RN 4) stated Patient 13 had three (3) wounds; sacrum, lower left leg, and right dorsal foot. Wound care would be provided to these areas. During an observation of the home visit on 6/16/2025, at 10:30 a.m. RN 4 assessed Patient 13’s left heel. RN 4 stated Patient 13’s left heel was healed. During an observation of the home on 6/16/2025, at 10:32 a.m. RN 4 assessed and provided wound care to Patient 13’s sacrum. RN 4 stated the wound was considered Stage 4 with measurements of 4 cm (cm-centimeters, unit of measurement) length x (by) 5.5 cm (width) x 2 cm (depth). Undermining (measurement under the appearance of the wound) at 10-12 o’clock measuring 2.5 cm. The wound bed was beefy red with 100% granulation, no slough (dead tissue on the surface of the wound that appears yellow), and draining serosanguinous (a thin watery fluid with a pink, light red color, indicating small presence of blood) liquid. During an observation of the home visit on 6/16/2025, at 11:06 a.m. RN 4 noticed a dressing on Patient 13’s lower right buttocks. RN 4 removed the dressing (a type of bandage) and assessed the wound. RN 4 stated there was a wound on the right horizontal gluteal fold. RN 4 stated the wound was a friction association skin breakdown. During an interview at the home visit on 6/16/2025, at 11:06 a.m., Caregiver 3 (CGV 3) stated Patient 13 has had the right horizontal gluteal fold wound for 3 months. CVG 3 stated visiting nurses had taken a picture of the wound and had forgotten about it. CVG 3 stated the nurses did not treat the wound. CVG 3 stated she paid for collagen and treated the wound herself. During a concurrent observation and interview at the home visit on 6/16/2025, at 11:30 a.m., RN 4 proceeded to do wound care on the left lateral leg. CGV 3 stated some parts of the wound on the left leg were getting better, while other parts of the wound were opening again. During a concurrent observation and interview at the home visit on 6/16/2025, at 11:35 a.m., RN 4 proceeded to do wound care on the right ankle. The wound was closed (healed) CGV 3 stated the wound had been healed for 2 months. During an interview at the home visit on 6/16/2025, at 12:00 p.m., CGV 3 stated was concerned with the wound on the left leg. CGV 3 stated Patient 13 was not getting wound care three times a week. During an interview on 6/16/2025 at 2:32 p.m., RN 3 stated Patient 13 had a total of 4 wounds. The wound location was in the sacrum, left gluteal fold, lateral left leg, and right anterior ankle. RN 4 stated a full head to toe body assessment was expected every visit. If a wound was identified, the nurse was supposed to call the doctor, the same day, discuss the assessment, get a wound treatment order and update the plan of care. Updating the plan of care was important because the plan of care includes the doctor’s order. If it is not there, the following clinician will not know the condition or treatment that is supposed to be done. Staff do not know what is supposed to be monitored to see if there is improvement or worsening. RN 3 reviewed the Home Care Visit notes from 5/5/2025 thru 5/19/2025, and stated the notes did not indicate the gluteal wound was identified and assessed. During a concurrent interview and record review on 6/16/2025, at 2:22 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 5/23/2025. The record indicated, “New DTI to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD, secure with gauze roll and tape, daily and as needed. Visit Notes: Wound healed no infection noted.” RN 3 stated there was no assessment of the left leg. During a concurrent interview and record review on 6/16/2025, at 2:50 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 5/23/2025. The record indicated, “New DTI to right anterior ankle area. SN/caregiver to monitor site, may apply betadine and cover with DSD, secure with gauze roll and tape, daily and as needed.” RN 3 stated this intervention came from the plan of care, that was carried over from the previous recertification period. RN 3 stated that she was not sure if the patient had this wound on the current certification period because the documentation was not clear to explain what happened. During a concurrent interview and record review on 6/16/2025, at 2:50 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/26/2025 and 5/29/2025). RN 3 stated there was no documentation to explain what happened, or any attempts to reschedule the visit. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. RN 3 stated whenever there is a missed visit, the doctor was supposed to be notified on why the visit was missed and there should have been an attempt to reschedule the visit the same week so that a visit is not missed. During a concurrent interview and record review on 6/16/2025, at 3:00 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 5/26/2025. The record indicated, “As per PCG (primary care giver) wound vac stays for 1 day and then start leaking due to urine incontinent.” RN 3 stated there was no mention that another visit was made to check and assess the stats of the wound vac. RN 3 stated another visit was needed to make sure the wound vac is working well, and to make sure the wound care treatment is being done correctly. RN 3 continued to review the document and stated there was no assessment made to the left leg. RN 3 stated one of the characteristics to determine if a wound was getting better was the size of the wound: the wound would get smaller. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:05 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 5/29/2025. RN 3 stated the sacrum, left leg, and right ankle were assessed. However, the measurements were not taken for any of the wounds. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:22p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/2/2025. RN 3 stated there was no wound measurement for the sacrum wound and no wound treatment and measurement for the left leg. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:29 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/4/2025. RN 3 stated there was no wound measurement for the sacrum wound and no wound treatment and measurement for the left leg. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:31 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/6/2025. RN 3 stated there was no wound measurement and assessment for the sacrum and left leg. RN 3 stated there was no wound treatment for the sacrum and left leg. RN 3 stated she did not know if the wounds on the sacrum and left leg were improving or worsening because there was no information to review. RN 3 continued to review t the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:36 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/9/2025. RN 3 stated there was no wound measurement and assessment for the sacrum and left leg. RN 3 stated there was no wound treatment for the sacrum and left leg. RN 3 stated there was no mention of the right gluteal wound. During a concurrent interview and record review on 6/17/2025 at 9:44 a.m., RN 3 reviewed Patient 13’s Home Care Visits, dated 5/26/25, 5/29/25, and 6/16/25. RN 3 stated the visit note for 5/26/25 did not have a complete wound assessment of the sacrum, to determine if the wound was improving or worsening. RN 3 reviewed the wound assessment measurements of 5/26/2025, as these were the most recent measurements prior to 6/16/2025. The sacrum wound measurements on 5/26/2025 were: 3.97 cm x 5.03 cm x 1.5 cm. The sacrum wound measurements on 6/16/2025 were 4 cm x 5.5 cm x 2 cm., with undermining at 2.5 cm. RN 3 stated the sacrum wound assessment on 6/16/2025 indicated an increase in size compared to 5/26/2025. RN 3 stated the sacrum wound was not progressing towards the desired goal of healing. When the wound is not progressing, the wound might worsen. The patient might need more interventions such as checking nutritional status to optimize wound healing. If there was signs and symptoms of infection, all these can lead to wound infection and hospitalization. The worse case scenario is that the patient can get sepsis (blood infection that affect the entire body), which can lead to death. During a concurrent interview and record review on 6/17/2025, at 10:00 a.m., RN 3 reviewed Patient 13’s Home Care Visits, dated 5/5/25 and 6/16/25. RN 3 stated the last completed wound assessment with measurements was on 5/5/2025. RN 3 stated the wound measurements to the left leg on 5/5/2025 indicated the wound was 4.25 cm x 1.35 cm x 0.2 cm, with no undermining. The wound measurements to the left leg on 6/16/2025, indicated the wound was 4 cm x 1.0 cm x 0.5 cm, no undermining. RN 3 stated it was hard to determine if the wound was improving or worsening because the size was decreasing, but the depth of the wound was increasing. RN 3 stated an additional wound assessment would be needed to determine if the wound on the left leg was improving or worsening. B: During a concurrent interview and record review on 6/13/25, at 2:45 p.m. RN 3 reviewed Patient 13’s SN OASIS Recertification assessment, dated 4/28/2025. The record indicated diagnosis of gastrostomy status (G-tube, an opening through the belly. A tube is used to provide fluids, food, and medication). RN 3 stated there was no assessment of the G-tube or status of the G-tube. RN 3 stated a complete assessment of the G-tube was to check what nutrition was being given, total amount being given, the G-tube site assessment, who was providing the G-tube nutrition, interval, G-tube size, site, and residual amount (how much is left after feeding). Patients who were on G-tube feeding need to be checked for risk of aspiration (food going to the lungs and causing complications), due to this type of feeding. RN 3 stated there was no aspiration precautions assessed in the recertification assessment. During a concurrent interview and record review on 6/13/2025 from 3:14 p.m. to 4:15 p.m. RN 3 reviewed Patient 13’s Home Care visits for certification period 5/3/2025 to 7/1/2025 were reviewed with RN 3. The documents indicted either missed or incomplete assessments of the gastrostomy status and aspiration precautions. During an observation of the home visit on 6/16/2025, at 10:20 a.m. RN 4 assessed Patient 13’s G-tube. During the assessment, RN 4 did not check for the residual amount. Residual amount was important to check because this assessment can prevent potential complication of G-tube feeding such as aspiration pneumonia (lung infection that happens after inhaling food, liquids, saliva or vomit). During an interview at the home visit on 6/16/2025 at 11:55 a.m., CGV 3 stated Patient 13 was hospitalized on August 2024 for aspiration pneumonia. 3. A record review of Patient 10’s documents indicated an SOC of 6/8/2025, with a diagnosis of Acute Kidney Failure: During an interview at the home visit on 6/12/2025, at 11:10 p.m., Registered Nurse 2 (RN 2) stated Patient 10 was in the Advanced Medical Care at Home program, for patients who need more care and more monitoring, as these patients were at higher risk of hospitalization. During an interview at the home visit on 6/12/25, at 11:20 a.m. Patient 10 stated to RN 2 that she had been having diarrhea, abdominal swelling, and has Crohn’s disease. Patient 10 stated she had really high blood pressure when she was hospitalized and was concerned, she would have a stroke (brain attack). Patient 10 stated she also had history of UTI (an infection of the urinary tract) as well. RN 2 stated it sounded like she had more issues going on. During a concurrent interview and record review on 6/12/25, at 3:00 p.m., RN 3 reviewed Patient 10’s OASIS Assessment, dated 6/8/25. RN 3 stated the assessment did not clearly indicate Patient 10 was having intestinal issues and additional interventions were needed for the plan of care such as assessing her gastro-intestinal symptoms, and teaching signs and symptoms to report to the doctor (such as belly swelling, pain, discomfort). The assessment did not identify the interventions needed in the plan of care for Patient 10’s Acute Renal Failure (ARF-kidneys not working well). RN 3 stated Patient 10 needed interventions for her ARF such as monitoring her fluid intake and output, signs of dehydration, which conditions to report to the doctor (such as decreased urine output, thirst, mental status changes, fever) During an interview on 6/17/2025, at 1:55 p.m., Registered Nurse 9 (RN 9) stated Patient 10 was hospitalized on 6/17/2025 for chest pain. 4. A record review of Patient 11’s documents indicated an SOC of 11/10/2024, with a primary diagnosis of Pressure Ulcer of Left Ankle Stage 4: A. During a concurrent interview and record review on 6/11/2025, at 3:36 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/14/2025. RN 3 stated the left ankle wound was assessed but no measurements was documented. RN 3 stated wound measurements were significant to the wound assessment as these help determine to see if the wound is improving or worsening. During a concurrent interview and record review on 6/11/2025, at 3:46 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/20/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. RN 3 stated the lack of assessment was a concern because an accurate assessment was needed to have an accurate plan of care and optimization of quality of care. During a concurrent interview and record review on 6/11/2025, at 3:50 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/25/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 3:54 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 5/27/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 3:55 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 6/3/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 3:56 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 6/6/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During a concurrent interview and record review on 6/11/2025, at 4:00 p.m., RN 3 reviewed Patient 11’s Home Care Visit, on 6/10/2025. RN 3 stated the left ankle wound was not assessed and no measurements were taken. During an interview at the home visit on 6/12/25, at 12:46 p.m., Caregiver 2 (CGV 2) stated Patient 11 had sores on her buttocks that he had been treating at home. During a concurrent observation and interview on 6/12/25, at 1:00 p.m., RN 2 provided wound treatment to the left lateral ankle. RN 2 stated the wound look closed and would notify the wound nurse to see if a different treatment was needed. During a concurrent interview and record review on 6/13/25, at 11:05 a.m., RN 3 reviewed Patient 11’s OASIS Recertification Assessment, dated 5/9/2025 and the Plan of Care (POC) dated 5/9/2025 to 7/7/2025. The POC indicated, “SN to perform wound care on Sacrum and bilateral (both) buttocks…” RN 3 stated the wounds on the buttocks were not identified in the OASIS recertification assessment. RN 3 stated the wounds should have been identified to monitor and to prevent further deterioration. RN 3 stated she reviewed all the home care visit notes for the current certification of 5/9/2025 to 7/7/2025 and determined there was no documentation that the nurses had monitored the wound on the buttocks. B. During an interview at the home visit on 6/12/25, at 12:45 p.m., Patient 11’s Caregiver (CGV 1), stated Patient 11 had COPD (Chronic Obstructive Pulmonary Disease, an illness that makes breathing difficult) and her oxygen saturations (O2% -the percent of oxygen in the blood) sometimes were in the 80’s (normal range is 95 to 100 percent). During an interview at the home visit on 6/12/25, at 1:30 p.m., CGV 2 stated Patient 11 was hospitalized twice this year for pneumonia. During a concurrent interview and record review on 6/13/25, at 9:50 a.m., RN 3 reviewed Patient 11’s OASIS Recertification Assessment, dated 5/9/2025. The assessment did not address the COPD that was diagnosed in January 2025. During a concurrent interview and record review on 6/13/25, at 10:10 a.m., RN 3 reviewed Patient 11’s previous certification OASIS Recertification Assessment, dated 3/8/2025. The assessment indicated Patient 11’s O2 saturations were 92% breathing room air. RN 3 stated the assessment did not address Patient 11’s COPD and a thorough assessment was needed. The purpose of the thorough assessment was for proper care planning, proper interventions, education to the family and patient on which symptoms to report to the doctor, with the goal to prevent complications and hospitalization. RN 3 stated had the nurse identified Patient 11’s respiratory problems in the previous certification period, it would have alerted the nurse to do a more thorough assessment in the current certification period, such as doing a careful respiratory assessment, asking the patient and family how her O2 reading have been, and if she had encountered any breathing problems. That way, the doctor be notified and the problem is added to the plan of care so staff can monitor her respiratory status. C. During an interview at the home visit on 6/12/25, at 12:46 p.m., Caregiver 2 (CGV 2) stated Patient 11 had swallowing problems. During a concurrent interview and record review on 6/13/25, at 10:40 a.m., RN 3 reviewed Patient 11’s OASIS Recertification Assessment, dated 5/9/2025. RN 3 stated there was no swallow risk assessment. If it was identified and assessed, this required interventions in the Plan of Care such as swallowing precautions, how to modify the food, signs and symptoms to report to the physician for swallowing. 