Heralds Home Health

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA, a public or private organization that provides skilled nursing, therapeutic services, such as physical or occupational therapy, and aide services to patients in their place of residence), failed to accurately complete OASIS, data Outcome and Assessment Information Set, (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) were completed and submitted to the CMS system for all Medicare patients, Medicaid patients, and patients utilizing any federally funded health plan options that are part of the Medicare program for six hundred thirty seven of one thousand nine hundred eighty five OASIS patients’ data collection) elements related to the patient’s integumentary status and history of injury for one of nine sampled patients (Patient 16). This deficient practice resulted in Patient 16’s OASIS assessment not accurately reflect the patient’s current clinical status. Findings: During a review of Patient 16’s Start of Care OASIS assessment, dated 1/19/2026, the OASIS indicated Patient 16’s integumentary status had no current skin lesions, wounds, or injuries present. During a joint home visit conducted at Patient 16’s residents on 1/28/2026, at 12:30 p.m., with the Licensed Vocational Nurse 1 (LVN1), and concurrent observation and interview at Patient 16’s residence, with LVN 1 and Caregiver 1 (CG 1), Patient 16 was observed to have a large healing scab present on the left lateral knee (side of knee). CG 1 stated the scab resulted from a fall that occurred 3 weeks ago. During a review of Patient 16’s skilled nurse (SN) visit note, dated 1/28/2025, the visit note indicated that LVN 1 documented, “left lateral left knee was noted to have some scabbing. During an interview on 1/28/2026 at 12:30 pm., with SN, SN asked Patient 16 and Patient 16’s caregiver what had happened. Both Patient 16 and caregiver stated “this was from a fall that happened about three weeks ago.” During a concurrent interview and a record review with the Director of Patient Care Services (DPCS) on 1/29/2026, at 1:00 p.m., Patient 16’s OASIS was reviewed. The DPCS stated there was no scab or skin injury was documented for Patient 16 on the OASIS assessment. The DPCS stated, “I don’t see the left lateral knee scab listed on the initial OASIS for Patient 16. There was no image uploaded of the scab on the OASIS date either. The DPCS stated that she (DPCS could not see an image uploaded from yesterday’s home visit and documentation by LVN 1 nurse visit note summary, also from yesterday, regarding the scab indicating that the patient and caregiver stated the scab resulted from a fall three weeks ago. The DPCS stated “this was missed by the initial OASIS nurse. It is important to have accurate documentation on the initial assessment because the initial assessment guides the patient care and accurately reflect the patients current status.” During a review of the agency’s policy and procedure, titled “Initial and Comprehensive Assessment”, dated 4/2021, the policy and procedure indicated, “The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs. The assessment will also include the exact use of the current versions of the Outcomes and Assessment Information Set (OASIS). This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter:...””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, 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 infection control practices were implemented for one of nine sampled patients (Patient 19), by the skilled nurse while providing wound care. This failure had the potential to result in cross contamination and jeopardize the health and safety of the patients. Findings: During a review of Patient 19’s “Plan of Care” dated 12/27/2025 to 2/24/2026, indicated Patient 19’s start of care date was 8/29/2025 with a diagnosis of pressure ulcer to the sacral region (wound on the tailbone caused by prolonged pressure, friction, or shear, commonly affecting immobilized or seated patients), stage two (wound extends into the bottom layers of the skin). The “Plan of Care” indicated wound care to the sacral/coccyx (triangular, fused bony structures located at the very base of the spine, connecting to the pelvis to provide support and stability) and caregiver to perform daily wound care on day skilled nurse is not present. During a joint home visit, on 1/28/2026 at 10:30 a.m., with the Licensed Vocational Nurse (LVN 2) at Patient 19’s residence. Patient 19 was observed lying down in the bedroom with caregiver present at bedside. LVN 2 was observed performing wound care to Patient 19’s coccyx and did not change gloves after removing the old dressing. During an interview on 1/29/2026 at 11:40 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that during wound care, skilled nurses should change gloves after the removal of the dirty dressing. DPCS stated that it is important to change gloves after removing the dirty dressing to prevent infection control. During a record review of the agency’s policy and procedure, titled “Standard Precautions” revised 4/2021, the policy and procedure indicated, that gloves are to be changed: 1. Between tasks and procedures on the same patient 2. During changing or cleaning an incontinent patient 3. After removing an old dressing 4. When the integrity of the glove is in doubt”

“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 observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that provides skilled nursing, therapeutic services, such as physical or occupational therapy, and aide services to patients in their place of residence) failed to review and document medications and treatments that were currently prescribed for two of nine sampled patients (Patient 16 and Patient 19). This failure had the potential to place the patients at risk of drug-to-drug interaction and declination of health conditions. a.During a record review of Patient 16’s Patient Profile sheet indicated a start of care date of 1/19/2026, with diagnoses including Diabetes mellitus without complications (a Chronic metabolic disorder characterized by high blood sugar due to insulin resistance). During a review of Patient 16’s “Plan of Care (POC, a mandatory, written, and patient-specific document that outlines necessary medical, rehabilitative, and supportive services to treat an injury or illness at home)”, dated 1/19/2026 to 3/19/2026, the POC indicated SN to instruct the patient/caregiver on medication regimen dose, indications, side effects, and interactions. During a concurrent interview and record review on 1/28/2026 at 12:35 pm with Licensed Vocational Nurse 1 (LVN 1), at Patient 16’s residence, LVN 1 reviewed the medication Patient 16 was taking using record titled, Medication Profile, dated 1/19/2026. LVN 1 stated the following medications were at home, patient reported taking, but was not listed: -Amlodipine Besylate 5mg (a medication to reduce blood pressure) take one tablet by mouth daily at bedtime. -Seroquel 25mg (Medication which is primarily used to treat bipolar disorder) take one tablet twice daily as needed for agitation. LVN 1 stated, “this was missed by the initial nurse. Medication reconciliation needs to be done on every visit by nurses. This is very important so we can keep track of all the current medications the patient has and communicate with the physician.” During an interview on 1/29/2026 at 11:46 pm with DPCS, DPCS stated, “To maintain continuity of medication use, to avoid confusion, and to prevent misinformation it is important to do medication reconciliation on every visit .” During a review of the agency’s policy and procedure, titled “Care Planning Process”, revised April 2021, the policy and procedure indicated “3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: K. All medications.” During a review of the agency’s policy and procedure, titled “Medication Profile”, revised April 2021, the policy and procedure indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record and medication profile will be updated for each change to reflect medications, new, and/or discontinued medications. b. During a record review of Patient 19’s “Plan of Care” dated 12/27/2025 to 2/24/2026, indicated a start of care date of 8/29/2025 with a diagnosis of pressure ulcer to the sacral region (wound on the tailbone caused by prolonged pressure, friction, or shear, commonly affecting immobilized or seated patients), stage two (wound extends into the bottom layers of the skin). The “Plan of Care” indicated that the skilled nurse is to instruct the caregiver on medication regimen dose, indications, side effects, and interactions. During a review of Patient 19’s current medication, on 1/28/2026 at 11:01 a.m. with the Licensed Vocational Nurse (LVN 2), the following medications were not available in Patient 19’s residence but were listed in Patient 19’s medication profile and plan of care provided by the HHA: Ascorbic Acid (used to treat and prevent vitamin C deficiency, support immune function, aid in wound healing), 500 milligrams (mg – unit of measurement) – take one tablet dailyDuring a review of Patient 19’s current medication, on 1/28/2026 at 11:01 a.m. with the LVN 2, the following medications were available at Patient 19’s residence but not listed in Patient 19’s medication profile or plan of cre provided by the HHA: Vitamin C Spray - 60 mgLiquid Vitamin B12 (support nerve and blood cell health) – 1,000 micrograms (mcg – unit of measurement) per servingVegan D3 (used to maintain optimal vitamin D levels, supporting immune function, bone health, calcium absorption, and muscle strength) Spray – 25 mcgDuring an interview on 1/29/2026 at 11:40 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that medication reconciliation should be done every visit. DPCS stated that it is important to do medication reconciliation every visit to make sure patients are taking the right medications and there are no changes and to maintain continuity of medication use. a. During a review of Patient 16’s Patient Profile sheet indicated a start of care date of 1/19/2026 with diagnosis including Diabetes Mellitus without complications (a Chronic metabolic disorder characterized by high blood sugar due to insulin resistance). During a review of Patient 16’s “Plan of Care (POC, a mandatory, written, and patient-specific document that outlines necessary medical, rehabilitative, and supportive services to treat an injury or illness at home)”, dated 1/19/2026 to 3/19/2026, the POC indicated SN (Skilled Nurse) to instruct the patient/caregiver on medication regimen dose, indications, side effects, and interactions. During a concurrent interview and record review on 1/28/2026 at 12:35 pm with Licensed Vocational Nurse 1 (LVN 1), at Patient 16’s residence, Patient 16’s medication profile (MP, medication list), dated 1/19/2026, was reviewed. LVN 1 stated the following medications were at home that Patient 16 reported taking, but was not listed in MP: -Amlodipine Besylate 5miligram (mg) (a medication to reduce blood pressure) take one tablet by mouth daily at bedtime. -Seroquel 25mg (Medication which is primarily used to treat bipolar disorder) take one tablet twice daily as needed for agitation. LVN 1 stated, “this was missed by the initial nurse. Medication reconciliation needs to be done on every visit by nurses. This is very important so we can keep track of all the current medications the patient has and communicate with the physician.” During an interview on 1/29/2026 at 11:46 pm with the Director of Patient Care Services (DPCS), the DPCS stated, “to maintain continuity of medication use, to avoid confusion, and to prevent misinformation it is important to do medication reconciliation on every visit .” b. During a record review of Patient 19’s “Plan of Care” dated 12/27/2025 to 2/24/2026, indicated a start of care date of 8/29/2025 with a diagnosis of pressure ulcer to the sacral region (wound on the tailbone caused by prolonged pressure, friction, or shear, commonly affecting immobilized or seated patients), stage two (wound extends into the bottom layers of the skin). The “Plan of Care” indicated that the skilled nurse is to instruct the caregiver on medication regimen dose, indications, side effects, and interactions. During a review of Patient 19’s current medication, on 1/28/2026 at 11:01 a.m. with the Licensed Vocational Nurse (LVN 2), the following medications were not available in Patient 19’s residence but were listed in Patient 19’s medication profile and plan of care provided by the HHA: Ascorbic Acid (used to treat and prevent vitamin C deficiency, support immune function, aid in wound healing), 500 milligrams (mg – unit of measurement) – take one tablet dailyDuring a review of Patient 19’s current medication, on 1/28/2026 at 11:01 a.m. with the LVN 2, the following medications were available at Patient 19’s residence but not listed in Patient 19’s medication profile or plan of care provided by the HHA: Vitamin C Spray - 60 mgLiquid Vitamin B12 (support nerve and blood cell health) – 1,000 micrograms (mcg – unit of measurement) per servingVegan D3 (used to maintain optimal vitamin D levels, supporting immune function, bone health, calcium absorption, and muscle strength) Spray – 25 mcgDuring an interview on 1/29/2026 at 11:40 a.m. with Director of Patient Care Services (DPCS), the DPCS stated that medication reconciliation should be done every visit. DPCS stated that it is important to do medication reconciliation every visit to make sure patients are taking the right medications and there are no changes and to maintain continuity of medication use. During a review of the agency’s policy and procedure, titled “Care Planning Process”, revised April 2021, the policy and procedure indicated “3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: K. All medications.” During a review of the agency’s policy and procedure, titled “Medication Profile”, revised April 2021, the policy and procedure indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record and medication profile will be updated for each change to reflect medications, new, and/or discontinued medications.”

“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 observation, 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 update and revise the Plan of Care (POC) for one of nine sampled patients (Patient 19). Patient 19 did not have a plan of care for Patient 19’s wound on the left heel and right heel. This deficient practice had the potential to place the patients at risk for not receiving the identified needs and services which could affect the patient’s quality of care and treatment. Findings: During a review of Patient 19’s “Plan of Care” dated 12/27/2025 to 2/24/2026, indicated Patient 19’s start of care date was 8/29/2025 with a diagnosis of pressure ulcer to the sacral region (wound on the tailbone caused by prolonged pressure, friction, or shear, commonly affecting immobilized or seated patients), stage two (wound extends into the bottom layers of the skin). The “Plan of Care” did not indicate that there was wound care orders to the left and right heel. During a record review of Patient 19’s “Wound Care Order” dated 1/16/2026, indicated Patient 19 was seen by the visiting skilled nurse with new onset of redness to three sites of her right lateral foot and redness to left heel. The “Wound Order” indicated wound care to the right foot lateral sites one, two, and three and wound care to the left heel to be performed every other day and as needed for loose or soiled dressing. During a joint home visit, on 1/28/2026 at 10:30 a.m., with the Licensed Vocational Nurse (LVN 2) at Patient 19’s residence. Patient 19 was observed lying down in the bedroom with caregiver present at bedside. LVN 2 was observed providing wound care to Patient 19’s left and right heel. LVN 2 stated that the wound care to the left and right heel were recent physician orders because redness was observed during one of the home visits (unknown date). During a concurrent record review and interview on 1/29/2026 at 11:40 a.m., with Director of Patient Care Services (DPCS), the DPCS stated that there was no mention on Patient 19’s current plan of care regarding wound care to be performed on patient’s left and right heel. DPCS stated that there was no updated plan of care to included the new wound order regarding Patient19’s left and right heel. During a record review of the agency’s policy and procedure, titled “Care Planning Process” revised 4/2021, the policy and procedure indicated, the patient plan of care will be developed or revised within five (5) business days of initiation of each service or of the reassessment of the patient. The policy and procedure further indicated plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element 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 physician reviewed and revised one of nine sampled patients’ (Patient 22) individualized plan of care. This failure had the potential to result in Patient 22 receiving inappropriate or lack of care and services. Findings: During a record review of Patient 22’s “Patient Profile” (admission sheet), the Patient Profile indicated Patient 22 start of care (SOC) date was 10/4/2024 with diagnoses including acute cystitis without hematuria (a bladder infection without blood in the urine) and Type 2 diabetes mellitus with hyperglycemia (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 1/26/2026 at 12:40 p.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 22’s Plan of care dated 11/28/2025 to 1/26/2026. Patient 22’s Plan of Care indicated the physician signed on 1/28/2026. The DPCS stated the Plan of Care was signed late by the physician. The DPCS stated the Plan of Care should have been signed within 30 days because the physician needs to be aware and approve the plan of care and orders. During a record review of the agency’s policy and procedure (P&P) titled, “Care Planning Process,” revised 4/2021, the P&P indicated, “A written plan of care will be completed within five (5) business days of start of care and updated at least every 60 days or as patient’s condition warrants. All clinicians involved in the patient’s care, either directly or indirectly, will contribute to the plan of care.””

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. 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 therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Reporting OASIS information electronically was met as follows: The Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) were completed and submitted to the CMS system for all Medicare patients, Medicaid patients, and patients utilizing any federally funded health plan options that are part of the Medicare program for six hundred thirty seven (637) of one thousand nine hundred eighty five (1985) OASIS patients’ data collection for the year 2024 to 2025. This failure resulted in the error summary report of the OASIS data leading to delayed comprehensive assessment of the patients’ identified needs, including prompt or timely interventions, treatment, and continuity of care for patients certified to receive the Medicare home health benefits. Refer to G372. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Reporting OASIS information to ensure all OASIS data are collected and submitted to CMS for accurate reimbursements of payment to these certified Medicare beneficiaries.”

“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 interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for care planning, coordination, and quality of care was met as follows: HHA failed to: 1.Ensure two of 15 sampled patients’ (Patient 3 and Patient 13) medication and treatment were provided as ordered by the physician. These failures had resulted in Patient 3 and Patient 13’s delayed treatment and medication error that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. (see G tag 580) 2.Provide one of three sampled patients (Patient 3) and their caregiver (CG 1) education and training regarding medication management. This failure had resulted in Patient 3’s care giver, CG 1’s lack of education and training to ensure CG 1 managed, complied, and administered Patient 3’s medication in accordance with the physician’s orders and prevent medication error such as: medications not administered to Patient 3 as ordered by the physician; Patient 3 receiving Furosemide without a physician’s order; and the risk of CG 1 administering the SQ injection correctly. (see G tag 610) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for care planning, coordination, and quality of care are provided to patients certified to receive home health benefits. Based on observation, interview and record review, Heralds Home Health, a Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to: 1. Ensure the plan of care for three of 15 sampled patients (Patient 3, Patient , and Patient 15) was signed by the physician at least every 60 days. This failure had the potential for Patient 3, ……. Patient and Patient 15 plan of care to not be verified by the physician, delay of care and could result in patients’ exacerbation of health condition and possible re-hospitalization. 2. Ensure one of 15 sampled Patient (Patient 13) have documented evidence that an attempt to reschedule and notify the physician responsible for the missed visit. This failure had the potential for Patient 13’s disruption to medical and wound treatment plan and may lead to worsened wound and health condition. (Refer to G-tag 572) Based on observation, interview and record review, Heralds Home Health, a Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure two of 15 sampled patients’ (Patient 3 and Patient 13) medication and treatment were provided as ordered by the physician when: 1a. Patient 3’s medication profile (comprehensive record of all medications a patient currently takes, has taken in the past, or has been prescribed) was accurate and updated to reflect Patient 3’s medication, as prepared and administered by Patient 3’s caregiver, was in accordance with the physician’s order. 1b. Patient 3’s “Drug Regimen Review” (a list of current medication the patient currently takes) was created and given to the patient to reflect Patient 3’s accurate and current medication list. 2a. Patient 13’s wound care treatment on the right back was not provided when, Vashe solution (antimicrobial and debridement solution) was not used as ordered by the physician. 2b. There was no documented evidence that Patient 13’s Vashe solution supply was ordered and delivered to address the needs of the patient to use for wound care. These failures had resulted in Patient 3 and Patient 13’s delayed treatment and medication error that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. (Refer to G-tag 580) Based on observation, interview and record review, Heralds Home Health, a Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure one of three sampled patients’ (Patient 13), Patient 13’s wound care treatment from Wound Care Specialist when: a. Patient 13’s wound care treatment on the right back was not provided when, Vashe solution (antimicrobial and debridement solution) and was not used as ordered by the physician. b. There was no documented evidence that Patient 13’s Vashe solution supply was ordered and delivered to address the needs of the patient to use for wound care. c. Patient’s 13’s wound care treatment orders by 2 Wound Care Specialist were not carried out and added to the plan of care. These failures had resulted in Patient 13’s delayed treatment, medication, and supplies were not provided, an error that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. (Refer to G-tag 604) Based on interview and record review, Heralds Home Health, a Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to provide one of three sampled patients (Patient 3) and their caregiver (CG 1) education and training regarding medication management by failing to do the following: 1. Patient 3 and CG 1 was not provided a copy of the patient’s care plan, that reflects the patient’s plan for medication management, and a copy of “Drug Regimen Review” (a list of current medication the patient currently takes), that reflects Patient 3’s current medications as ordered by the physician. 2. CG 1 was not assessed by the visiting nurse (SN) to ensure CG 1 was correctly filling Patient 3’s medication box. Patient 3’s pill box included Furosemide (used to treat fluid retention and high blood pressure) was not in the physician’s order. Patient 3’s pill box did not have Metoprolol (used to treat high blood pressure) as ordered by the physician. 3. CG 1 was not assessed by the SN to ensure CG 1 was able to verbalize understanding of indication for each medication. CG 1 verbalized Tamsulosin (used to manage symptoms associated with an enlarged prostate) was used for nasal symptoms. 4. CG 1, who administered Patient 3’s Zepbound (used for weight loss) subcutaneous injection (SQ, administering medication by injecting into the fatty layer of tissue), did not have documented evidence that CG 1 was assessed by the SN to ensure CG 1 was able to draw Patient 3’s correct dose of injectable medication and administered injectable medication using proper techniques. This failure had resulted in Patient 3’s care giver, CG 1’s lack of education and training to ensure CG 1 managed, complied, and administered Patient 3’s medication in accordance with the physician’s orders and prevent medication error such as: medications not administered to Patient 3 as ordered by the physician; Patient 3 receiving Furosemide without a physician’s order; and the risk of CG 1 administering the SQ injection correctly. (Refer to G-tag 610)”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview and record review, the Heralds Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Organization and administration of services was not met as follows: HHA failed to ensure the following: 1. For Patient 3, Occupational Therapy (OT, a rehabilitation that focused on helping recover the skills needed for daily living) referral for patient safety, was ordered on 7/16/2025. There was no documented evidence that Patient 3’s OT referral was conducted, and OT services was provided to the patient. 