5. During a record review on 6/11/2025 of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025, provided on 6/11/2025, indicated a start of care date of 6/7/2025, with a primary diagnosis of pressure ulcer (an injury to the skin and underlying tissue caused by prolonged pressure) of unspecified site, unspecified stage. The form did not indicate it was signed by a physician. Lastly, the form indicated Patient 14’s care planned included 1. Code status, 2. History of falls/fall risk, 3. Home safety, and 4. Patient requires monitoring of vital signs/weight. The form did not indicate Patient 14’s wounds were care planned. During a record review of Patient 14’s medical record form titled “Referral Information” dated 6/4/2025, indicated Patient 14 was being referred to HHA services due to a left posterior thigh open wound. During a record review of Patient 14’s medical record form titled “Progress Notes” dated 6/6/2025, indicated it was completed by Patient 14’s physician (MD1). The form indicated MD1 documented Patient 14 had two wounds on coccyx and left thigh, and an injury to her (Patient 14) right elbow cause by the family when transferring from bed to wheelchair. The form also indicated one of Patient 14’s past medical history included hypertension (high blood pressure). Lastly, the form indicated MD1 ordered Mupirocin ointment (antibacterial) and Calmoseptin ointment (moisture barrier that protects and heals skin irritations). During a record review of Patient 14’s medical record form titled “Active Medications” dated 6/4/2025, indicated Mupirocin and Calmoseptin was ordered for Patient 14 on 6/6/2025. During a record review on 6/11/2025, of Patient 14’s Electronic Medical Record (EMR), the EMR did not indicate Patient 14 had a wound assessment. During a record review on 6/11/2025, of Patient 14’s medical record form titled “SN (skilled nurse) OASIS Start of Care” dated 6/7/2025, indicated Registered Nurse 1 (RN1) completed the form. The form also indicated Patient 14 had an unhealed pressure ulcer/injury at Stage 2 (open wound expanding into deeper layers of the skin) or higher. The form also indicated RN1’s encounter notes stated, “Unable to visualize wound today”. The form indicated Patient 14’s vital signs were not assessed due to “PT (patient) fighting”. The form did not indicate Patient 14’s wound was assessed. Lastly, the form indicated Patient 14’s daughter (CGV6) stated she provided care and safety due to “cognitive impairment”. During a concurrent interview and record review on 6/11/2025 at 2:20 p.m. with the Senior Clinical Practice Nurse (RN9) of Patient 14’s EMR, the RN9 stated Patient 14’s wounds were not assessed on 6/11/2025 during the initial nursing assessment and does not know the reason why the wounds were not assessed. During an interview on 6/12/2025 at 9 a.m. with Registered Nurse 7 (RN7), RN7 she (RN7) was conducting Patient 14’s second home visit since her start of care date of 6/7/2025. The RN7 stated that during Patient 14’s first home visit on 6/72025, the admitting nurse (RN1) was unable to assess Patient 14’s wounds because there was no one to assist and because there were no wound supplies available. The RN7 also stated that Patient 14 was receiving home health services due to having a wound on her (Patient 14) left thigh. Lastly, the RN7 stated Patient 14’s primary caregiver/daughter (CGV7) stated there was always someone with Patient 14. During a concurrent observation and interview on 6/12/2025 at 9 a.m. at Patient 14’s home joint home visit with Registered Nurse 7 (RN7), Patient 14 was observed laying supine in bed and had a dressing on the right outer left elbow. Patient 14’s grandsons and caregiver (CGV8) at bedside. The RN7 requested Patient 14’s grandson (GS) to assist in holding Patient 14’s arms to be able to complete an assessment. The RN7 assessed Patient 14’s reported left posterior thigh. The RN7 stated Patient 14’s left posterior thigh wound was healed. The RN7 removed Patient 14’s right outer elbow dressing and stated it was a new skin tear. The RN7 cleaned Patient 14’s right outer elbow wound with normal saline and placed a dry dressing. Patient 14’s CGV8 and GS requested RN7 to assess Patient 14’s right hand wound. The RN 7 with Patient 14’s GS assistance opened, cleaned with normal saline, and applied a dry dressing on Patient 14’s right hand. Patient 14’s daughter (CGV6) arrived. The RN7 with the assistance of CGV6 turned Patient 14 to assess her back and buttocks. There was redness noted on Patient 14’s left buttocks. The RN7 stated Patient 14’s left buttocks had a Stage I (Un blanchable redden skin) pressure ulcer. The RN7 stated she (RN7) did not measure or take pictures of Patient 14’s right hand, right elbow and left buttocks because pictures and measurements are taken when there is a Stage II or higher, pressure ulcer. During a record review on 6/13/2025, of Patient 14’s medical record form titled “SN Home Visit” dated 6/12/2025, did not indicate Patient 14’s left buttocks pressure Stage I was documented. During a record review on 6/13/2025 of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025, provided on 6/13/2025, indicated a start of care date of 6/7/2025, with a primary diagnosis of pressure ulcer (an injury to the skin and underlying tissue caused by prolonged pressure) of unspecified site, unspecified stage. The form did not indicate it was signed by a physician. Lastly, the form indicated Patient 14’s left buttocks pressure injury, right elbow tear, and right palm of hand wound care started on 6/12/2025. During a concurrent interview and record review on 6/16/2025 at 3:30 p.m. with the RN9 of Patient 14’s EMR, the RN9 stated Patient 14 had a nursing comprehensive assessment on 6/12/2025 during the joint home visit. The RN9 stated Patient 14’s initial open wound on the left posterior thigh was resolved and three new skin issues were identified by RN7, which included Patient 14’s right hand, right elbow, and left buttocks. The RN9 stated RN7’s wound assessment was not complete on 6/12/2025, because there were no measurements or pictures taken of the three new skin issues. The RN9 also stated that there was no documentation that Patient 14’s physician was notified and informed of the three new skin issues and the healed left posterior thigh wound. The RN9 stated that it was important to perform a complete assessment to have a baseline and follow the progress or deterioration of the wounds. 6. During a record review of Patient 16’s medical record form titled “Home Health Plan of Care” dated from 5/22/2025 to 7/20/2025, indicated a start of care date of 5/22/2025 with a primary diagnosis of aftercare following joint replacement surgery, encounter for change or removal of surgical wound dressing... The form also indicated Patient 16’s was ordered physical therapy services twice a week for three weeks. During a record review of Patient 16’s medical record form titled “Order” dated 4/29/2025, indicated Patient 16 was referred to Home Health (HH) services for aftercare right total knee arthroplasty on 4/29/2025. The form also indicated under order comments, “Please remove Mepilex dressing at 7-10 days post-op… surgery date 5/21/2025.” Lastly, the form also indicated under “Total Joint Care – edema management and surgical site observation.” During a record review of Patient 16’s medical record form titled “Other” dated 5/22/2025, indicated Physical Therapy 1 (PT1) received Patient 16’s physician (MD2) orders for incision management. The form also indicated Patient 16’s was ordered physical therapy services twice a week for three weeks. During a record review on 6/11/2025, of Patient 16’s Electronic Medical Record (EMR), the EMR did not indicate Patient 16’s right knee incision dressing was removed and assessed/ evaluated by PT1. During a record review of Patient 16’s medical record form titled “PT OASIS Start of Care” dated 5/22/2025, indicated PT1 conducted the visit. The form also indicated under “active wound – wound incision 5/21/25 right knee – surgical incision with dressing.” The form also indicated Patient 16’s primary diagnosis was aftercare following join replacement surgery – encounter for change or removal of surgical wound dressing. Lastly, the form indicated PT1 documented Patient 16’s incision appearance as “R KNEE incision covered by non-removal dressing (Mepilex) which presents as clean and intact.” During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/23/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/27/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/29/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 6/3/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT OASIS Discharge” date 6/5/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact”. During a concurrent interview and record review on 6/17/2025 at 9:45 a.m. with RN9 of Patient 16’s EMR, the RN9 stated the main reason Patient 16 was referred to HH services was for the surgical site observation. The RN9 stated she (RN9) was unable to find any documentation Patient 16’s right knee incision site was assessed or observed. The RN9 stated it was important that Patient 16’s incision site to be assessed to prevent infection, delay in recovery and healing, or complications. 7. During a record review of Patient 17’s medical record form titled “Home Health Plan of Care – Recertification” dated from 3/16/2025 to 5/14//2025, indicated a start of care date of 1/26/2023 with a primary diagnosis of pressure ulcer of sacral region, stage 3. The form also indicated Patient 17 was to receive skilled nurse visits twice a week for 8 weeks (3/16/25 - 5/10/25) and once a week for 1 week (5/11/25 - 5/14/25). Lastly, the form indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN (skilled nurse)/PCG (patient care giver) cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x week and as needed and re-evaluate in 2 week(s).” During a record review of Patient 17’s medical record form titled “SN Home Visit” dated 5/9/2025, indicated the form was completed and signed by Registered Nurse 5 (RN5). RN5 documented Patient 17’s sacrococcyx stage IV (wound penetrates all three layers of skin, exposing muscle, tendons, and bones; can also extend into cartilage and ligaments, and may involve tunneling and undermining) wound did not have evidence of tunneling or undermining since 3/10/2025. RN5 documented Patient 17’s sacrococcyx wound had a depth of less than 1 cm. Lastly, the form indicated Patient 17 wound treatment recommendation was as follows: cleanse with wound cleanser, pat dry, soak wound bed with gauze moisten Vashe for 5 minutes, pat dry, apply no sting barrier on peri wound, pack loosely wound bed with Aquacel Ag rope, cover with bordered foam gauze, may secure with tape to avoid rolling, 2x weekly and PRN (as needed) for dislodgement and soilage. During a record review of Patient 17’s medical record form titled “SN OASIS Recertification” dated 5/13/2025, indicated Patient 17 had an unhealed pressure ulcer/injury at Stage 2 (open wound expanding into deeper layers of the skin) or higher with a primary diagnosis of pressure ulcer of sacral region; stage 3. Lastly, the form indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN/PCG cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x week and as needed and re-evaluate in 2 week(s).” During a concurrent interview and record review on 6/11/2025 at 3:40 p.m. with RN9 of Patient 17’s EMR, the RN9 stated Patient 17’s last documented comprehensive assessment was completed on 5/13/2025 by Registered Nurse 8 (RN8). The RN9 stated RN8 did not complete a wound assessment during the recertification comprehensive nurse assessment dated 5/13/2025, but a picture was taken. The RN9 stated that based on the wound picture, she (RN9) was unable to stated the anatomical location of the said wound. The RN9 stated the last documented wound assessment completed for Patient 17 was on 5/9/2025. The RN9 stated wounds are to be assessed during every skilled nurse visits. The RN9 stated Patient 17 did not have a wound flowsheet that showed her (Patient 17) wound assessment. During a record review of Patient 17’s medical record form titled “Home Health Plan of Care – Recertification” dated from 5/15/2025 to 7/13/2025, indicated a start of care date of 1/26/2023 with a primary diagnosis of pressure ulcer of sacral region, stage 3 (wound that extends through the dermis and into the fatty tissue below the skin). Lastly, the form indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN/PCG cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x (times) week and as needed and re-evaluate in 2 week(s).” During a record review of Patient 17’s medical record form titled “SN Home Visit” dated 5/16/2025, indicated RN8 documented “Wound to sacral area remained with depth… Wound depth 1.2 cm.” The form also indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN/PCG cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x (times) week and as needed and re-evaluate in 2 week(s).” During a record review of Patient 17’s medical record form titled “SN Home Visit” dated 5/23/2025, indicated the form was completed and signed by RN8. RN8 documented “wound care provided”. The form did not indicate Patient 17’s wound was assessed. Lastly, the form indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN/PCG cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x (times) week and as needed and re-evaluate in 2 week(s).” During a record review of Patient 17’s medical record form titled “SN Home Visit” dated 5/27/2025, indicated the form was completed and signed by RN11. The form indicated Patient 17’s wound depth measurement was 0.5cm. Lastly, the form indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN/PCG cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x week and as needed and re-evaluate in 2 week(s).” During a record review of Patient 17’s medical record form titled “SN Home Visit” dated 5/30/2025, indicated the form was completed and signed by RN8. RN8 documented that Patient 17’s wound remained the same with no deterioration and no improvement. The form did not indicate Patient 17’s wound was measured. Lastly, the form indicated there was one problem care planned for Patient 17; skin integrity – pressure injuries with the following nursing intervention: Sacrococcyx pressure injury stage 3 wound care: SN/PCG cleanse surrounding skin with wound cleanser, soak wound bed with Vashe solution, moisten gauze for 5 minutes. Protect peri wound skin with no sting skin protectant. Fill/pack tunnel/undermining with Aquacel Ag, apply triad cream to white thick edges of skin. Cover with foam dressing, may secure with tape. Frequency 2x week and as needed and re-evaluate in 2 week(s).” During a concurrent interview and record review on 6/11/2025 at 3:40 p.m. with RN9 of Patient 17’s EMR, the RN9 stated Patient 17’s physician was not notified after the 2 weeks re-evaluation as ordered. The RN9 stated, “The doctor needed to be notified of the results of the re assessment to be updated of the wound progress because he wanted to know what the progress is. He needs to know if the treatment needs to be changed.” A record review of the HHA’s document titled, Initial and Comprehensive assessment, revised on 9/2023, indicated, “During the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient’s progress toward goals and other relevant information will be documented in the patient’s clinical record…the comprehensive assessment should determine: A. Patient problems/needs/strengths…A plan of care will be developed from information gathered during the initial and comprehensive assessments”. A record review of the HHA’s document titled, Rover/Tissue Analytics Wound Photo and Assessment Documentation, revised on 12/2023, indicated the Tissue Analytics Photo would be used once a week on the first visit of the week. The record further indicated all wound assessment and treatment documentation must be entered with every dressing change. Continued review of the record indicated “Confirm photo and wound LDA (a comprehensive wound/skin assessment and treatment flow shared across all SCAL (southern California) and Hawaii care setting to improve timely and accurate communication between physician and bedside/field clinicians” documentation is accurate and complete. This serves as your comprehensive wound assessment/wound check. A record review of the HHA’s document titled, Ongoing Assessments, revised 4/2021, indicated, “During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using standards of care identified by the organization, the clinician will assess and reassess the patient (as appropriate) using a complete head to toe systems assessments within the scope of practice…Based on each reassessment, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the clinician. Change in condition will be reported to the physician.” 1. .During a review of Patient 6’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 3/4/2022, with a diagnosis that included Lymphedema (swelling mostly in arm or leg, caused by lymphatic system blockage). During a review of Patient 6’s Home Health Certification and POC for the certification period starting from 4/17/2025 to 6/15/2025, the POC included an order for the skilled nurse (SN) to visit three times a week for two weeks, one visit daily for eight days then re-assess, to assess all body system with emphasis on the patient’s integumentary system (skin) on every visits. One of the nursing interventions was to provide wound care on lymphedema on right lower extremity (RLE) as follows: cleanse with no-rinse foam pat dry, apply moisturizer on intact skin, wrap RLE with Urgo K2 compression from above the ankle to tibial notch twice weekly (Monday and Thursday). During a home visit observation, and interview on 6/12/2025, at 1:30 p.m., with Registered Nurse 5 (RN 5), Patient 6 was observed sitting on her chair at the dining room with both legs elevated on top of a stool. RN 5 stated Patient 6 had a pitting edema +3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower legs were swollen wrapped with compression wrap. RN 5 did not remove the compression wrap or assess the lymphedema at right lower leg for any signs and symptoms of any deterioration or skin complications. A review of Patient 6’s Re-certification Comprehensive Adult Nursing Assessment (OASIS-to determine the need for nursing services) dated 4/17/2025, indicated under the Skin and Wound Assessment that there was no documented evidence of a skin assessment of lymphedema on right lower leg and was not addressed. A review of Patient 6’s Home Care Visit Notes from dates 4/17/2025 to 6/12/2025, indicated no documented evidence the visiting nurse did a wound assessment for the lyphedema on right lower leg. During a phone interview with registered nurse (RN 10) on 6/16/2025, at 12:30 p.m., RN 10 stated he did the re-certification visit on April 2025 for Patient 6. RN 10 also stated he forgot to assess the patient’s lymphedema skin condition at right lower leg and he failed to document the wound assessment in the OASIS note. During a phone interview with license vocational nurse (LVN 2) on 6/16/2025, at 12:50 p.m., LVN 2 stated Patient 6’s was observed having swollen legs during her visits. LVN 2 also stated that she did not know that she needs to measure the size circumference of the lymphedema at right lower leg as part of her wound assessment.. During an interview with RN 9 on 6/13/2025, at 1 p.m. RN 9 stated all of Patient 6’s OASIS Recertification Assessment, from the SOC of 3/4/2022 to 4/16/2025, did not indicate a wound assessment for the existing lymphedema on both lower extremities. RN 9 also stated there were no documented evidence that the visiting nurse did a wound assessment of patient’s lymphedema on both lower extremities in their nursing visit notes. RN 9 further stated a wound assessment would be needed to determine if the lymphedema was improving or worsening. RN 9 stated, since SOC 3/4/2022 there is no documented evidence of any skin assessment, circumference or photos for Patient 6’s bilateral lower extremity lymphedema. A review of the HHA’s policy and procedure “Rover/Tissue Analytics Wound Photo and Assessment Documentation, revised date 12/2023, indicated that all wound assessment and treatment documentation must be entered with every dressing change. A review of the agency/s policy and procedure “Initial and Comprehensive Assessment”, dated 9/2023, indicated during the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient’s progress toward goals and other relevant information will be documented in the patient’s medical record with at least the following information, a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, height/weight, nutritional status, and other relevant data related to pertinent physical findings.”

“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 observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to review and document all the medications the patient is currently using for six of seventeen sampled patients (Patient 1, Patient 6, Patient 11, Patient 13, Patient 15, and Patient 17). This deficient practice placed patients at risk of drug-to- drug interaction and harm by not knowing which medications were being taken. 2. During a review of Patient 6’s document, the document indicated Patient 6’s start of care (SOC) date was 3/4/2022, with an admission diagnosis of lymphedema (an abnormal collection of lymphatics [vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] fluid in the tissues just beneath the skin). During a review of Patient 6’s Home Health Certification and POC for the certification period starting from 4/17/2025 to 6/15/2025, the Home Health Certification and POC included an order for the skilled nurse (SN) to visit three times a week for two weeks, one visit daily for eight days then re-assess, to instruct patient/caregiver on name, dose, frequency, indication, duration of drug therapy and expiration dates. There was a physician’s order included in the POC to administer 2.5 milligrams (mg) oral tab , to take as directed by anticoagulation clinic for blood thinning indications: blood clots in deep veins and in blood vessel of the lung. During a joint home visit, observation, and interview on 6/12/2025, at 1:30 p.m., with RN 5 at Patient 6’s home, RN 5 stated Patient 6 had a pitting edema plus (+) 3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower leg were swollen wrapped with compression wrap. Patient 6’s medications were checked. There was a bottle of Warfarin 2.5 mg oral tab to take as directed by anticoagulation clinic. During an interview on 6/12/2025, at 2 p.m., with Patient 6, She stated she takes Warfarin ½ tab two days a week (Thursday and Sunday) and one tab (2.5 mg) five days a week. During an interview with RN 5 on 6/12/2025, at 2:15 p.m., RN 5 stated she was aware Patient 6 was taking Warfarin ½ tab on Thursday and Sunday and one tab five days a week but there was no order for that. RN 5 also stated she did not coordinate with the HHA to update the medication profile list. During an interview on 6/13/2025, at 1 p.m., with RN 9, RN 9 stated that RN 5 should have checked and verify all the medications Patient 6 were taking during her visits and coordinate with the HHA whatever changes on patient’s medication regimen. 1. During a record review of Patient 1’s electronic medical record indicated Patient 1with a start of care (SOC) of 3/6/2025, with an admission diagnosis of unspecified open wound of left foot. During a concurrent observation, interview, and record review at the home visit on 6/12/2025, at 1:30 p.m. Registered Nurse 6 (RN 6) reviewed the medications Patient 1 was taking, using Patient 1’s medication list. The following medications was not being taken by Patient 1, but was listed, as stated by RN 6: Albuterol (a medication used to treat lung diseases such as asthma and chronic obstructive pulmonary disease. Used to prevent and treat difficulty breathing, shortness of breath, coughing, and chest tightness) 90mcg/actuation Inhaler, inhale 2 puffs into the lungs every four hours as needed. RN 6 stated, “the medication reconciliation should be done on every visit. The Albuterol is not here but listed on the medication profile.” During an interview on 6/12/2025 at 1:35 pm with Patient 1’s Care giver 5 (CGV 5), CGV 5 stated, “Patient 1 has never used Albuterol. We haven’t had it.” 3. A record review of Patient 11’s documents indicated an SOC of 11/10/2024, with a primary diagnosis of Pressure Ulcer of Left Ankle Stage 4 (wound extending to bone and muscle). During a concurrent observation, interview, and record review at the home visit on 6/12/2025, at 1:20 p.m. Registered Nurse 2 (RN 2) reviewed the medications Patient 11 was taking, using Patient 11’s medication list. The following medications were being taken by Patient 11, but were not listed, as stated by RN 2: Acetaminophen (pain reliever) 500 mg (mg-milligrams, unit of measurement) 2 tablets by mouth as needed for pain every 6 hours. Naproxen (for pain, joint stiffness, swelling. Reduces inflammation) 220 mg. Rivastigmine (treats Dementia, a brain condition that affects memory) 9.5 mg patch. Apply 1 patch to skin daily. Caregiver 2 (CGV 2) stated the medication was prescribed 2 years ago on 7/3/2024. Miralax (a laxative) Fleet enema (a laxative)180 ml, 1 bottle per day as needed. RN 2 stated the following medication were listed but Patient 11 was no longer taking: Restasis (a solution for the eyes. Treats chronic dry eye condition). Atropine (affects the parasympathetic nervous system). During an interview on 6/12/2025, at 1:45 p.m., Registered Nurse 3 (RN 3) stated medication reconciliation was one of the national patient safety goals. Medications needed to be reconciled every visit. If there was a discrepancy, the doctor should be called, and an order is obtained. RN2 stated the importance of medication recon ciliation every visit was due to medications changing all the time. RN 2 stated the staff needed to update the records. Especially when patients are not compliant. 4. A record review of Patient 13’s document indicated an SOC of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle): During a concurrent observation, interview, and record review at the home visit on 6/16/2025, at 11:40 p.m. Registered Nurse 4 (RN 4) reviewed the medications Patient 13 was taking, using Patient 13’s medication list. Caregiver 3 (CGV 3) stated Patient 13 took all her medications through her G-tube (Gastrostomy tube, a tube is inserted through the belly into the stomach). R 4 stated the following medications had the wrong route listed. These medications were listed to be taken by mouth: Baclofen (for muscle spasms cased by a spinal disease) Keppra (for epilepsy) Midodrine (for dizziness upon standing due to a drop in blood pressure) Percocet (pain reliever) Seroquel (repeated episodes of anxiety) Flomax (for urination problems) RN 4 continued to review the medications taken by Patient 13. RN 4 stated the following medications were listed and Patient 13 was no longer taking: Loperamide (diarrhea) Santyl (for wounds). 5. During a record review of Patient 15’s medical record form titled “Home Health 60-day Summary” dated 3/22/2025, indicated Patient 15 had a PICC (peripherally inserted central catheter – a thin flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest) line inserted on 4/1/2025 for daily Bumex (medication to treat water retention – edema) infusion. During a record review of Patient 15’s medical record form titled “Progress Notes” dated 5/13/2025, indicated Registered Nurse 13 (RN13) completed and signed the form. The Progress Notes indicated Patient 15’s Bumex was changed to 4 mg (milligrams – unit of measure) IV (intravenous – injected into a vein) every other day, “per MD”. During a record review of Patient 15’s medical record form titled “SN (skilled nurse) OASIS Recertification” dated 5/21/2025, indicated Patient 15’s primary diagnosis was acute on chronic systolic (congestive) heart failure (a condition where the heart does not function properly causing edema). The SN OASIS Recertification also indicated Registered Nurse 14 (RN14) completed a comprehensive drug regimen review and signed the form. Lastly, the SN OASIS Recertification form indicated Patient 15’s plans were to have SN visits every other day for Bumex 4 mg infusion via PICC line. During a record review of Patient 15’s medical record form titled “Home Health Plan of Care – Recertification” dated from 5/22/2025 to 7/20/2025, indicated Patient 15 was prescribed Bumex 16 mL intravenously daily. The Home Health Plan of Care – Recertification also indicated Patient 15 was prescribed Heparin 1 mL subcutaneously every 8 hours. During a record review of Patient 15’s medical record form titled “Medication Detail” dated 6/3/2025, indicated Patient 15 was prescribed Bumex 16 ml intravenously daily, with a start date of 6/3/2025. The Medication Detail form also indicated the MD3 was the prescribing provider. During a record review of Patient 15’s medical record form titled “Medication Detail” dated 6/12/2025, indicated the Medical Doctor 4 (MD4) was the prescribing provider. The Medication Detail also indicated Patient 15 was ordered Bumex 2 mg oral tabs, to take 2 mg by mouth daily. The Medication details also indicated under section “Notes to pharmacy - Patient takes 2 tablets daily for peripheral edema due to CHF if not receiving IV Bumex (16ml) inj.”. During a record review of Patient 15’s medical record form titled “Medication Detail” dated 6/3/2025, indicated Patient 15 was prescribed Heparin (medication to prevent blood clots) Porcine 5,000 unit/ml (milliliter – unit of measure) to inject 1 ml subcutaneously (injected under all the layers of the skin) every 8 hours, with a start date of 6/3/2025. The Medication Detail form also indicated the Medical Doctor 3 (MD3) was the prescribing provider. During a record review of Patient 15’s medical record form titled “Active Medication” date reviewed 5/21/2025 and printed for review on 6/11/2025, did not indicate Patient 15 was taking Bumex by mouth or Heparin subcutaneously. The Active Medication form also indicated Bumex – give 16 mL intravenously daily. During a concurrent observation and interview on 6/12/2025 at 10:25 a.m. with Registered Nurse 7 (RN7) and Registered Nurse 12 (RN12) at Patient 15’s home, RN5 completed a medication review/reconciliation. Patient 15 stated he takes Bumex 2 tabs on the days he does not receives it through the PICC line. RN5 stated patient medication reconciliation is done at every visit for safety to prevent overdose. RN5 stated Patient 15 takes 2 tablets of Bumex by mouth, but that she (RN5) does not recall the milligrams of the tablets. During an interview on 6/12/2025 at 10:25 a.m. with Patient 15, Patient 15 stated that he (Patient 15) receives IV Bumex every other day through his (Patient 15) PICC line. Patient 15 also stated that he takes 2 tables, equivalent to 4 mg, by mouth the days he does not receive Bumex through the IV. During a concurrent interview and record review on 6/12/2025 at 1;18 p.m. with RN12 of Patient 15’s EMR, RN12 stated patients medications are to be listed to ensure patients are taking the medications correctly and being treated properly. The RN12 stated if medications are not taken as prescribed there could be interactions, subtherapeutic effects that can cause exacerbation or drug reactions. The RN12 stated Patient 15’s Heparin medication is not listed on Patient 15’s Active Medication list. The RN12 stated Patient 15’s Heparin should be listed because it is part of Patient 15’s treatment plan and it needs to be managed and monitored by the home health team to ensure it is used therapeutically and for safety. During a concurrent interview and record review on 6/16/2025 at 3:45 p.m. with Registered Nurse 9 (RN9) of Patient 15’s EMR, the RN9 stated Patient 15’s active medication list needs to be updated for safety reasons. The RN9 stated an accurate medication patient list is one of the national safety goals. 6. During a record review of Patient 17’s medical record form titled “SN OASIS Recertification” dated 5/13/2025, indicated a start of care date of 1/26/2023 with a primary diagnosis of pressure ulcer of sacral region, Stage 3 (a full thickness tissue loss that breaks through the skin and into the fatty tissue below). The SN OASIS Recertification also indicated that Patient 17 wound was being treated with wound cleanser, Vashe solution (wound cleanser containing hypochlorous acid), no sting skin protectant, Aquacel AG (a soft, sterile, ribbon dressing composed of sodium carboxymethylcellulose and 1.2% ionic silver), and triad cream (a sterile zinc oxide based, hydrophilic, paste wound dressing). During a record review of Patient 17’s medical record form titled “Home Health Plan of Care -Recertification” dated from 5/15/2025 to 7/13/2025, The Home Health Plan of Care -Recertification indicated Patient 17 wound was being treated with wound cleanser, Vashe solution (wound cleanser containing hypochlorous acid), no sting skin protectant, Aquacel AG (a soft, sterile, ribbon dressing composed of sodium carboxymethylcellulose and 1.2% ionic silver), and triad cream (a sterile zinc oxide based, hydrophilic, paste wound dressing). During a record review of Patient 17’s medical record form titled “Active Medications” date reviewed 5/16/2025 and provided for review on 6/11/2025, did not indicate Patient 17’s wound medications were listed. During a concurrent interview and record review on 6/12/2025 at 1:55 p.m. with Registered Nurse 12 (RN12) of Patient 17’s EMR medical record form titled “Active Medications” date reviewed 5/16/2025 was reviewed. The RN9 stated Patient 17’s wound treatment was not listed on her (Patient 17) Active Medications form. The RN9 stated that Patient 17’s wound treatment should have been listed on her (Patient 17) Active Medications form. A record review of the HHA’s document titled, Medication List, revised on 6/2022, indicated, “Patients receiving medication will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medication and new and/or discontinued medications...4.During subsequent home visits, the active medication list will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen...””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to include information required in the Plan of Care (POC - an individualized written program for a patient that is developed by health care professionals) for ten of seventeen sample patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 10, Patient 11, Patient 13, Patient 14, Patient 15, and Patient 17). 1. For Patient 1, Patient 3, and Patient 4 the plan of care did not include instructions on when to notify the doctor pertaining to wound condition and management. 2. For Patient 5, the plan of care did not include intervention management for a patient with a colostomy. 3. For Patient 10, the plan of care did not include vital signs parameters and interventions for her kidney and digestive disease. 4. For Patient 11, the plan of care did not include vital signs parameters, interventions for her respiratory system, and difficulty swallowing. 5. For Patient 13, the plan of care did not include interventions for aspiration, G-tube, and vital sign parameters. 6. For Patient 14, the plan of care did not include the Stage I buttocks pressure injury and her (Patient 14) combative behavior. 7. For Patient 15, the plan of care did not include all his active medications, patient and/or caregiver/family education on anticoagulant and diuretic medications, fluid restrictions, oxygen use, and PICC line, pain and bilateral lower extremities edema management. 8. For Patient 17, the plan of care did not include patient and/or caregiver/family education on Stage 3 sacral wound management. This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. During a review of Patient 5’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 4/7/2022, with a diagnosis that included sacral Stage four pressure ulcer (severe deep wound that extend down to the muscle, tendon or bone and can include black tissue or puss). During a review of Patient 5’s Home Health Certification and POC for the certification period starting from 5/1/2025 to 7/19/2025, the POC included an order for the skilled nurse (SN) to visit once a week for nine weeks, to assess all body system with emphasis on the patient’s integumentary system (skin) on every visits. One of the nursing interventions was to instruct patient and family on ostomy appliance change. During a home visit observation, and interview on 6/12/2025, at 11 a.m., with License Vocational Nurse (LVN 3) , Patient 5 was observed lying in bed unable to move both lower extremities. Patient 5 had a colostomy intact at left upper quadrant of the abdomen. During a concurrent interview and record review, on 6/13/2025 at 12:45 p.m. with Registered Nurse 9 (RN 9), RN 9 reviewed Patient 5’s Home Health Certification and Plan of Care for the certification period starting from 5/1/25 to 7/19/25. The RN 9 stated and acknowledged there was no care plan developed with specific goals and interventions regarding Patient 5’s colostomy. RN 9 stated there should be a care plan to monitor Patient 5’s colostomy to assess the stoma and surrounding skin for possible signs and symptoms of infection or skin irritation and when to notify the physician regarding the change of condition. During a review of the undated agency’s policy and procedure (P&P) titled Care Planning Process ,the P&P indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient-specific clinical plan of care includes all pertinent primary and secondary diagnoses, start of care date and certification period, patient demographics, all patient care orders including verbal orders, measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care, frequency and duration of visits, functional limitations, nutritional requirements, food or drug allergies, medications and treatments, safety measures, patient-specific interventions and education, and discharge or referral plans. 