2. For Patient 12, Physical Therapy (PT – is a healthcare practice that uses physical techniques, such as service, massage, and heat therapy, to improve mobility, reduce pain, and restore function after an injury, illness, or surgery) referral, to establish treatment plan, was ordered on 12/27/2024. PT evaluation was conducted on 1/10/2025 (14 days after the PT referral was ordered). 3. For Patient 14, Speech Therapy (ST – is a treatment of communication and swallowing problems, helping people speak more clearly, understand language better, and use voice and swallowing skills effectively) referral, for assist for swallowing skills, for dysphagia, and speech exercise therapy, was ordered 11/29/2023. ST evaluation was conducted on 12/18/2023 (19 days after the ST referral was ordered). These failures had resulted in Patient 3, Patient 12, and Patient 14’s delayed treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. (Refer to G 964). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Organization and administration of services are provided to patients certified to receive home health benefits.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard 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 therapeutic services to a patient’s personal residence) failed to ensure the Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) were completed and submitted to the CMS system for all Medicare patients, Medicaid patients, and patients utilizing any federally funded health plan options that are part of the Medicare program for six hundred thirty seven (637) of one thousand nine hundred eighty five (1985) OASIS patients’ data collection for the year 2024 to 2025. This failure resulted in the error summary report of the OASIS data leading to delayed comprehensive assessment of the patients’ identified needs, including prompt or timely interventions, treatment, and continuity of care for patients certified to receive the Medicare home health benefits. During a review of “IQIES [Internet Quality Improvement and Evaluation System] Report, HHA Error Summary”, dated 10/22/2024 to 10/22/2025, HHA error summary report indicated, 637 assessments with errors out of 1985 assessments processed. During an interview on 10/22/2025 at 9:12 a.m., with Registered Nurse Quality Assurance (RNQA), RNQA stated the process for OASIS submission were as follows: Clinicians complete OASIS, reviewed by QA and the billing team exports the OASIS information to IQIES. SC 1 stated clinicians have 48 hours to submit OASIS report and reports are exported within 30 days. RNQA stated the late submissions are due to missing documents or information. During an interview on 10/22/2025, at 10 a.m., with Service Coordinator 1 (SC), SC1 stated OASIS submission were uploaded to IQIES once OASIS assessments were completed. SC1 stated late submissions were flagged and QA, Case Manager and clinician were notified. During a review of the facility’s Policy and Procedure (P&P) titled “Reassessment/Recertification” dated April 2021, P&P indicated: The comprehensive assessment must be updated and revised every 60 days beginning with the start of care. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes.”

“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 observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure orders for treatments and services indicated in the plan of care were implemented and signed by the physician for three of 14 sampled patients (Patient 3, Patient 13 and Patient 15). This failure had the potential risk for unverified physician’s orders in the POC, patients’ health status decline that could result to provision of a substandard quality of care. Findings: During a review of Patient 13’s “Patient Information”, indicated Patient 13, a 75 year-old female, with Start of Care (SOC) of 4/11/2025, had a primary diagnosis of secondary malignant (cancerous) neoplasm (is an abnormal growth of tissue, often called a tumor, that can be either benign or malignant) of skin and change or removal of nonsurgical (nonsurgical - not involving handwork or surgery) wound dressing. During a review of Patient 13’s “OASIS E1 Start of Care,” dated 4/11/2025, the” OASIS E1 Start of Care” indicated, “Orders for Discipline and Treatments: SN (Skilled Nurse)1w1, 3w8.” The 1x1 visit was the start of care for that week and then to be followed by three visits a week for eight weeks. During a review of Patient 13’s “Missed Visit Form (LPN/LVN - Skilled Nursing Visit),” dated 4/15/2025, 4/21/2025, 4/23/2025, 4/25/2025, 4/28/2025, 5/2/2025, 5/5/2025, and 5/9/2025, indicated “No answer to phone call.” During a review of Patient 13’s “Physician Order”, dated 4/23/2025, the “Physician Order” indicated, “Patient/family has traveled to Northern California for IV infusion and will not return until 5/5/2025. order as follows: hold skilled nursing services and resume on 5/6/2025.” During a concurrent interview and record review on 10/21/2025 at 3:55 p.m. with DPCS, the DPCS stated if there was a missed visit, and the reason was no answer from the patient or family member, the Licensed Nurse (LN – a trained and officially permitted healthcare professional who provides direct patient care, monitors health, gives basic treatments, and helps patients and families understands their health conditions and care plans) would have to called the office and then would have been told to proceed to the next home visit. The case manager would followed up the call to the patient/family. If the LN who had a missed home visit was a Licensed Vocational Nurse (LVN - healthcare professional who provides basic patient care under the supervision of a registered nurse or doctor), then the LVN would have called an RN and the Primary Care Physician to inform them of the missed visit. If it was a Registered Nurse (RN – is a licensed healthcare professional who provides direct patient care, assesses patient conditions, administers medications and treatments, monitors health status, and educates patients and families about health conditions) who had a missed visit, then the RN would have informed the Primary Care Physician. DPCS stated there was no documentation that RN and Physician were notified on all missed visits. Not missing a scheduled visit was important to promote the continuity of care and prevent worsened wound and health condition, whether for wound care, education of the patient or caregiver, patient have needs, follow up vital signs, and med reconciliation. During a review of the facility’s policy and procedure titled, “Missed Visits,” dated April 2021, the “P&P” indicated, “Purpose To ensure that missed visits are documented and does not affect the quality of patient care. Policy Missed visit will be communicated to the clinical supervisor and the patient’s physician (or other authorized licensed independent practitioner). A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Procedure 1. If a visit is missed for any reason, the clinician should attempt to reschedule it the same week so that the physician (or other authorized licensed independent practitioner) ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician (or other authorized licensed independent practitioner) of the Missed visit if there is potential for clinical impact upon the patient. The physician (or other authorized licensed independent practitioner) will decide if the visit may be skipped or additional intervention is required by the organization. B. If a visit is missed and not rescheduled the clinician will: 1. Notify the physician (or other authorized licensed independent practitioner) of the missed visit if there is potential for clinical impact upon the patient. The physician (or other authorized licensed independent practitioner) will decide if the visit may be skipped or additional intervention is required by the organization. 2. Notify the clinical supervisor of the missed visit and the for the missed visit. 3. Document in the patient’s clinical record the following information: d. Description of any unmet needs and how the patient’s needs were met. e. Physician (or other authorized licensed independent practitioner) notification including date, time, physician (or other authorized licensed independent practitioner) name, method of notification and the staff reporting the information f. Any other follow-up needed g. Other person(s) who were notified of the missed visit h. Signature of staff member reporting the information D. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. E. If a patient is routinely refusing visits, the clinician supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician (or other authorized licensed independent practitioner). Findings: 1.a During a review of Patient 3’s “Patient Information”, dated 10/16/2025, indicated Patient 3, a 73 year-old male, with Start of Care (SOC) of 7/31/2025, had a primary diagnosis of hypertension (High blood pressure) and other diagnosis including but not limited to benign prostatic hyperplasia (BPH, condition where the prostate gland enlarges, putting pressure on the urethra), hyperlipidemia (high cholesterol in the blood) and abdominal hernia (part of the intestine or other tissue protrudes through the abdominal wall). During a concurrent interview and record review on 10/16/2025 at 1:40 pm with the Registered Nurse Quality Assurance Director (RNQA). Patient 3’s “Home Health Certification and Plan of Care” (POC), dated 07/31/2025 was reviewed. The RNQA stated Patient 3’s POC was not signed by the physician. The RNQA stated POCs should be signed by the primary care physician within 30 days to verify the orders and treatment to provide the patient, or it may result in patients’ delay of care and lead to exacerbation of patients’ condition and possible re-hospitalization. 1.b. 1.c. During a review of Patient 15’s “Patient Information”, dated 10/20/2025, indicated Patient 15, a 86 year-old female, with SOC of 9/8/2025, had a primary diagnosis of stage two pressure injury on right lower back (bed sore, a skin damage cause by prolonged pressure in the same spot of the body) and other diagnosis including but not limited to Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 10/20/2025 at 11:35 am with the Director of Patient Care Services (DPCS). Patient 15’s POC, dated 9/8/2025 was reviewed. The DPCS stated Patient 15’s POC was not signed by the primary care physician. The DPCS stated once POC are created the primary care physician receives a copy of the POC through fax or hand deliver to retrieve signatures. During a review of HHA’s policies and procedure (P&P) titled “Care Planning Process”, undated. The P&P indicated “changes must be written, dated, and signed by the professional making the changes” ... “The case manager will sign the plan of care and document other clinical personnel who reviewed it” During a review of HHA’s P&P titled “Physician’s Participation in Plan of Care”, undated. The P&P indicated the following: - “The attending physician (or other authorized licensed independent practitioner) will certify that medical, skilled, rehabilitative, and social services provided by the organization are medically necessary...” - “The attending physician (or other authorized licensed independent practitioner) will sign the plan of care/treatment within 30 days of the start of care.””