1. During a record review of Patient 1’s electronic medical record indicated Patient 1with a start of care (SOC) of 3/6/2025, with an admission diagnosis of unspecified open wound of left foot. During a record review of Patient 1’s Plan of Care, for certification period 3/6/2025 to 5/4/2025 indicated doctors order for skilled nurse visit frequency of; once a week for one week, twice a week for one week, then twice a week for two weeks, then twice a week for four weeks. The plan of care further indicated skilled nurse patient caregiver to perform collagen silver to pack on the wound to assist wound healing as follows 1. cleanse/ irrigate with saline, gently pat dry 2. apply no sting barrier film on periwound 3. pack wound with collagen silver 4. cover with foam dressing twice a week weekly and as needed for dislodgement and soilage. The plan of care did not indicate when to notify doctor regarding wound care and wound condition. During a concurrent interview and record review on 6/12/2025 at 11:15 a.m. with QA LVN 1 of Patient 1’s Plan of care dated 3/6/2025 and recertification plan of care dated 5/2/2025 there was no documentation or required reporting indications to the MD for Patient 1’s wound care management. QA LVN 1 stated, “the plan of care is used as the guide to provide care to the patients. For Patient 1 there is no reporting parameters or indications for when to report to the physician for wound care and assessment listed in the plan of care. This is important because the wound can deteriorate and the nurses need to know what to report and document what is reported to the MD.” 2. During a record review of Patient 3’s electronic medical record indicated Patient 3 with a start of care (SOC) of 3/25/2025, with an admission diagnosis of pressure ulcer (a break in the skin caused by continues pressure to a body part) of other site, stage 3 (a characterized by full thickness skin loss, where the damage extends into the subcutaneous tissue, but not to underlying muscle, bone, or tendon). During a record review of Patient 3’s Plan of Care, for certification period 3/26/2025 to 5/24/2025 indicated doctors order for skilled nurse visit frequency of 1 visit per week, for 3 weeks, 3 visits as needed. The plan of care further indicated skilled nurse caregiver to perform wound care on pressure injury location left foot second toe pressure injury type stage 3 cleanse with wound cleanser, pat dry, apply hydrofiber with silver, wrap with gauze roll and secure with tape. Frequency of pressure injury wound care twice weekly and as needed for dislodgement. The plan of care did not indicate when to notify doctor regarding wound care and wound condition. During a concurrent interview and record review on 6/12/2025 at 12:30 p.m. with QA LVN 1 of Patient 3’s Plan of care dated 3/25/2025 and recertification plan of care dated 5/24/2025 there was no documentation or reporting indications to the MD for Patient 3’s wound care management. QA LVN 1 stated, “the plan of care is used as the guide to provide care to the patients. For Patient 3 there is no reporting parameters or indications for when to report to the physician for wound care and assessment listed in the plan of care. This is important because the wound can deteriorate and the nurses need to know what to report and document what is reported to the MD.” 3. During a record review of Patient 4’s electronic medical record indicated Patient 4 with a start of care (SOC) of 4/15/2025, with an admission diagnosis of unspecified open wound of left lower leg. During a record review of Patient 4’s Plan of Care, for certification period 4/15/2025 to 6/13/2025 indicated doctors order for skilled nurse visit frequency of; twice a week for two weeks. The plan of care further indicated skilled nurse to perform you wound care. won’t location left lower leg stasis won’t type stasis, cleanse with Vashe (a wound cleaner), pat dry, protect surrounding skin with A & D ointment (a petroleum jelly ointment for skin protection), apply ammonium lactate (medication used to treat dry, scaly, and itchy skin condition), wrap with conform gauze, secure with elastic bandage, frequency of wound care twice a week. The plan of care did not indicate when to notify doctor regarding wound care and wound condition. During a concurrent interview and record review on 6/13/2025 at 12:13 p.m. with QA LVN 1 of Patient 4’s Plan of care dated 4/15/2025, there was no documentation or reporting indications to the MD for Patient 4’s wound care management. QA LVN 1 stated, “the plan of care is used as the guide to provide care to the patients. For Patient 4 there is no reporting parameters or indications for when to report to the physician for wound care and assessment listed in the plan of care. This is important because the wound can deteriorate and the nurses need to know what to report and document what is reported to the MD.” During an interview on 6/16/2025 at 2:56 p.m. with DPCS, DPCS stated, “the plan of care for wound care needs to include reportable signs and symptoms of wound complications or possible deterioration to the MD. This is important so the skilled nurse knows what signs and symptoms to look for to make a determination if the care provided is right and optimum, and to report to the MD to prevent complications.” 4. A record review of Patient 10’s documents indicated an SOC of 6/8/2025, with a diagnosis of Acute Kidney Failure. During an interview at the home visit on 6/12/2025, at 11:10 p.m., Registered Nurse 2 (RN 2) stated Patient 10 was in the Advanced Medical Care at Home program, for patients who need more care and more monitoring, as these patients were at higher risk of hospitalization. A record review of Patient 10’s POC, dated 6/8/2025 to 8/6/2025 indicated daily skilled nurse visits for 6 days for IV (intravenous-a type of infusion through the vein by means of a tube called catheter) infusion of fluids. During an interview at the home visit on 6/12/25, at 11:20 a.m. Patient 10 stated to RN 2 that she had been having diarrhea, abdominal swelling, and has Crohn’s disease. Patient 10 stated she had really high blood pressure when she was hospitalized and was concerned, she would have a stroke (brain attack). Patient 10 stated she also had history of UTI (an infection of the urinary tract) as well. RN 2 stated it sounded like she had more issues going on. During a concurrent interview and record review on 6/12/25, at 3:00 p.m., RN 3 reviewed Patient 10’s OASIS Assessment, dated 6/8/25 and Patient 10’s Plan of Care, dated 6/8/2025 to 8/6/2025. RN 3 stated the assessment did not clearly indicate Patient 10 was having intestinal issues and additional interventions were needed for the plan of care such as assessing her gastro-intestinal symptoms, and teaching signs and symptoms to report to the doctor (such as belly swelling, pain, discomfort). The assessment did not identify the interventions needed in the plan of care for Patient 10’s Acute Renal Failure (ARF-kidneys not working well). RN 3 stated Patient 10 needed interventions for her ARF such as monitoring her fluid intake and output, signs of dehydration, education about intake and output (how much is a good amount/bad amount), and signs of dehydration. During a concurrent interview and record review on 6/12/25, at 3:00 p.m., RN 3 reviewed Patient 10’s OASIS Assessment, dated 6/8/25 and Patient 10’s Plan of Care, dated 6/8/2025 to 8/6/2025. RN 3 stated the OASIS indicated Patient 10 had a history of Crohn’s disease (a chronic inflammatory bowel illness that causes inflammation to the digestive tract). RN 3 stated the POC did not have instructions on when staff should call the doctor, known as reportable conditions. RN 3 stated the reportable conditions that should have been included in the POC were decreased urine output, thirst, mental changes, and/or fever. The importance of including these in the POC was because these symptoms were the reason for Patient 10’s readmission to the hospital, the reason for IV treatments. The nurse needed to assess the entire condition. During an interview and record review on 6/12/2025, at 1:46 p.m., Registered Nurse 2 (RN 2) reviewed Patient 10’s POC, dated 6/8/2025 to 8/6/2025. RN 2 stated Patient 10’s POC did not have vital sign (blood pressure, heart rate, temperature, respirations readings). RN 2 stated the vital sign parameters should be included in the POC because that is basic information needed. The vital signs tell nurses how the patient is doing. During an interview on 6/17/2025, at 1:55 p.m., Registered Nurse 9 (RN 9) stated Patient 10 was hospitalized on 6/17/2025 for chest pain. 5. A. A record review of Patient 11’s documents indicated an SOC of 11/10/2024, with a primary diagnosis of Pressure Ulcer of Left Ankle Stage 4 (wound extending to bone and muscle). During an interview at the home visit on 6/12/25, at 12:45 p.m., Patient 11’s Caregiver (CGV 1), stated Patient 11 had COPD (Chronic Obstructive Pulmonary Disease, an illness that makes breathing difficult) and her oxygen saturations (O2% -the percent of oxygen in the blood) sometimes were in the 80’s (normal range is 95 to 100 percent). During an interview at the home visit on 6/12/25, at 1:30 p.m., CGV 2 stated Patient 11 was hospitalized twice this year for pneumonia. During a concurrent interview and record review on 6/13/25, at 10:10 a.m., RN 3 reviewed Patient 11’s POC, dated 3/10/2025 to 5/8/2025 and Patient 11’s previous certification OASIS Recertification Assessment, dated 3/8/2025. RN 3 stated Patient 11 was diagnosed with COPD in January 2025. The assessment indicated Patient 11’s O2 saturations were 92% breathing room air. RN 3 stated the assessment did not address Patient 11’s COPD and a thorough assessment was needed. The purpose of the thorough assessment was for proper care planning, proper interventions, education to the family and patient on which symptoms to report to the doctor, with the goal to prevent complications and hospitalization. RN 3 stated had the nurse identified Patient 11’s respiratory problems in the previous certification period, it would have alerted the nurse to do a more thorough assessment in the current certification period, such as doing a careful respiratory assessment, asking the patient and family how her O2 reading have been, and if she had encountered any breathing problems. That way, the doctor be notified and the problem is added to the plan of care so staff can monitor her respiratory status. A record review of Patient 11’s POC dated 5/9/2025 to 7/7/2025, did not indicate vital sign parameters and no respiratory interventions. B. During an interview at the home visit on 6/12/25, at 12:46 p.m., Caregiver 2 (CGV 2) stated Patient 11 had swallowing problems. During a concurrent interview and record review on 6/13/25, at 10:40 a.m., RN 3 reviewed Patient 11’s OASIS Recertification Assessment, dated 5/9/2025. RN 3 stated there was no swallow risk assessment. If it was identified and assessed, this required interventions in the Plan of Care such as swallowing precautions, how to modify the food, signs and symptoms to report to the physician for swallowing. A record review of Patient 11’s POC dated 5/9/2025 to 7/7/2025, did not indicate any interventions for Patient 11’s swallowing problems. 6. A. A record review of Patient 13’s document indicated an SOC of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle). During a concurrent interview and record review on 6/13/25, at 2:45 p.m. RN 3 reviewed Patient 13’s SN OASIS Recertification assessment, dated 4/28/2025. The record indicated diagnosis of gastrostomy status (G-tube, an opening through the belly. A tube is used to provide fluids, food, and medication). RN 3 stated there was no assessment of the G-tube or status of the G-tube. RN 3 stated a complete assessment of the G-tube was to check what nutrition was being given, total amount being given, the G-tube site assessment, who was providing the G-tube nutrition, interval, G-tube size, site, and residual amount (how much is left after feeding). Patients who were on G-tube feeding need to be checked for risk of aspiration (food going to the lungs and causing complications), due to this type of feeding. RN 3 stated there was no aspiration precautions assessed in the recertification assessment. During a concurrent interview and record review on 6/13/25, at 2:45 p.m. RN 3 reviewed Patient 13’s POC dated 5/3/2025 to 7/1/2025. RN 3 stated there was no interventions/instructions for G-tube assessment and management. The POC did specify the diet and there were no aspiration precautions in the plan of care. B. During a concurrent observation, interview, and record review at the home visit on 6/16/2025, at 11:40 p.m. Registered Nurse 4 (RN 4) reviewed the medications Patient 13 was taking. RN 4 reviewed Patient 13’s POC dated 5/3/2025 to 7/1/2025. RN 4 stated, Patient 13 was taking Midodrine, a medication used to treat low blood pressure. RN 4 stated the POC did not have any blood pressure parameters. RN 4 stated Patient 13 needed to have blood pressure parameters in the POC. Further review of the POC did not indicate any vital sign parameters for Patient 13. 7. During a record review of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025 received on 6/11/2025, with a start of care date of 6/7/2025, and a primary diagnosis of pressure ulcer of unspecified site, unspecified stage. The Home Health Plan of Care form had four problems care planned for Patient 14. The four problems listed on Patient 14’s Home Health Plan of Care were: 1. Code status, 2. History of falls/fall risk, 3. Home safety, and 4. Patient requires monitoring of vital signs/weight. The Home Health Plan of Care did not indicate Patient 14’s admitting diagnosis of a pressure ulcer or fighting behavior were care planned. During a record review of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025 received on 6/13/2025, the Home Health Plan of Care form had six problems care planned for Patient 14. The four problems listed on Patient 14’s Home Health Plan of Care were: 1. Code status, 2. History of falls/fall risk, 3. Home safety, 4. Patient requires monitoring of vital signs/weight, 5. pressure injury, and 6. wound care. The Home Health Plan of Care did not indicate Patient 14’s fighting behavior was care planned. During a record review of Patient 14’s medical record form titled “Progress Notes” dated 6/6/2025, indicated Medical Doctor 1 (MD1) was Patient 14’s primary doctor and completed and signed the Progress Notes. MD1 documented that Patient 14 had the following diagnosis major neurocognitive disorder due to unspecified disease (unspecified dementia) (mental health disorders that affect behavior). During a record review of Patient 14’s medical record form titled “SN (skilled nurse) OASIS Start of Care” dated 6/7/2025, indicated Registered Nurse 1 (RN1) was unable to visualize Patient 14’s wound. The SN OASIS Start of Care form did not indicate the reason as to why Patient 14’s wound was unable to be visualized by RN1. The SN OASIS Start of Care form indicated Patient 14’s daughter stated she provided (CGV6) care and safety due to “cognitive impairment”. Lastly, the form did not indicate Patient 14’s vital signs were measured. The RN1 documented under “BP – unable to assess PT (patient) fighting.” During a record review of Patient 14’s medical record form titled “Episode Information” undated, indicated Patient 14’s vital signs were not able to be assessed due to “Fighting”. During a concurrent observation and interview on 6/12/2025 at 9 a.m. with Registered Nurse 5 (RN5) and Registered Nurse 12 (RN12) at Patient 14’s joint home visit, Patient 14 was noted laying supine on a hospital bed with hands clinched. The RN 5 assessed Patient 14 with the assistance of Patient 14’s grandson (GS) due to Patient 14 was swinging both arms to RN5. RN5 was observed and stated Patient 14 hit her (RN5) on her (RN5) chest. Patient 14 was actively swing both arms towards RN5 and GS throughout the nursing assessment. During a record review of Patient 14’s medical record form titled “SN Home Visit” dated 6/12/2025, indicated Registered Nurse 7 (RN7) completed and signed the form. The SN Home Visit form did not indicate Patient 14 was combative during the home visit. During a concurrent interview and record review on 6/11/2025 at 2:20 p.m. with the Senior Clinical Practice Nurse (RN9) of Patient 14’s EMR, the RN9 stated Patient 14’s wounds were not assessed or vital signs taken on 6/11/2025 during the initial comprehensive assessment because “maybe” Patient 14 was combative. During a concurrent interview and record review on 6/12/2025 at 12:35 p.m. with the RN12 of Patient 14’s EMR, the RN12 stated that there were no problems identified for Patient 14’s wounds. The RN12 stated the primary reason Patient 14 was receiving home health services was for her wound and that there should have been interventions and goals in her plan of care. The RN12 stated that a patients care plan gives direction for the patients care and drives the home care team to reach their goals. The RN12 stated that Patient 14’s combative behavior should have been documented and care planned for everyone’s safety, including the visiting nurse. During a concurrent interview and record review on 6/13/2025 at 3 p.m. with the RN12 of Patient 14’s EMR, the RN12 stated, “I don’t see any documentation from yesterday’s home visit or the updated care plan that indicates the patient was combative. It is not on the care plan. It should be on the care plan one, to give direction and coordinate info on how to manage the patient because it’s a safety issue. Identify way to manage the combativeness to stay safe and keep the patient safe too.” 8. During a record review of Patient 15’s medical record form titled “SN (skilled nurse) OASIS Recertification” dated 5/21/2025, indicated a start of care date of 1/22/2025 with a primary diagnosis of acute on chronic systolic (congestive) heart failure (CHF - a condition where the heart does not function properly causing edema). The SN OASIS Recertification indicated Patient 15 had a single lumen PICC (peripherally inserted central catheter – a thin flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest) line on his (Patient 15) upper right arm. The SN OASIS Recertification also indicated Patient 15 complained of back pain with a rating of 4 out of 10, when his worst pain was rated at an 8. The SN OASIS Recertification indicated Patient 15 was on fluid restriction and had edema +2 (slight indentation, which is considered a moderate level of pitting edema) to bilateral lower extremities. Lastly, the SN OASIS Recertification indicated Patient 15 was using oxygen at 3 liters per minute via a nasal cannula. During a record review of Patient 15’s medical record form titled “Home Health 60-day Summary” dated 3/22/2025, indicated Patient 15 had a line inserted on 4/1/2025 for daily Bumex (medication to treat water retention – edema) infusion. During a record review of Patient 15’s medical record form titled “Progress Notes” dated 5/13/2025, indicated Patient 15’s had BLE (bilateral lower extremities) swelling and was on fluid restrictions. The Progress Notes also indicated Patient 15’s Bumex intravenous medication administration was changed to every other day. During a record review of Patient 15’s medical record form titled “Medication Detail” dated 6/3/2025, indicated Patient 15 was prescribed Heparin (medication to prevent blood clots) Porcine, with a start date of 6/3/2025. During a record review of Patient 15’s medical record form titled “Home Health Plan of Care – Recertification” dated from 5/22/2025 to 7/20/2025, indicated Bumex by mouth and Heparin were not listed under “Medications”. The Home Health Plan of Care Recertification also indicated Bumex intravenous was to be given daily. The Home Health Plan of Care Recertification indicated Patient 15’s fluid restriction, edema, oxygen use, or pain were not mentioned or care planned. Lastly, the Home Health Plan of Care Recertification did not indicate Patient 15 and/or family/caregiver were provided education on signs and symptoms of adverse reactions to Heparin, Bumex, or PICC line, edema, fluid restrictions, oxygen use, or pain management. During a concurrent interview and record review on 6/11/2025 at 4:30 p.m. with Registered Nurse 9 (RN9) of Patient 15’s Electronic Medical Record (EMR), the RN9 stated Patient 15’s BLE edema, pain, oxygen use, and fluid restrictions were not care planned. The RN9 stated that all of Patient 15’s issues needed to be care planned to ensure the home health care team will be aware and able to manage his (Patient 15) conditions. The RN9 stated, “The patients pain needs to be care planned so that we can provide the appropriate pain management for his, is part of providing nursing care. We will miss the opportunity to notify the physician about the patients’ pain, to be able to control the patient’s pain. The patient can be suffering from pain, and we would not know, that is why we are there to provide overall care for the patient.” During a concurrent observation and interview on 6/12/2025 at 10:25 a.m. with Registered Nurse 7 (RN7) and Registered Nurse 12 (RN12) at Patient 15’s home, Patient 15 stated he takes Bumex 2 tabs on the days he does not receives it through the PICC line. Patient 15 stated that he (Patient 15) receives IV Bumex every other day through his (Patient 15) PICC line. Patient 15 stated that he had chronic lower back pain and swelling to his legs. RN5 stated Patient 15 takes 2 tablets of Bumex by mouth, but that she (RN5) does not recall the milligrams of the tablets. During a concurrent interview and record review on 6/12/2025 at 1:18 p.m. with Registered Nurse 12 (RN12) of Patient 15’s EMR, the RN12 stated Patient 15’s care plan did not indicate Patient 15 was taking Bumex by mouth or Heparin. The RN12 stated all the patients’ medications need to be listed to ensure they are taken as indicated and there are no interactions. The RN12 stated Patient 15, and his family/caregiver needed to be educated on the risk associated with taking Heparin, for example bleeding and bruising. The RN12 stated Patient 15’s plan of care did not indicate Patient 15’s PICC line dressing was to be changed every week because it has a high risk of infection. The RN12 stated that Patient 15 was using oxygen due to having CHF and both were not care planned. The RN12 stated Patient 15 and his (Patient 15) family/caregiver needed to be educated on how to manage the oxygen in their home. Lastly, the RN12 stated Patient 15’s lower leg edema and pain were not care planned. 