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element 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 therapeutic services to a patient’s personal residence) failed to provide the patient’s occupational therapy (OT) needs as ordered by the referring physician for one of 14 sampled patients (Patient 3). This failure had resulted in Patient 3’s delayed treatment that could lead to patient’s harm, deterioration or exacerbation of patient’s medical condition and/or unplanned hospitalization. Findings: During a review of Patient 3’s “Patient Information”, undated, indicated Patient 3’s Start of Care (SOC) of 7/31/2025, with a primary diagnosis of hypertension (High blood pressure). The other diagnoses including but not limited to benign prostatic hyperplasia (BPH, condition where the prostate gland enlarges, putting pressure on the urethra), hyperlipidemia (high cholesterol in the blood) and abdominal hernia (part of the intestine or other tissue protrudes through the abdominal wall). During a concurrent interview review on 10/17/2025 at 3:46 pm., with the Director of Patient Care Services (DPCS). Patient 3’s “Admission Order,” dated 7/16/2025 was reviewed. The “Admission Order” indicated Patient 3 was referred to HHA for “PT (physical therapy), OT (occupational therapy) for safety, and for medication reconciliation”. The DPCS stated the HHA used the referral order for the rehabilitation staff to provide services to patients. During a review of Patient 3’s “Physician Order”, dated 7/29/2025, indicated for therapy services to begin on 7/31/2025. During a concurrent interview, and record review on 10/21/2025 at 9:23 am, with the DPCS, Patient 3’s “Episode Manager: Therapy,” for service period of 7/31/2025 to 9/28/2025 was reviewed. The DPCS stated there was no documentation to indicate Patient 3 was seen or provided OT services during the service period (7/312025 to 9/28/2025). During a concurrent interview and record review on 10/22/2025 at 9:35 am., with the DPCS, Patient 3’s “OASIS E-1 Start of Care” (the initial comprehensive assessment completed by the nurse upon the start of care), dated 7/31/20205 was reviewed. The “OASIS E-1 Start of Care” indicated Patient 3’s treatments included skilled nursing services and physical therapy evaluation. The “OASIS E-1 Start of Care” did not indicate Patient 3 will receive OT services. The DPCS stated there should be a documentation in the assessment that included the occupational therapy was ordered by the physician. The DPCS stated having the initial assessment without the mention of Patient 3’s need for occupational therapy resulted from patients missing the opportunity window that he would benefit from therapy and may lead to potential injury, deterioration and possible hospitalization. During a review of HHA’s policies and procedure (P&P) titled “Initial and Comprehensive Assessment”, undated. The P&P indicated “The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social and discharge planning needs.” … “The comprehensive assessment shall reflect and determine: Patient problems/needs/strengths, the patient’s continuing needs for home care”. During review of HHA’s P&P titled “Internal Referral Process”, undated. The P&P indicated “The additional services needed will be communicated to clinical supervisors/nursing supervisor or scheduler who will assign the appropriate clinician.””

“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, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure two of 14 sampled patients’ medication and treatment were followed as ordered by the physician (Patient 3 and Patient 13). a. Patient 3’s medication profile (comprehensive record of all medications a patient currently takes, has taken in the past, or has been prescribed) was not accurate and updated to reflect Patient 3’s medication prepared and administered by Patient 3’s caregiver in accordance with the physician’s order. Patient 3’s “Drug Regimen Review” (a list of current medication the patient currently takes) given to the patient caregiver did not reflect Patient 3’s accurate and current medication list. b. Patient 13’s wound care treatment on the right back with Vashe solution (antimicrobial and debridement solution) was not administered as ordered by the physician. These failures had the potential to result in patients not receiving their prescribed medications, and delayed treatment and services that could affect their health status and wellbeing. On 10/22/2025 4:13 p.m. the IJ was removed in the presence of the Administrator (ADM) after the facility submitted an acceptable IJ Removal Plan and the surveyor verified and confirmed onsite the facility’s implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 10/22/2025 at 4:13 p.m., included the following: On 10/22/2025 Immediate action upon receipt of the Immediate Jeopardy determination, the Director of Patient Care Services (DPCS) immediately implemented emergency corrective measures to ensure no active patient is at risk due to delayed therapy coordination. On 10/21/2025 All three LVNs previously assigned to the patient’s wound care were identified. Two LVNs no longer employed were previously removed from the active roster, and HR confirmed they will not be rehired. LVN 1 receive 1:1 wound care retraining with an experienced nurse consultant. On 10/21/2025 Care Coordinators and QA Coordinator completed a 100% review of all active wound care patients to confirm wound care orders match those in the EMR and the plan of care. QA staff also reviewed documentation in the EMR to verify that each nurse’s narrative/wound care worksheet matches the most current wound order and that the order error pattern is fully corrected agency-wide. On 10/22/2025 Patient 16, 17, 18, and 19 charts were reviewed to verify wound care orders match EMR plan of care. Effective 10/21/2025, QA staff will conduct these wound care order-to-documentation audits weekly for four consecutive weeks or until 100% compliance is achieved, then biweekly for the next 60 days, and monthly thereafter on an ongoing basis. Audit results will be reviewed by the DPCS and discussed in QAPI meetings to ensure sustained compliance and identify any recurrence trends. On 10/22/2025, a standardized monitoring checklist entitled “Wound Care Communication & Verification Checklist” was created to document completion of all required steps (order uploaded to EMR, assigned visiting nurse(s) notified through secure email of updated order, visiting nurse acknowledgement of order review received via secure email, documentation of verification included in the next visit note). The DPCS will review all completed checklists weekly to verify that all required steps were followed. Effective 10/21/2025, the agency implemented a standardized wound supply ordering protocol to ensure patients consistently receive the correct supplies for ordered wound care. The assigned care coordinator will verify that wound care orders include all required supplies (solution, dressing, secondary dressing, tape, gloves, etc.). QA staff or the DPCS will confirm during weekly audits that supplies ordered match the physician’s active wound care orders and that delivery is documented, as well as auditing the wound care spreadsheet used by care coordinators to document supplies ordered. Effective 10/21/2025, a new communication and verification process was implemented for all external wound care or specialist orders. On 10/21/2025, A new “Wound care/medications match physician orders” template was created for use in the EMR system and will be required weekly for all patients (if the patient does not have a wound, then the wound care orders portion of the template may be omitted). The purpose of this template is to ensure that all wound care performed by skilled nursing staff is consistent, documented and aligns with patient’s medication profile to prevent discrepancies between wound treatment and prescribed topical or systemic medications. On 10/19/2025 Patient 3’s physician was contacted to verify medication list in EMR. Same day an in-home medication reconciliation for Patient 3 was conducted with patient and caregiver to confirm medication accuracy. The patient and caregiver were re-educated using the Medication Education Checklist and the Medication Education Template within the EMR system. A copy of this checklist was left in the patient’s home. Education included a review of each active prescribed medication and over-the-counter medication. On 10/18/2025 and 10/20/2025, all active patient medication profiles were reviewed and verified against medications present in each patient’s home. Skilled nurses conducted in-person and telephonic medication review visits and calls to reconcile each medication list with the patient’s current home medications. Discrepancies were immediately corrected in the electronic medical record (EMR) and communicated to the physician for verification. Also, Upon receipt of any wound care orders, the care coordinator or DPCS will review the specialist’s order for completeness and accuracy, then create a physician order in the EMR to reflect the treatment exactly as prescribed by the specialist. On 10/21/2025 Staff trained on how to verify physician orders in the EMR before each visit, including Plan of Care (485), Orders Tab, and Misc. Docs. Facility emphasized immediate action if an order is missing or unclear: stop, call the physician, document, and obtain a verbal order before care. On 10/21/2025 Mandatory all-staff in-service was conducted by an experienced nurse consultant to ensure all field nurses were competent with following physician orders and covered the following topics: Reviewed CMS CMS §484.60(b); explained the risk of noncompliance, staff responsibilities for verifying documenting and communicating all physician orders and ensuring patients and patientcare givers understand; Outlined QA/QI monitoring expectations of ongoing audits, coordination between disciplines and corrective training for missed delays. On 10/22/2025 LVN 3 and LVN 4 were called for an interview to verify in-service. Both LVNs stated attending in-service and its contents. On 10/21/2025, a staff competency checklist regarding following physician orders was created to ensure that all clinical staff demonstrates competence in verifying, implementing, and documenting physician or allowed practitioner orders in accordance with CMS §484.60(b) and agency policy. On 10/22/2025 record reviewed indicated all staff attended in-service and checked off on competency checklist. Effective 10/21/2025 Facility will conduct weekly wound care conferences held by DPCS, Care Coordinators, and/or QA coordinator. Effective 10/21/2025 on-going staff education will occur quarterly every three months, upon hire, QA audits or when adverse event happens. Education will include: CMS requirements for physician-approved plan of care, verifying MD orders, wound care and medication discrepancies, documentation expectations when using “Wound Care Verification” template, communication order changes or clarifications. Effective 10/2025 Wound Care & Physician Order Verification Audit Tool” will be incorporated into the agency’s monthly Quality Assurance (QA) review process. This tool will be used by the QA Coordinator or DPCS to review a minimum of 10% of all active wound care patient charts each month. Each audited chart will be reviewed for: Documentation of MD order date of wound care, verification of clinician using “Wound Care Verification” template, consistency between wound care documentation and the active plan of care and medication profile. Findings: 1. During a review of Patient 3’s “Patient Information” undated, indicated a Start of Care (SOC) of 7/31/2025, had a primary diagnosis of hypertension (High blood pressure) and other diagnosis including but not limited to benign prostatic hyperplasia (BPH, condition where the prostate gland enlarges, putting pressure on the urethra), hyperlipidemia (high cholesterol in the blood) and abdominal hernia (part of the intestine or other tissue protrudes through the abdominal wall). During Patient 3’s home visit on 10/15/2025 at 10:39 am, with Licensed Vocational Nurse 1 (LVN 1), a medication reconciliation (process of creating the most accurate and complete list of a patient’s current medications, comparing it against the medications ordered by physician, and resolving any discrepancies) was conducted. LVN 1 was observed looking for Patient 3’s “Drug Regimen Review” in the patient’s home health folder. LVN 1 stated Patient 3 did not have the “Drug Regimen Review,” to indicate the patient’s current medications. LVN 1 stated the medication list should be available in the