9. During a record review of Patient 17’s medical record form titled “SN OASIS Recertification” dated 5/13/2025, indicated a start of care date of 1/26/2023 with a primary diagnosis of pressure ulcer of sacral region, Stage 3 (a full thickness tissue loss that breaks through the skin and into the fatty tissue below). The SN OASIS Recertification also indicated that Patient 17 wound was being treated with wound cleanser, Vashe solution (wound cleanser containing hypochlorous acid), no sting skin protectant, Aquacel AG (a soft, sterile, ribbon dressing composed of sodium carboxymethylcellulose and 1.2% ionic silver), and triad cream (a sterile zinc oxide based, hydrophilic, paste wound dressing). During a record review of Patient 17’s medical record form titled “Home Health Plan of Care -Recertification” dated from 5/15/2025 to 7/13/2025, The Home Health Plan of Care -Recertification indicated Patient 17 had a primary diagnosis of pressure ulcer of sacral region, Stage 3. The Home Health Plan of Care did not indicate Patient 17’s treatment order under section “Medications”. The Home Health Plan of Care did not indicate Patient 17, or the family/caregivers were educated on how to manage Patient 17’s sacral wound. During a concurrent interview and record review on 6/12/2025 at 1:55 p.m. with RN12 of Patient 17’s EMR, the RN12 stated Patient 17’s plan of care did not indicate Patient 17’s family/caregivers were education on how to manage Patient 17’s sacral wound. The RN12 stated family/caregivers’ education should have consisted of how and when to change the wound dressing and the signs or symptoms of complications to prevent worsening of the pressure wound. Lastly, the RN12 stated there was no care planned for pain due to Patient 17 did not complain of pain. A record review of the HHA’s document titled, Care Planning Process, revised on 8/2017, indicated, “3. Based on the assessment and conclusions, the plan of care will include, but not limited to: M. All necessary interventions to address the underlying risk factors...O. Patient specific interventions and education; measurable outcomes and goals identified by the home health agency and patient...13. Problems and/or needs related to the patient’s condition, desires, abilities, family/caregiver support systems, and relevant medication monitoring will be included in the plan of care.””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure the plan of care was updated after new doctor’s orders for one of seventeen sampled patients (Patient 1). The deficient practice had the potential to result in confusion on the most current treatment plan. Findings: During a record review of Patient 1’s electronic medical record indicated Patient 1with a start of care (SOC) of 3/6/2025, with an admission diagnosis of unspecified open wound of left foot. During a record review of Patient 1’s Plan of Care, for recertification period 5/5/2025 to 7/3/2025 indicated doctors order for skilled nurse visit frequency of; twice a week for three weeks. The plan of care further indicated wound care performed by skilled nurse/ caregiver to perform wound care on left foot stage 3 pressure ulcer as follows: 1. cleanse/ irrigate with saline, gently pat dry, 2. soak with moistened gauze antimicrobial wound cleanser for 5 minutes 3. apply no sting barrier film on periwound 4. pack wound with honey dressing infused with alginate 5. cover with Abd pad 6. secure with tape. Daily; reassess in two weeks; patient’s husband is able and willing to perform wound care as validated during home visit with the start date of 4/7/2025 and updated on 4/24/2025. During the record review of an intervention order for Patient 1, dated 5/8/2025, the intervention order indicated updated 5/8/2025, skilled nurse caregiver to perform wound care on left foot stage 3 pressure ulcer as follows: 1. cleanse/ irrigate with saline, gently pat dry 2. applied Santyl ointment (Medication used to remove dead tissue from chronic skin ulcers and severely burned areas) 3. apply calmoseptine (a topical ointment that acts as a moisture barrier and helps to soothe and protect skin irritation) to periwound 4. Cover with dry dressing 5. secure with tape daily; reassess in two weeks; patients husband is able and willing to perform wound care as validated during home visit. During a concurrent interview and record review on 6/12/2025 at 11:30 a.m. with QA LVN 1 of Patient 1’s recertification plan of care dated 5/2/2025 the plan of care indicated treatment for wound left foot 1. cleanse/ irrigate with saline, gently pat dry, 2. soak with moistened gauze antimicrobial wound cleanser for 5 minutes 3. apply no sting barrier film on periwound 4. pack wound with honey dressing infused with alginate 5. cover with Abd pad 6. secure with tape. During a review of SN visit notes dating 5/8/2025 to 6/10/2025 the wound care indicated 1. cleanse/ irrigate with saline, gently pat dry 2. applied Santyl ointment 3. apply calmoseptine to periwound 4. Cover with dry dressing 5. secure with tape QA LVN 1 stated, “there are doctors orders from 5/8/2025 with new wound care orders, but the Plan of care was not updated to reflect the changes. This was missed. This is important to update the plan of care because it’s the guide book for the nurses to properly follow the care and follow it timely.” During an interview on 6/16/2025 at 3:06 p.m. with DPCS, DPCS stated, “The plan of care needs to be updated every time there is a change. This is important because this is what skilled nurses use to guide their care.” During a record review of the HHA’s document titled, Care Planning Process, revised on 8/2017, indicated, “10. changes in the plan of care will be noted with the following documentation: A. Assessment B. Plan of care will with clinical outcome goals C. Care plan with specific services/ actions to be taken D. Clinical notes E. Verbal orders.””

“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 observation, interview and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed ensure three of 17 sampled patients (Patient 6, Patient 13, and Patient 16) physician orders were carried out as ordered. For Patient 13, the HHA failed to provide wound care treatment to stage 4 pressure ulcer to sacrum, and stage 4 wound to left leg with wound vac (is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess wound exudate and to promote healing). For Patient 16, the HHA did not provide care and treatment to Patient 16’s right knee incision. For Patient 6, the HHA did not provide care and treatment to Patient 6’s Lymphedema (a condition where lymphatic [circulatory system] fluid builds up in soft tissues, causing swelling, most commonly in the arms or legs). As a result of non-compliance, For Patient 13, the noncompliance resulted in worsening of the sacral wound, placing Patient 13 at risk of infection, which could lead to hospitalization and/or death. For Patient 16, the noncompliance resulted in Patient 16 being discharge to an outpatient rehabilitation without assessing the condition of his right knee incision that could place Patient 16 at risk for non-healing incision to right knee, infection, and hospitalization For Patient 6, had the potential to experience worsening of the lymphedema on both lower extremities that could lead to infection and hospitalization. On 6/18/2025 at 11:45 a.m., the Department called an immediate jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s staff, Nurse Leader, Senior Director 1, Senior Director 2, Administrator, Clinical Practice Nurse, DPCS, Improvement Advisor, and Clinical Supervisor, related to the HHA failure to ensure physician order was followed for three of 17 sampled patients (Patient 13, Patient 16, and Patient 6). On 6/18/2025 at 2 p.m., the survey team completed the survey task and conducted an exit conference in the presence of Nurse Leader, Senior Director 1, Senior Director 2, Administrator, Senior Clinical Practice Nurse, DPCS, Improvement Advisor, Clinical Supervisor, and Service Line Administrator, with the IJ not removed. 1.During a review of Patient 6’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 3/4/2022, with a diagnosis that included Lymphedema (swelling mostly in arm or leg, caused by lymphatic system blockage). During a review of Patient 6’s Home Health Certification and POC for the certification period starting from 4/17/2025 to 6/15/2025, the POC included an order for the skilled nurse (SN) to visit three times a week for two weeks, one visit daily for eight days then re-assess, to assess all body system with emphasis on the patient’s integumentary system (skin) on every visits. One of the nursing interventions was to provide wound care on lymphedema on right lower extremity (RLE) as follows: cleanse with no-rinse foam pat dry, apply moisturizer on intact skin, wrap RLE with Urgo K2 compression from above the ankle to tibial notch twice weekly (Monday and Thursday). During a home visit observation, and interview on 6/12/2025 (Thursday), at 1:30 p.m., with Registered Nurse 5 (RN 5), Patient 6 was observed sitting on her chair at the dining room with both legs elevated on top of a stool. RN 5 stated Patient 6 had a pitting edema +3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower legs were swollen wrapped with compression wrap. RN 5 did not provide wound care on patient’s RLE lymphedema, she did not remove the compression wrap or assess the lymphedema at right lower leg for any signs and symptoms of any deterioration or skin complications. A review of Patient 6’s Re-certification Comprehensive Adult Nursing Assessment (OASIS-to determine the need for nursing services) dated 4/17/2025, indicated under the Skin and Wound Assessment that there was no documented evidence that the visiting nurse provided wound treatment for the RLE during the visit. A review of Patient 6’s Home Care Visit Notes from dates 4/17/2025 to 6/12/2025, indicated no documented evidence the visiting nurse provided wound care at RLE lymphedema as ordered. During an interview with Registered Nurse 9 (RN 9) on 6/13/2025, at 1 p.m. RN 9 stated RN 5 should have provided wound care treatment for Patient 6’s RLE lymphedema during her visit on 6/12/2025. RN 9 also stated the patient’s OASIS Recertification Assessment on 4/17/2025, did not indicate a wound care treatment for the existing lymphedema on right lower extremity was provided during the visit. RN 9 also stated there were no documented evidence that the visiting nurse provided a wound care treatment of patient’s lymphedema on RLE in their nursing visit notes. RN 9 further stated the patient’s if wound care was not provided, the patient’s lymphedema at RLE could get infected and delay the healing process. A review of the HHA’s policy and procedure “Verification Of Physician’s Orders and Medication Order Requirement” revised date 8/2022 indicated that orders will be obtained from a licensed physician for care and services to be provided to home health patients. 2. A record review of Patient 13’s document indicated an SOC of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle): A. A record review of Patient 13’s Plan of Care, for certification period 5/3/2025 to 7/1/2025 indicated doctors order for wound treatment to the sacrum and left leg. There was a wound treatment order to a stage 4 sacrum wound with a frequency of twice a week. The other wound treatment order was for a stage 4 wound on the left leg with a frequency of daily wound by the SN (skilled nurse)/caregiver. During a concurrent interview and record review on 6/13/2025, at 12:51 p.m., Registered Nurse 3 (RN 3) reviewed Patient 13’s doctor order dated 5/5/2025. RN 3 stated Patient 13 was supposed to be visited three times a week for 8 weeks from 5/4/2025 to 6/28/2025 for wound vac change. During a concurrent interview and record review on 6/13/2025 from 4:07 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/17/2025. The document indicated, “SN change dressing to both lower leg wound and change wound vac dressing to sacrum. Wounds not heal.” RN 3 stated there was no documented evidence the nurse provided wound treatment to the sacrum and left leg. RN 3 stated the risk of not assessing the wounds were: not knowing the progress, not knowing if there are signs and symptoms of infection, not knowing if the wound is improving or worsening.” During a concurrent interview and record review on 6/13/2025 from 4:10 p.m. RN 3 reviewed Patient 13’s Home Care Visit, dated 5/19/2025. The record indicated, “wound care and wound vac completed as ordered.” RN 3 stated the record did not specify the wound treatment provided, to the specific location. During a concurrent interview and record review on 6/13/2025, at 4:15 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/19/2025 and 5/23/2025). RN 3 stated there was no documentation to explain what happened. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. During a concurrent observation and interview at the home visit on 6/16/2025, at 11:30 a.m., RN 4 proceeded to do wound care on the left lateral leg. CGV 3 stated some parts of the wound on the left leg were getting better, while other parts of the wound were opening again. CGV 3 stated the wound nurse visited on 5/29/2025 and changed the wound treatment frequency on the left leg from 2 times a week to 1 time a week. CGV 3 stated she was doing wound care to the left leg once a week. During an interview at the home visit on 6/16/2025, at 12:00 p.m., CGV 3 stated was concerned with the wound on the left leg. CGV 3 stated Patient 13 was not getting better. A record review of Patient 13’s doctor order, dated 5/29/2025, indicated a change to the wound treatment to the left leg frequency to 2 times a week. During a concurrent interview and record review on 6/16/2025, at 2:50 p.m., RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 only got two visits (5/26/2025 and 5/29/2025). RN 3 stated there was no documentation to explain what happened, or any attempts to reschedule the visit. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. RN 3 stated whenever there is a missed visit, the doctor was supposed to be notified on why the visit was missed and there should have been an attempt to reschedule the visit the same week so that a visit is not missed. During a concurrent interview and record review on 6/16/2025, at 3:00 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 5/26/2025. The record indicated, “As per PCG (primary care giver) wound vac stays for 1 day and then start leaking due to urine incontinent.” RN 3 stated there was no mention that another visit was made to check and assess the status of the wound vac. RN 3 stated another visit was needed to make sure the wound vac is working well, and to make sure the wound care treatment is being done correctly. RN 3 stated one of the characteristics to determine if a wound was getting better was the size of the wound: the wound would get smaller. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:22p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/2/2025. RN 3 stated there was no wound treatment and measurement for the left leg. During a concurrent interview and record review on 6/16/2025, at 3:29 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/4/2025. RN 3 stated there was no wound treatment to the left leg. During a concurrent interview and record review on 6/16/2025, at 3:31 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/6/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. RN 3 stated she did not know if the wounds on the sacrum and left leg were improving or worsening because there was no information to review. During a concurrent interview and record review on 6/16/2025, at 3:36 p.m., RN 3 reviewed Patient 13’s Home Care Visit, dated 6/9/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. During a concurrent interview and record review on 6/17/2025 at 9:44 a.m., RN 3 reviewed Patient 13’s Home Care Visits, dated 5/26/25, 5/29/25, and 6/16/25. RN 3 stated the visit note for 5/26/25 did not have a complete wound assessment of the sacrum, to determine if the wound was improving or worsening. RN 3 reviewed the wound assessment measurements of 5/26/2025, as these were the most recent measurements prior to 6/16/2025. The sacrum wound measurements on 5/26/2025 were: 3.97 cm x 5.03 cm x 1.5 cm. The sacrum wound measurements on 6/16/2025 were 4 cm x 5.5 cm x 2 cm., with undermining at 2.5 cm. RN 3 stated the sacrum wound assessment on 6/16/2025 indicated an increase in size compared to 5/26/2025. RN 3 stated the sacrum wound was not progressing towards the desired goal of healing. When the wound is not progressing, the wound might worsen. The patient might need more interventions such as checking nutritional status to optimize wound healing. If there was signs and symptoms of infection, all these can lead to wound infection and hospitalization. The worse case scenario is that the patient can get sepsis (blood infection that affect the entire body), which can lead to death. During a concurrent interview and record review on 6/17/2025, at 10:00 a.m., RN 3 reviewed Patient 13’s Home Care Visits, dated 5/5/25 and 6/16/25. RN 3 stated the last completed wound assessment with measurements was on 5/5/2025. RN 3 stated the wound measurements to the left leg on 5/5/2025 indicated the wound was 4.25 cm x 1.35 cm x 0.2 cm, with no undermining. The wound measurements to the left leg on 6/16/2025, indicated the wound was 4 cm x 1.0 cm x 0.5 cm, no undermining. RN 3 stated it was hard to determine if the wound was improving or worsening because the size was decreasing, but the depth of the wound was increasing. RN 3 stated an additional wound assessment would be needed to determine if the wound on the left leg was improving or worsening. 3. During a record review of Patient 16’s medical record form titled “Home Health Plan of Care” dated from 5/22/2025 to 7/20/2025, indicated a start of care date of 5/22/2025 with a primary diagnosis of aftercare following joint replacement surgery, encounter for change or removal of surgical wound dressing. The form also indicated Patient 16’s was ordered physical therapy services twice a week for three weeks. During a record review of Patient 16’s medical record form titled “Order” dated 4/29/2025, indicated Patient 16 was referred to Home Health (HH) services for aftercare right total knee arthroplasty on 4/29/2025. The form also indicated under order comments, “Please remove Mepilex dressing at 7-10 days post-op… surgery date 5/21/2025.” Lastly, the form indicated under “Total Joint Care – edema management and surgical site observation.” During a record review of Patient 16’s medical record form titled “Other” dated 5/22/2025, indicated Physical Therapy 1 (PT1) received Patient 16’s physician (MD2) orders for incision management. During a record review of Patient 16’s medical record form titled “PT OASIS Start of Care” dated 5/22/2025, indicated PT1 conducted the visit. The form also indicated under “active wound – wound incision 5/21/25 right knee – surgical incision with dressing.” The form also indicated Patient 16’s primary diagnosis was aftercare following join replacement surgery – encounter for change or removal of surgical wound dressing. Lastly, the form indicated PT1 documented Patient 16’s incision appearance as “R KNEE incision covered by non-removal dressing (Mepilex) which presents as clean and intact.” During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/23/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/27/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 5/29/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT Home Visit” dated 6/3/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a record review of Patient 16’s medical record form titled “PT OASIS Discharge” date 6/5/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact”. During a record review of Patient 16’s Electronic Medical Record (EMR), the EMR did not indicate Patient 16’s right knee incision dressing was removed and assessed/ evaluated by PT1. During a concurrent interview and record review on 6/17/2025 at 9:45 a.m. with RN9 of Patient 16’s EMR, the RN9 stated the main reason Patient 16 was referred to HH services was for the surgical site observation. The RN9 stated she (RN9) was unable to find any documentation Patient 16’s right knee incision site was assessed or observed while receiving home health services. The RN9 stated it was important that Patient 16’s incision site to be assessed to prevent infection, delay in recovery and healing, or complications. A record review of the HHA’s document titled, Care Planning Process, revised 8/2017, indicated “5. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs...16. Missed visit frequency requires a physician verbal order.” 1.During a review of Patient 13’s medical record (in general) indicated, Patient 13’s Start of Care (SOC) date of 9/5/2024, with an admission diagnosis of Pressure Ulcer of Sacral Region, State 4 (wound extending to bone and muscle): During a review of Patient 13’s Plan of Care, for certification period 5/3/2025 to 7/1/2025 indicated a doctor’s order for wound treatment to the sacrum and left leg. Patient 13’s Plan of Care indicated a wound treatment order to a stage 4 sacrum wound with a frequency of wound care treatment twice a week. Patient 13’s Plan of Care indicated wound treatment order for a stage 4 wound on the left leg with a frequency of daily wound care by the SN (skilled nurse)/caregiver. During a concurrent interview and record review on 6/13/2025, at 12:51 p.m., with Registered Nurse 3 (RN 3), RN 3 reviewed Patient 13’s doctor’s order dated 5/5/2025. RN 3 stated Patient 13 was supposed to be visited three times a week for 8 weeks from 5/4/2025 to 6/28/2025 for wound vac change. During a concurrent interview and record review on 6/13/2025 from 4:07 p.m. with RN3, RN3 reviewed Patient 13’s Home Care Visit, dated 5/17/2025. Patient 13’s Home Care Visit indicated, “SN change dressing to both lower leg wound and change wound vac dressing to sacrum. Wounds not heal.” RN 3 stated there was no evidence the nurse provided wound treatment to the sacrum and left leg. RN 3 stated the risk of not assessing the wounds were: not knowing the progress, not knowing if there are signs and symptoms of infection, not knowing if the wound is improving or worsening.” During a concurrent interview and record review on 6/13/2025 at 4:10 p.m., with RN3 RN 3 reviewed Patient 13’s Home Care Visit, dated 5/19/2025. Patient 13’s Home Care Visit indicated, “wound care and wound vac completed as ordered.” RN 3 stated the Home Care Visit did not specify the wound treatment provided, to the specific location. During a concurrent interview and record review on 6/13/2025, at 4:15 p.m., with RN3, RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive 3 visits during the week. Patient 13 was provided with only two visits (5/19/2025 and 5/23/2025). RN 3 stated there was no evidence to explain what happened. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. During a concurrent observation and interview at the home visit on 6/16/2025, at 11:30 a.m., with RN 4, RN 4 proceeded with wound care on Patient 13’s left lateral leg. During a concurrent interview with Caregiver 3 (CGV 3), CGV3 stated some parts of the wound on the left leg were getting better, while other parts of the wound were opening again. CGV 3 stated the wound nurse visited on 5/29/2025 and changed the wound treatment frequency on the left leg from two times a week to one time a week. CGV 3 stated she was doing wound care to the left leg once a week. During an interview at the home visit on 6/16/2025, at 12:00 p.m., with CGV 3, CGV 3 stated, she (CGV3) was concerned on Patient 13’s the wound on the left leg. CGV 3 stated Patient 13’s wound was not getting better. During a review of Patient 13’s doctor’s order, dated 5/29/2025, indicated a change to the wound treatment to the left leg frequency to two times a week. During a concurrent interview and record review on 6/16/2025, at 2:50 p.m., with RN3, RN 3 reviewed Patient 13’s visit notes. RN 3 stated Patient 13 was supposed to receive three visits during the week. Patient 13 was provided with only two visits (5/26/2025 and 5/29/2025). RN 3 stated there was no evidence to explain what happened, or any attempts to reschedule the visit. RN 3 stated this was considered a missed visit and the doctor’s order for wound treatment frequency was not followed. RN 3 stated whenever there is a missed visit, the doctor was supposed to be notified on why the visit was missed and there should have been an attempt to reschedule the visit the same week so that a visit is not missed. During a concurrent interview and record review on 6/16/2025, at 3 p.m., with RN3, RN 3 reviewed Patient 13’s Home Care Visit, dated 5/26/2025. Patient 13’s Home Care Visit indicated, “As per PCG (primary care giver) wound vac stays for 1 day and then start leaking due to urine incontinent.” RN 3 stated there was no mention that another visit was made to check and assess the status of the wound vac. RN 3 stated another visit was needed to make sure the wound vac is working well, and to make sure the wound care treatment is being done correctly. RN 3 stated one of the characteristics to determine if a wound was getting better was the size of the wound: the wound would get smaller. RN 3 continued to review the record and stated there was no mention of the wound on the right gluteal wound. During a concurrent interview and record review on 6/16/2025, at 3:22 p.m., with RN3, RN 3 reviewed Patient 13’s Home Care Visit, dated 6/2/2025. RN 3 stated there was no wound care treatment and measurement for the left leg. During a concurrent interview and record review on 6/16/2025, at 3:29 p.m., with RN3, RN 3 reviewed Patient 13’s Home Care Visit, dated 6/4/2025. RN 3 stated there was no wound treatment to the left leg. During a concurrent interview and record review on 6/16/2025, at 3:31 p.m., with RN3, RN 3 reviewed Patient 13’s Home Care Visit, dated 6/6/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. RN 3 stated she did not know if the wounds on the sacrum and left leg were improving or worsening because there was no information to review. During a concurrent interview and record review on 6/16/2025, at 3:36 p.m., with RN3, RN 3 reviewed Patient 13’s Home Care Visit, dated 6/9/2025. RN 3 stated there was no wound treatment for the sacrum and left leg. During a concurrent interview and record review on 6/17/2025 at 9:44 a.m., with RN3, RN 3 reviewed Patient 13’s Home Care Visits, dated 5/26/25, 5/29/25, and 6/16/25. RN 3 stated the visit note for 5/26/25 did not have a complete wound assessment of the sacrum, to determine if the wound was improving or worsening. RN 3 reviewed the wound assessment measurements of 5/26/2025, as these were the most recent measurements prior to 6/16/2025. The sacrum wound measurements on 5/26/2025 were: 3.97 cm x 5.03 cm x 1.5 cm. The sacrum wound measurements on 6/16/2025 were 4 cm x 5.5 cm x 2 cm., with undermining at 2.5 cm. RN 3 stated the sacrum wound assessment on 6/16/2025 indicated an increase in size compared to 5/26/2025. RN 3 stated the sacrum wound was not progressing towards the desired goal of healing. RN 3 stated, when the wound would not progress, the wound might worsen. RN 3 stated Patient 13 might need more interventions such as checking nutritional status to optimize wound healing. RN3 stated, if there was signs and symptoms of infection, all these can lead to wound infection and hospitalization. RN 3 stated, the worst-case scenario, that Patient 13 could get sepsis (blood infection that affect the entire body), which can lead to death. During a concurrent interview and record review on 6/17/2025, at 10:00 a.m., with RN3, RN3 reviewed Patient 13’s Home Care Visits, dated 5/5/25 and 6/16/25. RN 3 stated the last completed wound assessment with measurements was on 5/5/2025. RN 3 stated the wound measurements to the left leg on 5/5/2025 indicated the wound was 4.25 cm x 1.35 cm x 0.2 cm, with no undermining. RN 3 stated the wound measurements to the left leg on 6/16/2025, indicated the wound was 4 cm x 1.0 cm x 0.5 cm, no undermining. RN 3 stated it was hard to determine if the wound was improving or worsening because the size was decreasing, but the depth of the wound was increasing. RN 3 stated an additional wound assessment would be needed to determine if the wound on the left leg was improving or worsening. 2.During a review of Patient 16’s medical record form titled “Home Health Plan of Care” dated from 5/22/2025 to 7/20/2025, indicated, Patient 16’s start of care date was 5/22/2025 with a primary diagnosis of aftercare following joint replacement surgery, encounter for change or removal of surgical wound dressing. The Home Health Plan of Care form indicated Patient 16’s was ordered for physical therapy services twice a week for three weeks. During a review of Patient 16’s medical record form titled “Order” dated 4/29/2025, indicated Patient 16 was referred to Home Health (HH) services for aftercare right total knee arthroplasty (a surgical procedure where a damaged joint is replaced with an artificial one) on 4/29/2025. The “Order” form indicated under order comments, “Please remove Mepilex dressing at 7-10 days post-op… surgery date 5/21/2025.” The “Order” form indicated under “Total Joint Care – edema management and surgical site observation.” During a review of Patient 16’s medical record form titled “Other” dated 5/22/2025, indicated Physical Therapy 1 (PT1, a healthcare profession focused on improving movement and physical function, managing pain, and preventing or limiting physical disability) received Patient 16’s physician (MD2) orders for incision management. During a review of Patient 16’s medical record form titled “PT OASIS Start of Care” dated 5/22/2025, indicated PT1 conducted the visit. The PT OASIS Start of Care form indicated under “active wound – wound incision 5/21/25 right knee – surgical incision with dressing.” The PT OASIS Start of Care form indicated Patient 16’s primary diagnosis was aftercare following join replacement surgery, encounter for change or removal of surgical wound dressing. The PT OASIS Start of Care form indicated PT1 documented Patient 16’s incision appearance as “R KNEE incision covered by non-removal dressing (Mepilex) which presents as clean and intact.” During a review of Patient 16’s medical record form titled “PT Home Visit” dated 5/23/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact; initial Dressing”. During a review of Patient 16’s medical record form titled “PT Home Visit” dated 5/27/2025, indicated PT1 documented under “Assessment - dressing/Closure Status, Clean/Dry/Intact; initial Dressing”. During a review of Patient 16’s medical record form titled “PT Home Visit” dated 5/29/2025, indicated PT1 documented under “Assessment - dressing/Closure Status, Clean/Dry/Intact; initial Dressing”. During a review of Patient 16’s medical record form titled “PT Home Visit” dated 6/3/2025, indicated PT1 documented under “Assessment - dressing/Closure Status, Clean/Dry/Intact; initial Dressing”. During a review of Patient 16’s medical record form titled “PT OASIS Discharge” date 6/5/2025, indicated PT1 documented under “Assessment - dressing/Closure Status – Clean/Dry/Intact”. During a review of Patient 16’s Electronic Medical Record (EMR), the EMR did not indicate Patient 16’s right knee incision dressing was removed and assessed/ evaluated by PT1. During a concurrent interview and record review on 6/17/2025 at 9:45 a.m., with RN9 of Patient 16’s EMR, the RN9 stated the main reason Patient 16 was referred to HH services was for the surgical site observation. The RN9 stated she (RN9) was unable to find any documentation of Patient 16’s right knee incision site was assessed or observed while receiving home health services. The RN9 stated it was important that Patient 16’s incision site to be assessed to prevent infection, delay in recovery and healing, or complications. 3.During a review of Patient 6’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 6’s a start of care (SOC) date was 3/4/2022, with a diagnosis that included Lymphedema (a condition where lymphatic [circulatory system] fluid builds up in soft tissues, causing swelling, most commonly in the arms or legs). During a review of Patient 6’s Home Health Certification and POC for the certification period starting from 4/17/2025 to 6/15/2025, the Home Health Certification and POC included an order for the skilled nurse (SN) to visit three times a week for two weeks, one visit daily for eight days then re-assess, to assess all body system with emphasis on the patient’s integumentary system (skin) on every visits. One of the nursing interventions was to provide wound care on lymphedema on right lower extremity (RLE, both legs) as follows: cleanse with no-rinse foam pat dry, apply moisturizer on intact skin, wrap RLE with Urgo K2 compression from above the ankle to tibial notch twice weekly (Monday and Thursday). During a joint home visit observation, and an interview on 6/12/2025, at 1:30 p.m., with Registered Nurse 5 (RN 5), Patient 6 was observed sitting on her chair at the dining room with both legs elevated on top of a stool. RN 5 stated Patient 6 had a pitting edema +3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower legs were swollen wrapped with compression wrap. RN 5 did not provide wound care on patient’s RLE lymphedema, she did not remove the compression wrap or assess the lymphedema at right lower leg for any signs and symptoms of any deterioration or skin complications. During a review of Patient 6’s Re-certification Comprehensive Adult Nursing Assessment (OASIS-to determine the need for nursing services) dated 4/17/2025, indicated, under the Skin and Wound Assessment that there was no evidence that the visiting nurse provided treatment for the RLE during the visit. During a review of Patient 6’s Home Care Visit Notes from dates 4/17/2025 to 6/12/2025, there was no evidence the visiting nurse provided wound care at RLE lymphedema as ordered. During an interview on 6/13/2025, at 1 p.m., with RN 9, RN 9 stated RN 5 (conducted a home visit) should have provided care treatment as ordered for Patient 6’s RLE lymphedema during her visit on 6/12/2025. RN 9 stated, Patient 6’s OASIS Recertification Assessment on 4/17/2025, did not indicate the care treatment for Patient 6’s existing lymphedema on right lower extremity was provided during the visit. RN 9 stated there were no evidence in the nursing visit notes that the visiting nurse (in general) provided care treatment for Patient 6’s lymphedema on RLE. RN 9 stated, if wound care was not provided to Patient 6’s lymphedema at RLE, it could get infected and could delay the healing process. During a review of the HHA’s document titled, Care Planning Process, revised 8/2017, indicated “5. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs...16. Missed visit frequency requires a physician verbal order.” During a review of the HHA’s policy and procedure “Verification Of Physician’s Orders and Medication Order Requirement” revised date 8/2022 indicated that orders will be obtained from a licensed physician for care and services to be provided to home health patients.”