patient’s home. During a concurrent interview with Patient 3 stated the medication he was taking was in his pill box and the patient showed the medication bottles where the medications in the pill box came from. Patient 3 stated it was his caregiver (CG 1) who prepared and gave his medications. Patient 3’s medication bottles that correspond to the medications in the pillbox were: - Tamsulosin (to manage symptoms associated with an enlarged prostate) 0.4 milligram (mg, unit of measurement) one capsule daily - Valsartan-Hydrochloride (treatment of hypertension) 320-12.5 mg one tablet daily - Furosemide (used to treat fluid retention and high blood pressure) 20 mg half tablet daily - Atorvastatin (for treatment of high cholesterol) 40 mg one tablet daily Patient 3 stated he has Zepbound (injection used for weight loss) SQ 2.5 mg that was stored in the refrigerator and was being administered to him by CG 1. During Patient 3’s home visit on 10/15/2025 at 10:39 am, Patient 3’s medication profile in the electronic medical records was reviewed with LVN 1. Patient 3 had the following medications: - Zepbound (use for weight loss) [subcutaneous injection] (SQ, administering medication by injecting into the fatty layer of tissue) 2.5 mg/ 0.5 milliliters (ml, unit of volume) weekly for ...Anti-obesity - Ozempic (use for weight loss) SQ 0.25 mg/ 0.5ml weekly (Patient 3 did not have the medication) - Tamsulosin 0.4 mg one capsule daily - Metoprolol [extended release] (used to treat hypertension) 25 mg one tablet daily (was not in Patient 3’s pill box and the patient do not have the medication bottle) - Valsartan-Hydrochlorothiazide 320-12.5 mg one tablet daily - Atorvastatin calcium 40 mg one tablet daily The medication profile did not include Furosemide (Patient 3 and CG 1 indicated the patient was taking half tablet of Furosemide and the medication was found in Patient 3’s pill box and medication bottle). During a review of Patient 3’s “Admission Order”, dated 7/16/2025, indicated Patient 3 was referred to HHA for physical therapy, occupational therapy and for medication reconciliation. During a review of Patient 3’s “OASIS E1 Start of Care” (SOC) dated 7/31/2025, The “OASIS E1 Start of Care” indicated Patient 3 will benefit from HHA services for blood pressure management, mobility issues and risk for falls. The SOC further indicated that Patient 3 and CG 1 require reinforcement on medication management and BP monitoring. During a review of Patient 3 “HHA and Plan of Care,” dated 7/31/2025, indicated the following treatments: - “SN to assess the patient and caregiver filling the medication box to determine if patient is filling it correctly” - “SN to assess if the Patient/Caregiver is able to verbalize understanding of indication for each medication” - “SN to determine if the patient/caregiver is able to identify the correct dose, route and frequency of medication” During a review of Patient 3 “HHA and Plan of Care,” dated 9/29/2025, indicated the following treatments: - “SN to assess the patient and caregiver filling the medication box to determine if patient is filling it correctly” - “SN to assess if the Patient/Caregiver is able to verbalize understanding of indication for each medication” - “SN to determine if the patient/caregiver is able to identify the correct dose, route and frequency of medication” During an interview on 10/16/2025 at 1:40 pm, with the Registered Nurse Quality Assurance (RNQA), the RNQA stated the medication reconciliation entails comparing the home medications with the patient to the discharge medication list received. The RNQA stated the patient should have a copy of the list of current medication the patient is taking. The RNQA stated the medication management should include the patient and caregiver’s education on the medication side effects, signs and symptoms of exacerbation of condition, and administration of medication in accordance with the physician’s order. During an interview on 10/16/2025 at 2:42 pm, with CG 1. CG 1 stated she prepared Patient 3’s medication pill box and administer the Zepbound injection every Friday to the patient. CG 1 stated Patient 3 takes atorvastatin for cholesterol; valsartan, metoprolol and furosemide for blood pressure. CG 1 stated Patient 3 does not take tamsulosin anymore as this medication was for Patient 3’s nasal symptoms. CG 1 stated she did not receive a medication list from the HHA and that she uses the list of medications she received from the physician when she prepares Patient 3’s medications. During an interview on 10/16/2025 at 2:56 pm., with LVN 1 stated she was the assigned visiting nurse for Patient 3 twice a week. LVN 1 stated Patient 3 was receiving HHA services for hernia, fall risk, cholesterol and medication management. LVN 1 stated she did not write Patient 3’s current medications on the “Medication Drug Regimen” form. LVN 1 stated she never observed CG 1 to ensure CG 1 prepares Patient 3’s pill box correctly. LVN 3 stated the lack of CG 1’s observation for medication preparation and administration may result in Patient 3’s medication error that may lead to hospitalization. During a review of HHA’s P&P titled “Medication Profile”, undated. The P&P indicated the following: - “Medication Profile will be updated for each change to reflect current medications, new, and/or discontinued medications” - “A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed.” - “Using the medication profile to evaluate the use of medication in home setting” During a review of HHA’s P&P titled “Ongoing Assessments”, undated. The P&P indicated “the physician will be notified to verify any changes in medications” During a review of HHA’s P&P titled “Patient Self-Administration of Medication”, undated. The P&P indicated the following: - “[The HHA] will provide teaching about the correct administration of medications by patient and family/caregiver as ordered by the attending physician” - “The clinician will provide an opportunity for the patient to administer his/her own medications.” - “The clinician will assess patient [and caregiver] ability to self-administer medications correctly” - “The clinician will complete the medication profile for at admission and recertification” 2. During a review of Patient 13’s “Patient Information”, indicated a Start of Care (SOC) of 4/11/2025, had a primary diagnosis of secondary malignant (cancerous) neoplasm (is an abnormal growth of tissue, often called a tumor, that can be either benign or malignant) of skin, change or removal of nonsurgical wound dressing, and malignant neoplasm of the ovary. During a review of Patient 13’s “OASIS E1 Start of Care,” dated 4/11/2025, the OASIS E1 Start of Care” indicated Patient 13 had a 6 cm x 5 cm fungating/ulcerated back lesion with foul smell and dark discharge requiring daily dressing. A review of Patient 13’s “Health Certification and Plan of Care”, dated 4/11/2025 to 6/9/2025, indicated Patient 13’s wound care order were as follows: “Cleanse with NS or Vashe (antimicrobial cleaning solution used for debridement and wound irrigation), cover with calcium alginate silver dressing and ABD pad for fungating (cancerous growth that breaks through the skin creating an open ulcerated wound) back mass.” A review of Patient 13’s “Wound Evaluation,” dated 4/19/2025, authored by Nurse Practitioner 1 (NP 1), indicated Patient 13’s Wound Care were as follows: Clean the wound with Normal Saline (NS) and apply Vashe to the wound, soak the wound with Vashe for 10 minutes, by moistening sterile gauze with Vashe, and place it on the wound. Then pat the wound dry with sterile gauze, then apply ADAPTIC dressing to the wound, then cover with non-adhering gauze dressing. Cover the non-adhering gauze dressing with abdominal pad (s). Then cover with abdominal binder. A review of “Home Health Wound Care Orders,” dated 4/29/2025, indicated Patient 13’s wound care orders were as follows: Flush wound with saline and then Vashe solution, pat dry with gauze, and apply “Layer 1: Adaptic. Layer 2: Silver alginate. Layer 3: ABD pad. Layer 4: Secure with abdominal binder. Frequency: 2-3x a day.” A review of Patient 13’s “Missed Visit Form (LPN/LVN - Skilled Nursing Visit),” dated 4/15/2025, 4/21/2025, 4/23/2025, 4/25/2025, 4/28/2025, 5/2/2025, 5/5/2025, and 5/9/2025, indicated “No answer to phone call.” “The Patient/Family has travelled to Northern California for IV infusion and will not return until 5/5/2025.” “Hold skilled nursing service and resume on 5/5/2025.” A review Patient 13’s “LPN/LVN - Skilled Nursing Visit” dated 5/7/2025, indicated Patient 13’s right back wound measures 9.6 cm x 10.4 cm x 2.3 cm with tunneling and foul odor. A review of Patient 13’s “LPN/LVN - Skilled Nursing Visit,” dated 5/7/2025, 5/10/2025, 5/11/2025, 5/13/2025, and 5/19/2025, indicated Patient 13’s wound treatment was as follows: “Cleanse with NS or Vashe, cover with calcium alginate silver dressing and ABD (Wound care order was to flush wound with saline and then Vashe, then apply adaptic, then silver alginate, then ABD pad).” A review of Patient 13’s “LPN/LVN - Skilled Nursing Visit,” dated 5/27/2025, indicated Patient 13’s right back wound measures 11.2 cm x 14.4 cm x 3.8 cm with bloody drainage and foul odor. “Treatment: wound care was done by daughter prior to SN.” During a review of the facility’s “Patient Grievance Tracking Log,” undated, indicated on on 5/16/2025, “daughter (Patient 13’s daughter) called to complain about the home health supplies. Daughter insisted on a specific wound care solution (Vashe) she wants to use is the only one that works for her mother. It was explained to the daughter that we do not currently have orders for the treatment she insists on, but we would call and clarify the treatment orders with the physician. Daughter was not happy with having to wait for the doctor to provide home health with the orders she is requesting.” A review of “McKesson - Order #47215145”, dated 4/17/2025, indicated 2 bottles of Vashe solution 250 ml, were ordered and shipped to Patient 13’s home. A review of “McKesson - Order #49165961”, dated 5/15/2025, indicated 24 bottles of Vashe solution 118 ml were ordered and shipped to Patient 13’s home (28 days after since the last Vashe [2 bottles of 250 ml] were delivered to the patient). In an interview on 10/17/2025 at 11:11 am., with the Director of Patient Care Services (DPCS), the DPCS stated Patient 13 was seen by Wound Care Specialist on 4/17/2025 and 5/15/2025. The DPCS stated both orders indicated for Patient 13 to use Vashe solution as part of the wound care treatment. During a concurrent interview with DPCS stated that when a patient was seen by the wound care specialist, the wound care orders would be sent to the facility so that the new wound care orders would be caried out and updated. Paitent13’s wound care orders given by the wound care specialist on 4/17/2025 and 5/15/2025 were not carried out and updated. The visiting nurses were following Patient 13’s wound care orders written on 4/11/2025. The DPCS stated wound care orders should be followed for the wound to get better and not get worse. Using the Vashe solution on the wound, as ordered by the physician, was important to prevent bacteria from growing and to prevent wound infection. During an interview on 10/17/2025 at 12:30 pm., with the DPCS, the DPCS stated she only has documentation of Vashe solution delivery to Patient 13 on 4/17/2025 and 5/15/2025. The DPCS stated there was no other documentation to indicate Vashe solution was delivered to Patient 13 on other dates. During a review of the facility’s policy and procedure (P&P), “Verification of Physician Orders,” undated, the P&P indicated the following: - “Orders will be obtained from a licensed physician for care and services to be provided to home health patients.” - “A qualified individual will review each order or prescription before care is provided.” During a review of the facility’s P&P titled, “Wound Assessment and Documentation,” undated, the P&P indicated, “Document the following on the visit report…The treatment and condition of the wound (each visit)…Update the patient care plan as indicated by any coordination by the physician as indicated.” During a review of the facility’s P&P titled “Care/Service Coordination,” undated, the P&P indicated the following: - “Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. - “The clinician/technician will be responsible for facilitating communications about changes in the patient’s status…” - Care coordination will include, but not limited to…Integration of 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.” - “Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the condition of care activities.””