“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 interview and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence failed to insure the physician was made aware two of seventeen sampled patients (Patient 6 and Patient 14) had change of conditions. This failure had the potential to result in the physician not being aware the patients are not receiving HHA services, which can result in a delay in care and possibly a decline in their health status. 1.During a review of Patient 6’s document, the document indicated Patient 6’s start of care (SOC) date was 3/4/2022, with an admission diagnosis of lymphedema (an abnormal collection of lymphatics [vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] fluid in the tissues just beneath the skin). During a review of Patient 6’s Home Health Certification and POC for the certification period starting from 4/17/2025 to 6/15/2025, the Home Health Certification and POC included an order for the skilled nurse (SN) to visit three times a week for two weeks, one visit daily for eight days then re-assess, to instruct patient/caregiver on name, dose, frequency, indication, duration of drug therapy and expiration dates. There was a physician’s order included in the POC to administer Furosemide 20 milligrams (mg) oral to take one tab by mouth daily as needed for swelling. During a joint home visit, observation, and interview on 6/12/2025, at 1:30 p.m., with RN 5 at Patient 6’s home, RN 5 stated Patient 6 had a pitting edema plus (+) 3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower leg were swollen wrapped with compression wrap. Patient 6’s medications were checked. There was a bottle of Furosemide 20 milligrams (mg) oral to take one tab by mouth daily as needed for swelling. During an interview with Patient 6 on 6/12/2025, at 2 p.m., Patient 6 stated she was not taking the Furosemide 20 mg medication at all because she gets stomach upset when she took the medication the first time. During an interview with RN 5 on 6/12/2025, at 2:15 p.m., RN 5 stated she was aware Patient 6 was not taking the Furosemide medication in spite of still having swelling on both lower leg. RN 5 also stated she did not notify the physician and the HHA regarding the patient not taking the Furosemide medication as ordered. During an interview on 6/13/2025, at 1 p.m., with RN 9, RN 9 agreed that RN 5 should have notified the physician regarding of Patient 6 not taking the Furosemide medication as ordered for her swollen lower legs. 2. During a record review on 6/11/2025, of Patient 14’s medical record form titled “SN (skilled nurse) OASIS Start of Care” dated 6/7/2025, indicated a start of care date of 6/7/2025 with a primary diagnosis of pressure ulcer (an injury to the skin and underlying tissue caused by prolonged pressure) of unspecified site, unspecified stage. The SN OASIS Start of Care indicated Patient 14 had an unhealed pressure ulcer/injury at Stage 2 (open wound expanding into deeper layers of the skin) or higher. The SN OASIS Start of Care also indicated Patient 14’s vital signs were not assessed due to “PT (patient) fighting”. The form did not indicate Patient 14’s wound was assessed. During a record review on 6/11/2025 of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025, provided on 6/11/2025, indicated a primary diagnosis of pressure ulcer of unspecified site, unspecified stage. The Home Health Plan of Care form did not indicate Patient 14’s wounds were care planned. During a record review of Patient 14’s medical record form titled “Progress Notes” dated 6/6/2025, indicated it was completed by Patient 14’s physician (MD1). The Progress Notes indicated MD1 documented Patient 14 had two wounds on coccyx and left thigh, and an injury to her (Patient 14) right elbow cause by the family when transferring from bed to wheelchair. During a concurrent interview and record review on 6/11/2025 at 2:20 p.m. with the Senior Clinical Practice Nurse (RN9) of Patient 14’s EMR, the RN9 stated Patient 14’s wounds were not assessed on 6/11/2025 during the initial nursing assessment and does not know the reason why the wounds were not assessed. During an interview on 6/12/2025 at 9 a.m. with Registered Nurse 7 (RN7), RN7 she (RN7) was conducting Patient 14’s second home visit since her start of care date of 6/7/2025. The RN7 stated that during Patient 14’s first home visit on 6/7/2025, the admitting nurse (RN1) was unable to assess Patient 14’s wounds because there was no one to assist and because there were no wound supplies available. The RN7 also stated that Patient 14 was receiving home health services due to having a wound on her (Patient 14) left thigh. During a concurrent observation and interview on 6/12/2025 at 9 a.m. at Patient 14’s home joint home visit with RN7 and Registered Nurse 12 (RN12), Patient 14 was observed laying supine in bed and had a dressing on the right outer left elbow. The RN7 stated Patient 14’s left posterior thigh wound was healed. The RN7 removed Patient 14’s right outer elbow dressing and stated it was a new skin tear. Patient 14’s CGV8 and GS requested RN7 to assess Patient 14’s right hand wound. The RN 7 with Patient 14’s GS assistance opened, cleaned with normal saline, and applied a dry dressing on Patient 14’s right hand. The RN7 with the assistance of Patient 14’s daughter (CGV6) turned Patient 14 to assess her back and buttocks. There was redness noted on Patient 14’s left buttocks. The RN7 stated Patient 14’s left buttocks had a Stage I (Un blanchable redden skin) pressure ulcer. The RN7 stated she (RN7) did not measure or take pictures of Patient 14’s right hand, right elbow and left buttocks because pictures and measurements are taken when there is a Stage II or higher, pressure ulcer. During a record review on 6/13/2025, of Patient 14’s medical record form titled “SN Home Visit” dated 6/12/2025, did not indicate Patient 14’s left thigh wound was resolve and a new wound was noted on Patient 14’s left buttocks Stage I. During a record review on 6/13/2025 of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025, provided on 6/13/2025, indicated Patient 14’s left buttocks pressure injury, right elbow tear, and right palm of hand wound care started on 6/12/2025. During a concurrent interview and record review on 6/13/2025 at 3 p.m. with Registered Nurse 12 (RN12) of Patient 14’s Electronic Medical Record (EMR), the RN12 stated the he (RN12) was not able to find a communication note in Patient 14’s EMR that indicates Patient 14’s physician was made aware of Patient 14’s new wounds or that the left hip wound was healed. The RN12 stated Patient 14’s physician needed to be made aware of the new wounds on Patient 14 to be able to decide the medical care needed. The RN12 stated RN7’s nurse home visit dated 6/12/2025 did not indicate she communicated with Patient 14’s physician to inform him/her about Patient 14’s new wounds or that the left hip wound was healed. The RN 12 stated wound orders are needed based on the patients assessment. During a concurrent interview and record review on 6/16/2025 at 3:30 p.m. with the RN9 of Patient 14’s EMR, the RN9 stated Patient 14 had a nursing comprehensive assessment on 6/12/2025 during the joint home visit. The RN9 stated Patient 14’s initial open wound on the left posterior thigh was resolved and three new skin issues were identified by RN7, which included Patient 14’s right hand, right elbow, and left buttocks. The RN9 also stated that there was no documentation that Patient 14’s physician was notified and informed of the three new skin issues and the healed left posterior thigh wound. The RN9 stated Patient 14’s physician needed to be made aware of Patient 14’s change of condition to be able to order the appropriate treatment. A record review of the HHA’s document titled, Ongoing Assessments, revised on 4/2021, indicated, “1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial and subsequent visits...E. Based on each reassessment, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the clinician. Change in condition will be reported to the physician.” 1.During a review of Patient 6’s document, the document indicated Patient 6’s start of care (SOC) date was 3/4/2022, with an admission diagnosis of lymphedema (an abnormal collection of lymphatics [vessels and tissues that protect you from infection and keep a healthy balance of fluids throughout your body] fluid in the tissues just beneath the skin). During a review of Patient 6’s Home Health Certification and POC for the certification period starting from 4/17/2025 to 6/15/2025, the Home Health Certification and POC included an order for the skilled nurse (SN) to visit three times a week for two weeks, one visit daily for eight days then re-assess, to instruct patient/caregiver on name, dose, frequency, indication, duration of drug therapy and expiration dates. There was a physician’s order included in the POC to administer Furosemide 20 milligrams (mg) oral to take one tab by mouth daily as needed for swelling. During a joint home visit, observation, and interview on 6/12/2025, at 1:30 p.m., with RN 5 at Patient 6’s home, RN 5 stated Patient 6 had a pitting edema plus (+) 3 (moderate to severe degree of swelling where indentation remains after pressing on swollen area) at right foot and both lower leg were swollen wrapped with compression wrap. Patient 6’s medications were checked. There was a bottle of Furosemide 20 milligrams (mg) oral to take one tab by mouth daily as needed for swelling. During an interview with Patient 6 on 6/12/2025, at 2 p.m., Patient 6 stated she was not taking the Furosemide 20 mg medication at all because she gets stomach upset when she took the medication the first time. During an interview with RN 5 on 6/12/2025, at 2:15 p.m., RN 5 stated she was aware Patient 6 was not taking the Furosemide medication in spite of still having swelling on both lower leg. RN 5 also stated she did not notify the physician and the HHA regarding the patient not taking the Furosemide medication as ordered. During an interview on 6/13/2025, at 1 p.m., with RN 9, RN 9 agreed that RN 5 should have notified the physician regarding of Patient 6 not taking the Furosemide medication as ordered for her swollen lower legs. 2. During a record review on 6/11/2025, of Patient 14’s medical record form titled “SN (skilled nurse) OASIS Start of Care” dated 6/7/2025, indicated a start of care date of 6/7/2025 with a primary diagnosis of pressure ulcer (an injury to the skin and underlying tissue caused by prolonged pressure) of unspecified site, unspecified stage. The SN OASIS Start of Care indicated Patient 14 had an unhealed pressure ulcer/injury at Stage 2 (open wound expanding into deeper layers of the skin) or higher. The SN OASIS Start of Care also indicated Patient 14’s vital signs were not assessed due to “PT (patient) fighting”. The form did not indicate Patient 14’s wound was assessed. During a record review on 6/11/2025 of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025, provided on 6/11/2025, indicated a primary diagnosis of pressure ulcer of unspecified site, unspecified stage. The Home Health Plan of Care form did not indicate Patient 14’s wounds were care planned. During a record review of Patient 14’s medical record form titled “Progress Notes” dated 6/6/2025, indicated it was completed by Patient 14’s physician (MD1). The Progress Notes indicated MD1 documented Patient 14 had two wounds on coccyx and left thigh, and an injury to her (Patient 14) right elbow cause by the family when transferring from bed to wheelchair. During a concurrent interview and record review on 6/11/2025 at 2:20 p.m. with the Senior Clinical Practice Nurse (RN9) of Patient 14’s EMR, the RN9 stated Patient 14’s wounds were not assessed on 6/11/2025 during the initial nursing assessment and does not know the reason why the wounds were not assessed. During an interview on 6/12/2025 at 9 a.m. with Registered Nurse 7 (RN7), RN7 she (RN7) was conducting Patient 14’s second home visit since her start of care date of 6/7/2025. The RN7 stated that during Patient 14’s first home visit on 6/7/2025, the admitting nurse (RN1) was unable to assess Patient 14’s wounds because there was no one to assist and because there were no wound supplies available. The RN7 also stated that Patient 14 was receiving home health services due to having a wound on her (Patient 14) left thigh. During a concurrent observation and interview on 6/12/2025 at 9 a.m. at Patient 14’s home joint home visit with RN7 and Registered Nurse 12 (RN12), Patient 14 was observed laying supine in bed and had a dressing on the right outer left elbow. The RN7 stated Patient 14’s left posterior thigh wound was healed. The RN7 removed Patient 14’s right outer elbow dressing and stated it was a new skin tear. Patient 14’s CGV8 and GS requested RN7 to assess Patient 14’s right hand wound. The RN 7 with Patient 14’s GS assistance opened, cleaned with normal saline, and applied a dry dressing on Patient 14’s right hand. The RN7 with the assistance of Patient 14’s daughter (CGV6) turned Patient 14 to assess her back and buttocks. There was redness noted on Patient 14’s left buttocks. The RN7 stated Patient 14’s left buttocks had a Stage I (Un blanchable redden skin) pressure ulcer. The RN7 stated she (RN7) did not measure or take pictures of Patient 14’s right hand, right elbow and left buttocks because pictures and measurements are taken when there is a Stage II or higher, pressure ulcer. During a record review on 6/13/2025, of Patient 14’s medical record form titled “SN Home Visit” dated 6/12/2025, did not indicate Patient 14’s left thigh wound was resolve and a new wound was noted on Patient 14’s left buttocks Stage I. During a record review on 6/13/2025 of Patient 14’s medical record form titled “Home Health Plan of Care” dated from 6/7/2025 to 8/5/2025, provided on 6/13/2025, indicated Patient 14’s left buttocks pressure injury, right elbow tear, and right palm of hand wound care started on 6/12/2025. During a concurrent interview and record review on 6/13/2025 at 3 p.m. with Registered Nurse 12 (RN12) of Patient 14’s Electronic Medical Record (EMR), the RN12 stated the he (RN12) was not able to find a communication note in Patient 14’s EMR that indicates Patient 14’s physician was made aware of Patient 14’s new wounds or that the left hip wound was healed. The RN12 stated Patient 14’s physician needed to be made aware of the new wounds on Patient 14 to be able to decide the medical care needed. The RN12 stated RN7’s nurse home visit dated 6/12/2025 did not indicate she communicated with Patient 14’s physician to inform him/her about Patient 14’s new wounds or that the left hip wound was healed. The RN 12 stated wound orders are needed based on the patients assessment. During a concurrent interview and record review on 6/16/2025 at 3:30 p.m. with the RN9 of Patient 14’s EMR, the RN9 stated Patient 14 had a nursing comprehensive assessment on 6/12/2025 during the joint home visit. The RN9 stated Patient 14’s initial open wound on the left posterior thigh was resolved and three new skin issues were identified by RN7, which included Patient 14’s right hand, right elbow, and left buttocks. The RN9 also stated that there was no documentation that Patient 14’s physician was notified and informed of the three new skin issues and the healed left posterior thigh wound. The RN9 stated Patient 14’s physician needed to be made aware of Patient 14’s change of condition to be able to order the appropriate treatment. A record review of the HHA’s document titled, Ongoing Assessments, revised on 4/2021, indicated, “1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial and subsequent visits...E. Based on each reassessment, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the clinician. Change in condition will be reported to the physician.””

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to coordinate the services needed for one of seventeen sampled patients (Patient 10). This deficient practice resulted in delay of care and health goals. A record review of Patient 10’s documents indicated an SOC of 6/8/2025, with a diagnosis of Acute Kidney Failure. A record review of Patient 10’s POC, dated 6/8/2025 to 8/6/2025 indicated daily skilled nurse visits for 6 days for IV (intravenous-a type of infusion through the vein by means of a tube called catheter) infusion of fluids. Patient 10 was to receive 1000 ml (milliliters, unit of measurement) of Sodium Chloride (a type of electrolyte replenisher) daily. During an interview at the home visit on 6/12/2025, at 11:10 p.m., Registered Nurse 2 (RN 2) stated Patient 10 was in the Advanced Medical Care at Home program (AMCAH), for patients who need more care and more monitoring, as these patients were at higher risk of hospitalization. During an interview at the home visit on 6/12/2025, at 11:40 a.m. Patient 10 stated she was having issues receiving her IV fluids because her IV site was not working well. Patient 10 stated she was going to be having a midline catheter (a bigger vein is used to deliver fluids) inserted on 6/12/2025 by another agency, coordinated by the HHA, at her home. Patient 10 stated she was waiting for a call to know what time the midline catheter would be placed. Patient 10 stated issues with the IV catheter began on 6/8/2025. Patient 10 stated the following: On 6/8/2025, due to IV issues, she received “very little” infusion. On 6/9/2025, due to IV issues, she received “little” infusion. On 6/12/2025, she only received 250 ml. During an interview on 6/12/2025, at 3:32 p.m., Registered Nurse 3 (RN 3) stated the order for a midline catheter was placed on 6/11/2025. During a concurrent interview and record review on 6/12/2025, at 3:50 p.m., RN 3 reviewed Patient 10’s laboratory results. RN 3 stated Patient 10 was still dehydrated and was in need of the IV fluid infusion. During an interview on 6/17/2025, at 1:00 p.m. RN 3 stated Patient 10 got her midline catheter placed on 6/13/2025. RN 3 stated the AMCAH doctor had arranged it. RN 3 stated the HHA did not know what happened, but the vendor was unable to go to place the midline catheter until 6/13/2025. RN 3 stated Patient 10 missed her IV infusion on 6/12/2025. RN 3 stated there was no documentation that the HHA was communicating with the vendor to ensure Patient 10 got her midline catheter placed. During an interview on 6/17/2025, at 1:07 p.m., Registered Nurse 9 (RN 9) stated Patient 10 waited for 2 days to get the midline catheter placed and this was unacceptable. During an interview on 6/17/2025, at 1:07 p.m. RN 3 stated Patient 10’s medical condition required IV infusion. Patient 10’s labs were unstable. With Crohn’s disease (a condition that cause inflammation and other symptoms in the digestive system), it placed Patient 10 at higher risk of health status decline and complications. The worsening condition of her kidney failure and dehydration, placed Patient 10 at risk for hospitalization. During an interview on 6/17/2025, at 1:55 p.m., RN 9 stated Patient 10 was hospitalized on 6/17/2025 for chest pain. A record review of the HHA’s document titled, Care Coordination, revised on 9/2023, indicated, “Policy...Timely and ongoing communication is the responsibility of each team member...Written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient’s clinical records...5. All organization personnel involved in patient care, including those providing contracted services, will have access to the plan of care and all other relevant patient information to ensure coordination and continuity of care. All personnel will be knowledgeable regarding patient needs, goals of care and services.””

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to provide educations regarding the care they received to patients and/or family members/caregivers for three of seventeen sample patients (Patient 13, Patient 15 and Patient 17). These failures had the potential to result in patients and their family/caregiver not providing care and treatment correctly which could lead to complication. 1. During a review of Patient 13’s medical record indicated Patient 13 had a start of care on 9/5/2024, with an admission diagnosis of Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) of sacral region (right above tailbone). During an home visit observation on 6/16/2025, at 10:20 a.m., at Patient 13’s home, Registered Nurse 4 (RN 4) assessed Patient 13’s G-tube (gastrostomy tube: a tube inserted through the belly to deliver food, fluids, and medicine to the stomach). During a concurrent observation on 6/16/2025, at 11:05 a.m., at Patient 13’s home, RN 4 interviewed Caregiver 3 (CGV 3). RN 4 asked CGV 3 if the nurses had told CGV 3 regarding situations such as signs and symptoms of infection that required a notification to doctor, CGV 3 stated, “They haven’t done anything like that”. During an interview with CGV 3 on 6/16/2025, at 11:55 a.m., at Patient 13’s home, CGV 3 stated “nobody” had instructed her on how often to change the G-tube dressing (a type of bandage). CGV 3 stated Patient 13 was hospitalized in August 2024 for aspiration pneumonia (an infection in the lungs as a result of food, fluids entering the lungs) because the previous caregiver did not position her correctly when giving her water. During a concurrent interview and record review on 6/16/2025, at 12:00 p.m., Registered Nurse 3 (RN 3) reviewed Patient 13’s HHA folder (a series of documents given to patients such as copies of bill of rights, consents, schedules, plan of care, education, and so forth). RN 3 reviewed the documents in the folder and stated that there was no written educational materials for G-tube care, wound care, aspiration precautions, and medications. 2. During a record review of Patient 15’s medical record form titled “SN (skilled nurse) OASIS Recertification” dated 5/21/2025, indicated Patient 15 had a SOC date of 1/22/2025 with a primary diagnosis of acute on chronic systolic (congestive) heart failure (CHF - a condition where the heart does not function properly causing edema). The SN OASIS Recertification indicated Patient 15 had a single lumen PICC (peripherally inserted central catheter – a thin flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest) line on Patient 15’s right upper arm. The SN OASIS Recertification indicated Patient 15 complained of back pain rated 4 out of 10, and the worst pain was at 8. The SN OASIS Recertification indicated Patient 15 was on fluid restriction and had edema +2 (slight indentation, which is considered a moderate level of pitting edema) to bilateral lower extremities. The SN OASIS Recertification indicated Patient 15 was using oxygen at 3 liters per minute via a nasal cannula. During a review of Patient 15’s medical record titled “Progress Notes”, dated 5/13/2025, indicated Patient 15’s had BLE (bilateral lower extremities) swelling and was on fluid restrictions. During a review of Patient 15’s medical record titled “Medication Detail”, dated 6/3/2025, indicated Patient 15 was prescribed Heparin (medication to prevent blood clots) Porcine, with a start date of 6/3/2025. During a review of Patient 15’s medical record titled “Home Health Plan of Care – Recertification”, from 5/22/2025 to 7/20/2025, indicated Bumex (medication to treat edema) by mouth and Heparin were not listed under “Medications”. The Home Health Plan of Care Recertification indicated Patient 15’s fluid restriction, edema, oxygen use, or pain were not documented or care planned. The Home Health Plan of Care Recertification did not indicate Patient 15 and/or family members/caregivers were provided education on signs and symptoms of adverse reactions to Heparin, Bumex, or PICC line, edema, fluid restrictions, oxygen use, or pain management. During a concurrent interview and record review on 6/11/2025 at 4:30 p.m. with Registered Nurse 9 (RN9) and a review of Patient 15’s Electronic Medical Record (EMR), the RN9 stated there was no care plan for Patient 15’s BLE edema, pain, oxygen use, and fluid restrictions. RN9 stated that Patient 15 and his family members/caregivers should be educated on Patient 15’s treatment plan to prevent complications, for example, fluid overload and safe way to store and use oxygen. RN9 stated Patient 15 and Patient 15’s family caregivers should be educated when to send Patient 15 to the hospital or call his doctor. During a concurrent interview and record review on 6/12/2025 at 1:18 p.m. with Registered Nurse 12 (RN12) and a review of Patient 15’s EMR, RN12 stated Patient 15’s care plan did not indicate Patient 15 was taking Bumex by mouth and Heparin. RN12 stated Patient 15 and his family members/caregivers should be educated on the risk associated with taking Heparin, for example, bleeding and bruising. RN12 stated that Patient 15 was using oxygen due to having CHF and this was not care planned. RN12 stated Patient 15 and his family members/caregivers should be educated on how to manage the oxygen in their home. 3. During a review of Patient 17’s medical record form titled “SN OASIS Recertification” dated 5/13/2025, indicated a SOC date of 1/26/2023 with a primary diagnosis of pressure ulcer of sacral region, Stage 3 (a full thickness tissue loss that breaks through the skin and into the fatty tissue below). During a review of Patient 17’s medical record titled “Home Health Plan of Care -Recertification”, from 5/15/2025 to 7/13/2025, The Home Health Plan of Care -Recertification indicated Patient 17 had a primary diagnosis of pressure ulcer of sacral region, Stage 3. The Home Health Plan of Care did not indicate Patient 17’s treatment order under section “Medications”. The Home Health Plan of Care did not indicate Patient 17, or the family/caregivers were educated on how to manage Patient 17’s sacral wound. During a concurrent interview and record review on 6/12/2025 at 1:55 p.m. with RN12 and a review of Patient 17’s EMR, RN12 stated Patient 17’s plan of care did not indicate Patient 17’s family/caregivers were educated on how to manage Patient 17’s sacral wound. The RN12 stated family/caregivers’ education should have consisted of how and when to change the wound dressing and the signs or symptoms of complications to prevent worsening of the pressure wound. During a review of the HHA’s document titled “Care Planning Process”, revised on 8/2017, indicated, “3. Based on the assessment and conclusions, the plan of care will include, but not limited to...N. Patient and caregiver education and training to facilitate timely discharge.””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure written information regarding the visit schedule was provided to one of seventeen sampled patients (Patient 13). This failure had the potential to result in patients’ confusion about the plan of care that could affect their quality of life. During a review of Patient 13’s medical record indicated Patient 13 had a start of care (SOC) on 9/5/2024, with an admission diagnosis of Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) of sacral region (right above tailbone). During an interview with Caregiver 3 (CGV 3) on 6/16/2025, at 10:15 a.m., at Patient 13’s home, CGV 3 stated she was expecting a nursing visit on 6/13/2025 for Patient 13’s wound care. CGV 3 stated she was waiting all day for the nurse, not knowing what time the nurse would arrive. CGV 3 stated she did the wound care because the nurse did not come. During an interview with CGV 3 on 6/16/2025, at 10:30 a.m., at Patient 13’s home, CGV 3 stated there had been missed nursing visits. CGV 3 stated she sometimes waited all day for the nurse to come. CGV 3 stated there was no consistent schedule and CGV 3 was not told when the nurse would come. During an interview with CGV 3 on 6/16/2025, at 12:00 p.m., at Patient 13’s home, CGV 3 stated she and Patient 13 was not informed whether there was a change of visit schedule. CGV 3 stated she did not have a written schedule of nurse visits. During a concurrent interview and record review on 6/16/2025, at 12:00 p.m., with Registered Nurse 3 (RN 3) and a review of Patient 13’s HHA folder (a series of documents given to patients such as copies of bill of rights, consent, schedules, plan of care, education, and so forth). A visit calendar was inside the folder, labeled 2024. RN 3 stated the last time the Plan of Care was printed and placed in the folder was for the first certification period in 2024. During a review of the HHA’s document titled “Care Planning Process”, revised on 8/2017, indicated, “3. Based on the assessment and conclusions, the plan of care will include, but not limited to...D. Type, frequency, and duration of visits to be made. 7. The patient will be provided with written information to include...A. Visit schedule, including frequency of visits by HH agency personnel.””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure written information regarding the patient’s medication regime was up to date for one of seventeen sampled patients (Patient 15). This deficient practice had the potential to increase the risk of medication errors, unnecessary medications, and delayed identification of adverse drug reactions, which could adversely affect the health and safety of Patient 15. During a review of Patient 15’s medical record titled “SN (skilled nurse) OASIS Recertification”, dated 5/21/2025, indicated Patient 15 had a start of care date on 1/22/2025, with a primary diagnosis of acute on chronic systolic (congestive) heart failure (CHF - a condition where the heart does not function properly causing edema). During a review of Patient 15’s medical record titled “Home Health Plan of Care – Recertification”, from 5/22/2025 to 7/20/2025, indicated Patient 15 was prescribed Heparin (medication to prevent blood clots) Porcine 1 mL (milliliter – unit of measure) subcutaneously (under all the skin layers) every 8 hours. The Home Health Plan of Care Recertification did not indicate Patient 15 and/or family/caregiver were provided education on Heparin administration and precautions. During a review of Patient 15’s medical record titled “Medication Detail”, dated 6/3/2025, indicated Patient 15 was prescribed Heparin, with a start date of 6/3/2025. During a review of Patient 15’s medical record form titled “Active Medication (AM)”, dated 5/21/2025 and printed for review on 6/11/2025, the AM did not indicate Heparin was listed. During a concurrent observation and interview on 6/12/2025 at 10:25 a.m. with Registered Nurse 7 (RN7) and Registered Nurse 12 (RN12) at Patient 15’s home, RN7 completed a medication review/reconciliation (a formal process to ensure medication are complete, accurate and suitable). Patient 15 stated he injected Heparin every 8 hours. During a concurrent interview and record review on 6/12/2025 at 1:18 p.m. with RN12 and a review of Patient 15’s EMR, RN12 stated Patient 15’s medications should be listed to ensure Patient 15 were taking the medications correctly and being treated properly. RN12 stated, if medications were not taken as prescribed there could be interactions, subtherapeutic effects that could cause exacerbation or drug reactions. RN12 stated, Patient 15’s Heparin was not listed on Patient 15’s Active Medication list. RN12 stated, Patient 15’s Heparin should be listed because it was part of Patient 15’s treatment plan and it needed to be managed and monitored by the home health team to ensure it was used therapeutically and safely. During a concurrent interview and record review on 6/16/2025 at 3:45 p.m. with Registered Nurse 9 (RN9) and a review of Patient 15’s EMR, RN9 stated Patient 15’s active medication list needed to be updated for safety reasons. RN9 stated an accurate medication patient list was one of the national medication safety goals. During a review of the HHA’s document titled “Care Planning Process”, revised on 8/2017, indicated, “3. Based on the assessment and conclusions, the plan of care will include, but not limited to...J. All medications and treatments. N. Patient and caregiver education and training to facilitate timely discharge...7. The patient will be provided with written information to include...B. Patient medication schedule/detailed instructions, including who administers the medication.””

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure nursing services were under the supervision of a registered nurse for one of seventeen sample patients (Patient 13). This deficient practice had the potential to result in negative or harmful outcomes if the care provided unsupervised. During a review of Patient 13’s document indicated Patient 13 had a start of care (SOC) on 9/5/2024, with an admission diagnosis of Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone) of sacral region (right above tailbone). During an interview conducted during the home visit on 6/16/2025, at 10:15 a.m., Caregiver 3 (CGV 3) stated the nurses who had been visiting Patient 13 did not know how to do the wound care. CGV 3 stated she had to show the nurses how to do the wound care. During a concurrent interview and record review on 6/16/2025, at 3:46 p.m. with Registered Nurse 3 (RN 3) and a review of Patient 13’s medical records. RN 3 stated Patient 13 was under care of Licensed Vocational Nurses (LVN) for 4 visits. RN 3 stated the HHA did not document supervisory visits and there was no documentation on who was supervising. RN 3 stated the HHA was compliant with the regulation by scheduling RNs to visit the patient after each LVN visit. During a review Patient 13’s medical record on 6/13/2025 from 3:14 p.m. to 4:15 p.m., Patient 13’s Home Care visits for certification period from 5/3/2025 to 7/1/2025 were reviewed with RN 3. The documents indicated there was no wound assessments, wound treatments, and/or new wounds documented.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interviews and record review the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to ensure clinical records that accurately reflect the cares for three of seventeen sampled patients (Patient 1, Patient 3, and Patient 4). This failure resulted in incomplete patients’ clinical records. 1. During a review of Patient 1’s electronic medical record (EMR), the EMR indicated Patient 1 had a start of care (SOC) on 3/6/2025, with an admission diagnosis of unspecified open wound of left foot. During a concurrent interview and record review on 6/12/2025 at 11:10 a.m. with QA (Quality Assurance)/Licensed Vocational Nurse 1(LVN 1) and a review of Patient 1’s SN (skilled nursing) visit note, dated 5/24/2025 and 5/27/2025, indicated, there was description if the wound had odor or not in wound care assessment. The QA stated, “it is very important to document whether there is an odor from the wound or not, because it can indicate infection. There is no documentation for odor of the wound on 5/24/2025 and 5/27/2025 for Patient 1.” 2. During a review of Patient 3’s EMR indicated Patient 3 had a SOC on 3/25/2025, with an admission diagnosis of pressure ulcer (a break in the skin caused by continues pressure to a body part) of other site, stage 3 (a characterized by full thickness skin loss, where the damage extends into the subcutaneous tissue, but not to underlying muscle, bone, or tendon). During a concurrent interview and record review on 6/13/2025 at 3:50 p.m. with RN 9 and a review of Patient 3’s wound flow sheet (WFS) from 3/25/2025 to 6/7/2025, the WFS dated 5/15/2025 missed the secondary dressing and dressing securement. RN 9 stated, “for 5/15/2025 the wound care documentation for patient 3, the section for secondary dressing and dressing securement is missing. This is important because if the charting is incomplete there is no way of knowing if the doctor’s orders are followed.” 3. During a review of Patient 4’s EMR, indicated Patient 4 had a SOC on 4/15/2025 with an admission diagnosis of unspecified open wound of lower left leg. During a concurrent interview and record review on 6/13/2025 at 3:05 p.m. with QA/LNV 1 and a review of Patient 4’s WFS from 5/8/2025 to 6/9/2025, the WFS dated 5/26/2025 missed the primary dressing. The WFS dated 5/30/2025 missed peri wound care. The WFS dated 6/2/2025 missed peri wound care. The WFS dated 6/4/2025 missed peri wound care. The WFS dated 6/6/2025 missed primary dressing. The QA/LVN 1 stated, “There are missing fields on the wound assessment for Patient 4 on those dates. It is incomplete. It is important to complete all the fields for comparison for the next assessment. Because some fields are missing in the wound care, we are unable to determine if the correct doctor’s orders are followed.” During an interview on 6/16/2025 at 3:00 p.m. with Director of Patient Care Services (DPCS), the DPCS stated, “all wound care assessment and treatment documentation needs to be completed. If there are missing fields, there is no way of knowing if all steps of the wound care and assessment were followed.” During a review of the HHA’s document titled “Entries into the Clinical Record”, revised on 12/2023, indicated, “1. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum...E. Dates, times, and types of interventions, assessments, and coordination of care.””

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA - a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s place of residence) failed to include information required in the medical record to reflect the care for one of seventeen sampled patients (Patient 14). The HHA failed to document Patient 14’s Stage I pressure ulcer of the left buttock. a. This failure had the potential to result in Patient 14 not receiving the identified needs and services causing a decline in health status that could affect their quality of care and well-being. During a review of Patient 14’s medical record titled “Progress Notes”, dated 6/6/2025, indicated Medical Doctor 1 (MD1) was Patient 14’s primary doctor who completed the progress notes. MD1 documented that Patient 14 had the following skin issues: two wounds on coccyx (tailbone, located at bottom of the spine). During a review of Patient 14’s medical record titled “SN (skilled nurse) OASIS Start of Care”, dated 6/7/2025, indicated Registered Nurse 1 (RN1) completed and signed the SN OASIS Start of Care form. The SN OASIS Start of Care form indicated Patient 14 had an unhealed pressure ulcer/injury at Stage 2 (open wound expanding into deeper layers of the skin) or higher. The SN OASIS Start of Care form did not indicate where Patient 14’s wound was. The SN OASIS Start of Care form indicated RN1 was unable to visualize Patient 14’s wound and did not indicate the reason as to why Patient 14’s wound was unable to be visualized. The SN OASIS Start of Care form indicated Patient 14 had a primary diagnosis of pressure ulcer of unspecified site, unspecified stage. During a record review of Patient 14’s Electronic Medical Record (EMR), on 6/11/2025, the EMR did not indicate Patient 14 had a wound assessment. During a concurrent interview and record review on 6/11/2025 at 2:20 p.m. with the Senior Clinical Practice Nurse (RN9) and review of Patient 14’s EMR, the RN9 stated Patient 14’s wound was not assessed on 6/11/2025 during the initial nursing assessment and does not know the reason why the wound was not assessed. During a concurrent observation and interview on 6/12/2025 at 9 a.m. with Registered Nurse 5 (RN5) and Registered Nurse 12 (RN12) at Patient 14’s home, Patient 14 was noted laying supine on a hospital bed. The RN 5 assessed Patient 14 with the assistance of Patient 14’s grandson (GS) and daughter (CVG6). Patient 14 was noted to have two red pressure marks on her left buttocks. The RN5 stated that pictures of wound pictures and measurements were required when a wound was a Stage 2 or higher. During a concurrent interview and record review on 6/12/2025 at 12:35 p.m. with Registered Nurse 12 (RN12) and a review of Patient 14’s EMR, RN12 stated Patient 14’s EMR did not indicate any identified wound. RN12 stated that Patient 14’s primary reason for home health admission was Patient 14’s wound. RN12 stated Patent 14’s wound should have been assessed and documented, interventions and goals identified should be documented. The RN12 stated visiting notes should be documented in the patients EMR within 24 hours of the actual home visit. During a review of Patient 14’s medical record titled “SN Home Visit”, dated 6/12/2025, the SN Home Visit did not indicated Patient 14’s two red marks on her (Patient 14) left buttocks were documented. During a concurrent interview and record review on 6/13/2025 at 3 p.m. with RN12 and a review of Patient 14’s nursing home visit note dated 6/12/2025. RN12 stated Patient 14’s wounds were not assessed during the home visit on 6/12/2025. RN12 stated that it was important to do a complete wound assessment on each wound to determine if the wounds were improving or deteriorating. RN12 stated that when a wound assessment is not done the possible outcomes could be deterioration of the wound which can lead to infection. During a concurrent interview and record review on 6/16/2025 at 3:30 p.m. with the RN9 and a review of Patient 14’s nursing comprehensive assessment dated 6/12/2025, RN9 stated there were three new skin issues identified by Registered Nurse 7 (RN7) including the two on Patient 14’s left buttocks. RN9 stated RN7’s wound assessment was not completed on 6/12/2025 because there were no measurements or pictures taken of the new skin issues. RN9 stated that it was important to perform a complete assessment to have a baseline of wound and follow the progress or deterioration. During a review of the HHA’s document titled “Entries into the Clinical Record”, revised on 12/2023, indicated, “3. Entries into the clinical record will be clear, concise, and specific statements of fact.””