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure one of 14 sampled patients (Patient 13) wound care treatment from Wound Care Specialist was implemented: a. Patient 13’s wound care treatment on the right back was not provided when Vashe solution (antimicrobial and debridement solution) and was not used as ordered by the physician. b. There was no documented evidence that Patient 13’s Vashe solution supply was ordered and delivered to address the needs of the patient to use for wound care. c. Patient’s 13’s wound care treatment orders by 2 Wound Care Specialists were not carried out and added to the plan of care. These failures had resulted in Patient 13’s delayed treatment, medication, and supplies were not provided, that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. Findings: During a review of Patient 13’s “Patient Information”, indicated Patient 13’s Start of Care (SOC) of 4/11/2025, had a primary diagnosis of secondary malignant (cancerous) neoplasm (is an abnormal growth of tissue, often called a tumor, that can be either benign or malignant) of skin and change or removal of nonsurgical (nonsurgical - not involving handwork or surgery) wound dressing. During a review of Patient 13’s “Health Certification and Plan of Care”, dated 4/11/2025 to 6/9/2025, indicated Patient 13’s wound care order were as follows: “Cleanse with NS or Vashe (antimicrobial cleaning solution used for debridement and wound irrigation), cover with calcium alginate silver dressing and ABD pad for fungating (cancerous growth that breaks through the skin creating an open ulcerated wound) back mass.” During a review of Patient 13’s “OASIS E1 Start of Care,” dated 4/11/2025, the OASIS E1 Start of Care” indicated, “Patient 13 had a 6 cm x 5 cm fungating/ulcerated back lesion with foul smell and dark discharge requiring daily dressing. Patient 13’s Wound Care Interventions: SN to instruct Patient/Caregiver on wound care as follows: Daily dressing changes required-cleanse with NS or Vashe, cover with calcium alginate silver dressing and ABD pad for fungating back mass.” During a review of Patient 13’s “Wound Evaluation,” dated 4/19/2025, authored by Nurse Practitioner (NP - a registered nurse with advanced graduate education and training who can provide a wide range of healthcare services, including diagnosing illnesses, creating treatment plans, and prescribing medications) 1, indicated Patient 13’s Wound Care were as follows: Clean the wound with Normal Saline (NS) and apply Vashe to the wound, soak the wound with Vashe for 10 minutes, by moistening sterile gauze with Vashe, and place it on the wound. Then pat the wound dry with sterile gauze, then apply ADAPTIC dressing to the wound, then cover with non-adhering gauze dressing. Cover the non-adhering gauze dressing with abdominal pad (s). Then cover with abdominal binder. During a review of “Home Health Wound Care Orders,” dated 4/29/2025 authored by Medical Doctor (MD – is a healthcare professional trained to diagnose (identify the nature of an illness or other problem by examination of the manifestation, treat, and help prevent illnesses and injuries) 1, indicated Patient 13’s “Home Health Wound Care Orders: Flush wound with saline and then Vashe solution, pat dry with gauze, and apply “Layer 1: Adaptic. Layer 2: Silver alginate. Layer 3: ABD pad. Layer 4: Secure with abdominal binder. Frequency: 2-3x a day.” During a review of Patient 13’s “LPN/LVN - Skilled Nursing Visit” dated 5/7/2025, indicated Patient 13’s right back wound measures 9.6 cm x 10.4 cm x 2.3 cm with tunneling and foul odor. During a review of Patient 13’s “LPN/LVN - Skilled Nursing Visit,” dated 5/7/2025, 5/10/2025, 5/11/2025, 5/13/2025, and 5/19/2025, indicated Patient 13’s wound treatment was as follows: “Cleanse with NS or Vashe, cover with calcium alginate silver dressing and ABD (Wound care order was to flush wound with saline and then Vashe, then apply adaptic, then silver alginate, then ABD pad).” During a review of Patient 13’s “LPN/LVN - Skilled Nursing Visit,” dated 5/27/2025, indicated Patient 13’s right back wound measures 11.2 cm x 14.4 cm x 3.8 cm with bloody drainage and foul odor. “Treatment: wound care was done by daughter prior to SN.” During a review of the facility’s “Patient Grievance Tracking Log,” undated, indicated on 5/16/2025, “daughter (Patient 13’s daughter) called to complain about the home health supplies. Daughter insisted on a specific wound care solution (Vashe) she wants to use is the only one that works for her mother. It was explained to the daughter that we do not currently have orders for the treatment she insists on, but we would call and clarify the treatment orders with the physician. Daughter was not happy with having to wait for the doctor to provide home health with the orders she is requesting.” During a review of “McKesson - Order #47215145”, dated 4/17/2025, indicated 2 bottles of Vashe solution 250 ml, were ordered and shipped to Patient 13’s home. During a review of “McKesson - Order #49165961”, dated 5/15/2025, indicated 24 bottles of Vashe solution 118 ml were ordered and shipped to Patient 13’s home (28 days after since the last Vashe [2 bottles of 250 ml] were delivered to the patient). During a concurrent interview and record review on 10/17/2025 at 11:11 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated Patient 13 was seen by Wound Care Specialist on 4/19/2025 and 4/29/2025. The DPCS stated both orders indicated for Patient 13 to use Vashe solution as part of the wound care treatment. The DPCS stated that when a patient was seen by the wound care specialist, the wound care orders would be sent to the facility so that the new wound care orders would be carried out and plan of care updated. Patient 13’s wound care orders given by the wound care specialist on 4/19/2025 and 4/29/2025 were not carried out and plans of care were not updated. The visiting nurses were following Patient 13’s wound care orders written on 4/11/2025. The DPCS stated wound care orders should be followed for the wound to get better and not get worse. Using the Vashe solution on the wound, as ordered by the physician, was important to prevent bacteria from growing and to prevent wound infection. During a review of the facility’s policy and procedure (P&P), “Verification of Physician Orders,” undated, the P&P indicated the following: - “Orders will be obtained from a licensed physician for care and services to be provided to home health patients.” - “A qualified individual will review each order or prescription before care is provided.” During a review of the facility’s P&P titled “Care/Service Coordination,” undated, the P&P indicated the following: - “Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. - “The clinician/technician will be responsible for facilitating communications about changes in the patient’s status…” - Care coordination will include, but not limited to…Integration of 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.” “Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in the condition of care activities.””

“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 interview and record review, the Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to provide one of 14 sampled patients (Patient 3) and caregiver (CG 1) education and training regarding medication management by failing to ensure the following: 1. Patient 3 and CG 1 were not provided a copy of the patient’s care plan, that reflects the patient’s plan for medication management, and a copy of “Drug Regimen Review” (a list of current medication the patient currently takes), that reflects Patient 3’s current medications as ordered by the physician. 2. CG 1 was not assessed by the visiting nurse (SN) to ensure CG 1 was correctly filling Patient 3’s medication box. Patient 3’s pill box included Furosemide (used to treat fluid retention and high blood pressure) was not in the physician’s order. Patient 3’s pill box did not have Metoprolol (used to treat high blood pressure) as ordered by the physician. 3. CG 1 was not assessed by the SN to ensure CG 1 was able to verbalize understanding of indication for each medication. CG 1 verbalized Tamsulosin (used to manage symptoms associated with an enlarged prostate) was used for nasal symptoms. 4. CG 1, who administered Patient 3’s Zepbound (used for weight loss) subcutaneous injection (SQ, administering medication by injecting into the fatty layer of tissue), did not have documented evidence that CG 1 was assessed by the SN to ensure CG 1 was able to draw Patient 3’s correct dose of injectable medication and administered injectable medication using proper techniques. This failure had resulted in Patient 3’s care giver, CG 1’s lack of education and training to ensure CG 1 managed, complied, and administered Patient 3’s medication in accordance with the physician’s orders and prevent medication errors that included medications not administered to Patient 3 as ordered by the physician; Patient 3 receiving Furosemide without a physician’s order; and the risk of CG 1 administering the SQ injection correctly that could impact the health and safety of the patient. On 10/20/2025 4:19 p.m. the IJ was removed in the presence of the Administrator (ADM) after the facility submitted an acceptable IJ Removal Plan and the surveyor verified and confirmed onsite the facility’s implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 10/20/2025 at 4:19 p.m., included the following: On 10/19/2025, Patient #3’s caregiver received immediate re-education on medication management, including dosage, schedule, storage, and administration by the visiting nurse. Patient #3’s medication plan of care was reviewed and updated to ensure accuracy and clarity. The caregiver who administers the medication was present during the visit; training and return demonstration was completed with caregiver; the patient/caregiver education checklist was completed and signed, and a signed copy has been added to the patient’s chart. On 10/18/2025 and 10/20/2025, all current, active patients were reviewed by clinical managers and visiting nurses to verify that the patient’s home binder contained a current plan of care, an accurate and up-to-date medication profile, and to confirm that patients and/or any applicable caregivers were knowledgeable about patient’s current and active medication profiles. This was performed through home visits and phone calls. On 10/18/2025, the agency DPCS created and disseminated a mandatory caregiver education compliance checklist for clinicians to use as a standard tool for patient and caregiver education. This checklist will be completed at Start of Care, Recertification and any time there is a change of medication. The visiting nurses are responsible for completing this checklist and providing the completed form to the office within 48 hours of their OASIS visit or the visit in which a change of medication was identified. The agency DPCS is responsible for ensuring the checklist is completed and implemented through weekly auditing. On 10/18/2025, an organization-wide mandatory in-service was conducted by an experienced nurse consultant and nurse educator to ensure all staff were competent with patient and caregiver education requirements. In-service content consisted of: proper education of medication management and storage, introduce the updated patient and caregiver education policy, train on the use of the patient and caregiver education checklist form, emphasize the importance of medication reconciliation and documentation, step by step instruction on the use of the medication education template within the EMR system, and ensure that all patients have a current plan of care and medication profile in their home binder. On 10/20/2025 record review of in-service attendance logs and signed competency attestations. On 10/20/2025 Interview with RN 4 and LVN 2 regarding in-service- Both stated the in-service contents. On 10/18/2025, one on one training with for LVN 1 was performed by facility. Facility leadership performed a root cause analysis to find out why she failed to provide the medication education. Effective 10/18/2025 QA staff will conduct weekly chart audits for four weeks or until 100% compliance is achieved, reviewing documentation for alignment with the POC and confirmation that required caregiver education was completed. On 10/18/2025 The “Patient and Caregiver Education” policy was revised to specify that all required education and training must be provided prior to or at the Start of Care, documented in the clinical record, reviewed during each supervisory visit, and verified using a standardized checklist. On 10/20/2025 record review of policy and procedure “Patient Caregiver Education” was reviewed. On 10/18/2025 A new “patient/caregiver education” template was created for use in the EMR system and will be used for all Oasis time points (SOC, Recertification, ROC and Discharge). The Patient/Caregiver Education Template was developed to standardize documentation of all education provided to patients and caregivers. QA is responsible for monitoring use of template by clinicians. On 10/19/2025 the facility implemented a Supervisory Oversight Process to ensure ongoing compliance with patient and caregiver education requirements and medication management. This updated process includes a mandatory monthly supervisory or case manager visit to each active patient’s home to: Verify medication and plan of care are current and available in home binder, provide reinforcement or retraining to the patient and/or caregiver on medication education, administration technique, and storage as needed. On 10/18/2025 the “Supervisory Visit” form was added as a patient communication template within the EMR to document patient/caregiver competency and education needs. Findings: During a review of Patient 3’s “Patient Information”, undated, indicated Patient 3 with Start of Care (SOC) of 7/31/2025, had a primary diagnosis of hypertension (High blood pressure) and other diagnosis including but not limited to benign prostatic hyperplasia (BPH, condition where the prostate gland enlarges, putting pressure on the urethra), hyperlipidemia (high cholesterol in the blood) and abdominal hernia (part of the intestine or other tissue protrudes through the abdominal wall). During Patient 3’s home visit on 10/15/2025 at 10:39 am, with Licensed Vocational Nurse 1 (LVN 1), a medication reconciliation (process of creating the most accurate and complete list of a patient’s current medications, comparing it against the medications ordered by physician, and resolving any discrepancies) was conducted. LVN 1 was observed looking for Patient 3’s “Drug Regimen Review” in the patient’s home health folder. LVN 1 stated Patient 3 did not have the “Drug Regimen Review,” to indicate the patient’s current medications. LVN 1 stated the medication list should be available in the patient’s home. Patient 3 stated the medication he was taking was in his pill box and the patient showed the medication bottles where the medications in the pill box came from. Patient 3 stated it was his caregiver (CG 1) who prepared and gave his medications. Patient 3’s medication bottles that correspond to the medications in the pill box were: - Tamsulosin 0.4 milligram (mg, unit of measurement) one capsule daily - Valsartan-Hydrochloride (treatment of hypertension) 320-12.5 mg one tablet daily - Furosemide 20 mg half tablet daily - Atorvastatin (for treatment of high cholesterol) 40 mg one tablet daily Patient 3 stated he has Zepbound SQ 2.5 mg that was stored in the refrigerator and was being administered to him by CG 1. During Patient 3’s home visit on 10/15/2025 at 10:39 am, Patient 3’s medication profile in the electronic medical records was reviewed with LVN 1. Patient 3 had the following medications: - Zepbound SQ 2.5 mg/ 0.5 milliliters (ml, unit of volume) weekly for ...Anti-obesity - Ozempic (use for weight loss) SQ 0.25 mg/ 0.5ml weekly (Patient 3 did not have the medication) - Tamsulosin 0.4 mg one capsule daily - Metoprolol [extended release] (used to treat hypertension) 25 mg one tablet daily (was not in Patient 3’s pill box and the patient do not have the medication bottle) - Valsartan-Hydrochlorothiazide 320-12.5 mg one tablet daily - Atorvastatin calcium 40 mg one tablet daily The medication profile did not include Furosemide (Patient 3 and CG 1 indicated the patient was taking half tablet of Furosemide and the medication was found in Patient 3’s pill box and medication bottle). During a review of Patient 3’s “Admission Order”, dated 7/16/2025. The “Admission Order” indicated Patient 3 was referred to HHA for physical therapy, occupational therapy and for medication reconciliation. A review of Patient 3 “HHA and Plan of Care” (POC), dated 7/31/2025. The POC indicated the following treatments: - “SN to assess the patient and caregiver filling the medication box to determine if patient is filling it correctly” - “SN to assess if the Patient/Caregiver is able to verbalize understanding of indication for each medication” - “SN to determine if the patient/caregiver is able to identify the correct dose, route and frequency of medication” - “SN to assess Patient/Caregiver ability to open medication containers and determine the proper dose that should be administered” During a review of Patient 3 “HHA and Plan of Care”, dated 9/29/2025. The POC indicated the following treatments: - “SN to assess the patient and caregiver filling the medication box to determine if patient is filling it correctly” - “SN to assess if the Patient/Caregiver is able to verbalize understanding of indication for each medication” - “SN to determine if the patient/caregiver is able to identify the correct dose, route and frequency of medication” - “SN to assess Patient/Caregiver ability to open medication containers and determine the proper dose that should be administered” - “SN to observe patient drawing up injectable medications to determine if the patient draw up the correct dose... [and] administering injectable medication to determine if proper techniques is utilized” During an interview on 10/16/2025 at 1:40 pm, with the Registered Nurse Quality Assurance (RNQA), the RNQA stated the medication management should include the patient and caregiver’s education on medication side effects, signs and symptoms of exacerbation of condition, and administration of medication in accordance with the physician’s order. During an interview on 10/16/2025 at 2:42 pm, with CG 1. CG 1 stated she prepares Patient 3’s medication pill box and administer the Zepbound injection every Friday to the patient. CG 1 stated Patient 3 takes atorvastatin for cholesterol; valsartan, metoprolol and furosemide for blood pressure. CG 1 stated Patient 3 does not take tamsulosin anymore as this medication was for Patient’s 3 nasal symptoms. CG 1 stated she did not receive a medication list from the HHA and that she uses the list of medications she received from the physician when she prepares Patient 3’s medications. During an interview on 10/16/2025 at 2:56 pm with LVN 1, LVN 1 stated she was the assigned visiting nurse for Patient 3 twice a week. LVN 1 stated Patient 3 was receiving HHA services for hernia, fall risk, high cholesterol and medication management. LVN 1 stated CG has a full-time job during the day, and she only talk to CG 1 via the phone. LVN 1 stated when she does her home visit, it was only with Patient 3 and CG 1 was not there. LVN 1 stated she did not write Patient 3’s current medications on the “Medication Drug Regimen” form. LVN 1 stated she never observed CG 1 to ensure CG 1 was administering the Zepbound SQ to Patient 3 to ensure CG 1 was doing it correctly. LVN 1 stated she never observed CG 1 to ensure CG 1 prepares Patient 3’s pill box correctly. LVN 3 stated the lack of CG 1’s observation for medication preparation and administration may result in Patient 3’s medication error that may lead to hospitalization. During a review of HHA’s policies and procedures (P&P) titled “Medication Profile”, undated. The P&P indicated the following: - “Medication Profile will be updated for each change to reflect current medications, new, and/or discontinued medications” - “During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver understand the medication regimen” - “Using the medication profile to evaluate the use of medication in home setting” During a review of HHA’s P&P titled “Patient Self-Administration of Medication”, undated. The P&P indicated the following: “[The HHA] will provide teaching about the correct administration of medications by patient and family/caregiver as ordered by the attending physician” “The clinician will provide an opportunity for the patient to administer his/her own medications.” “The clinician will assess patient [and caregiver] ability to self-administer medications correctly” “The clinician will complete the medication profile for at admission and recertification” During a review of HHA’s P&P titled “Patient “Patient Education Process”, undated. The P&P indicated the following: - “Patient and caregiver will receive education in verbal, visual, and written format, as appropriate. - The clinical will assess, plan, implement and evaluate each patient/caregiver for the level of knowledge in relation to the diagnoses, plan of care, required activities by patient.” - “If a patient’s condition prevent him/her from participating in instruction, family/caregivers will receive the information/instruction.””

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element 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 therapeutic services to a patient’s personal residence) failed to ensure the assigned clinical manager (case manager, a professional who coordinates patient care by developing holistic plans that address medical, psychosocial, and financial needs) for three of 14 sampled patients’ (Patient 3, Patient 12 and Patient 14) services referral was coordinated for the patients to receive services timely, as ordered by the physician and in accordance with the facility’s policy and procedure. 1. For Patient 3, Occupational Therapy (OT, a rehabilitation that focused on helping recover the skills needed for daily living) referral for patient safety, was ordered on 7/16/2025. There was no documented evidence that Patient 3’s OT referral was conducted, and OT services was provided to the patient. 2. For Patient 12, Physical Therapy (PT – is a healthcare practice that uses physical techniques, such as service, massage, and heat therapy, to improve mobility, reduce pain, and restore function after an injury, illness, or surgery) referral, to establish treatment plan, was ordered on 12/27/2024. PT evaluation was conducted on 1/10/2025 (14 days after the PT referral was ordered). 3. For Patient 14, Speech Therapy (ST – is a treatment of communication and swallowing problems, helping people speak more clearly, understand language better, and use voice and swallowing skills effectively) referral, for assist for swallowing skills, for dysphagia, and speech exercise therapy, was ordered 11/29/2023. ST evaluation was conducted on 12/18/2023 (19 days after the ST referral was ordered). These failures had resulted in Patient 3, Patient 12, and Patient 14’s delayed treatment that could lead to patient harm, deterioration or exacerbation of patient’s medical condition, unplanned hospitalization and/or death. On 10/22/2025 5:48 p.m., the IJ was removed in the presence of the Administrator (ADM) after the facility submitted an acceptable IJ Removal Plan and the surveyor verified and confirmed onsite the facility’s implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 10/22/2025 at 5:48 p.m., included the following: On 10/21/2025 Immediate action upon receipt of the Immediate Jeopardy determination, the Director of Patient Care Services (DPCS) immediately implemented emergency corrective measures to ensure no active patient is at risk due to delayed therapy coordination. Effective 10/22/2025 Emergency team meeting held with the Intake Coordinator and Care Coordinators to review the deficiency and re-educate staff on the requirement that all physician-ordered services must be coordinated and initiated timely (within 48 hours of order receipt or as ordered by the physician). Verbal and written instruction provided that if therapy cannot be initiated within 48 hours, the Care Coordinator(s) (licensed nurse(s)) must: notify physician, obtain order for delay of care, and report the delay to DPCS. Effective 10/22/2025 A new “Referral Coordination and Timeliness Competency Assessment” was implemented and completed by all staff. The assessment ensures that all personnel responsible for intake and care coordination are competent in regulatory requirements, referral timeliness, communication, and escalation processes, thereby supporting the agency’s compliance and patient-safety objectives. On 10/22/2025 The agency care coordinators have reviewed the active patient list in real time to identify any open cases with new or pending therapy referrals in the last 10 business days. On 10/22/2025 record review of patient 20 and 21 showed no delay of referral to OT, PT, ST. Effective 10/21/2025 A Referral Coordination Tracker was created and implemented to log any new therapy orders moving forward, ensuring DPCS oversight of all PT/OT/ST referrals within 24 hours of receipt. Effective 10/21/2025 the DPCS will ensure that all entries are completed and accurate. The DPCS reviews the tracker daily for any new or pending referrals and verifies completion of all steps. The DPCS initials and dates each verified entry under the “Verified by DPCS” column to confirm oversight. Any identified delay, missing entry, or documentation gap is corrected immediately through staff follow-up and documentation in the clinical record. The Referral Coordination Tracker is reviewed weekly during clinical management meetings and monthly by the QA coordinator as part of ongoing QAPI monitoring. On 10/22/2025 Patient #3: Follow-up completed regarding Occupational Therapy (OT) evaluation originally ordered in July 2025. Patient remains active on service. Patient 3’s caregiver declines OT. On 10/22/2025 All contracted therapy providers were notified of the agency’s 48-hour referral coordination requirement and instructed to report any scheduling barriers to the referring staff member (care coordinator, intake coordinator, DPCS) immediately. Effective 10/22/2025 Policy and Process Revision “Care/Service Coordination,” “Internal Referral Process,” and “Intake Process” were reviewed and revised, All “physician-ordered” services to be initiated within 48 hours of referral receipt or as ordered by the physician. On 10/21/2025 The Referral Coordination and Timeliness Competency Assessment was implemented as a permanent competency validation tool for all staff involved in intake, scheduling, and care coordination. The Referral Coordination Tracker will continue as the agency’s permanent tracking and monitoring system for therapy and ancillary service referrals. Effective 10/22/2025 The DPCS and QA Coordinator will conduct weekly audits of at least five active referrals to verify timeliness and proper documentation. On 10/22/2025 All contracted PT, OT, and ST providers were re-notified of the agency’s 48-hour referral policy and contracts will be reviewed annually to ensure clear language regarding timeliness, communication expectations, and escalation to the DPCS if unable to staff referrals promptly. Findings: 1. During a review of Patient 3’s “Patient Information”, undated, indicated Patient 3, a 73 year-old male, with Start of Care (SOC) of 7/31/2025, had a primary diagnosis of hypertension (High blood pressure) and other diagnosis including but not limited to benign prostatic hyperplasia (BPH, condition where the prostate gland enlarges, putting pressure on the urethra), hyperlipidemia (high cholesterol in the blood) and abdominal hernia (part of the intestine or other tissue protrudes through the abdominal wall). The “Patient Information” indicated the assigned case manager for Patient 3 was the Director of Patient Care Services (DPCS). During a review of Patient 3’s “Admission Order,” dated 7/16/2025, indicated Patient 3 was referred to HHA for “PT, OT for safety and for medication reconciliation.” During a review of Patient 3’s “Physician Order”, dated 7/29/2025, indicated a delay of Start of Care (SOC) to begin on 7/31/2025. During a review of Patient 3’s “OASIS E-1 Start of Care”, dated 7/31/20205. The “OASIS E-1 Start of Care” indicated Patient 3’s treatments included skilled nursing services and physical therapy evaluation. The “OASIS E-1 Start of Care” did not indicate Patient 3 will receive OT services. During a concurrent interview and record review on 10/21/2025 at 9:23 am, with the DPCS, Patient 3’s “Episode Manager: Therapy,” for service period of 7/31/2025 to 9/28/2025, was reviewed. The DPCS stated there was no documentation that indicated Patient 3 was seen by the OT during the service period (7/312025 to 9/28/2025). During an interview on 10/21/2025 at 9:23 am, with DPCS. The DPCS stated when an outside referral (PT, OT, ST) was received by the facility, the assigned case manager will facilitate for the ordered referral to be conducted. The DPCS stated when the patient/family refused the referral for services such as OT, the referring physician should be notified to receive an order to discontinue the OT services. The DPCS stated there should be a communication note on the patient’s record regarding patient’s refusal of the services. The DPCS stated there was no documentation that Patient 3’s OT referral was coordinated for the OT to evaluate the patient. The DPCS stated there was no documentation that the patient or family refused the OT services. The DPCS stated as Patient 3’s case manager, she “owns it” for the patient’s OT referral not conducted. The DPCS stated patients who did not receive OT services as ordered by the physician may be at risk for injury. The DPCS stated Patient 3 missing the OT services missed the window of time that the patient would benefit from reaching their goals (patient safety). 2. During a review of Patient 12’s “Patient Profile,” undated, the “Patient Profile” indicated, Patient 12, a 94 year-old male with a Start of Care (SOC) of 12/31/2024, had a diagnosis of acute bronchitis (an infection of the bronchial tubes, the airways that carry air to and from lungs), and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the arteries of the heart, causing the arteries to narrow, blocking blood flow). During a review of Patient 12’s “Referral Order,” dated 12/27/2024, the “Referral Order” indicated, “PT to eval and establish treatment plan.” During review of Patient 12’s “OASIS-E Start of Care,” on 12/31/2024, the “Orders for Discipline and Treatments” indicated, “SN 2w2,1w7; PT Eval/treat; OT Eval/treat.” During a review of Patient 12’s “PT Initial Evaluation” dated 1/10/2025, the “PT Initial Evaluation” indicated, the evaluation was completed. During a concurrent interview and record review on 10/21/2025 at 11:09 am with DPCS, the DPCS stated when a PT referral was received, the assigned case manager would look for available PT through their contracted PT company, who would accept the referral. Referral order would be sent to the PT within 24 hours after the referral order was received. The DPCS stated if there was a delay of referral services, the physician should be notified. The DPCS stated Patient 12’s PT evaluation was completed on 1/10/2025 (14 days after the referral order was received). The DPCS stated there was no documentation on Patien12’s record as to why Patient 12’s evaluation was delayed. The DPCS stated there was no documentation that the physician was notified regarding Patient 12’s delayed PT services. DPCS stated a delay in services would cause difficulty for the patient to reach their treatment goals, delay in their progress towards their discharge plan, and there would be potential injury. During an interview on 10/21/2025 at 3:21 pm., with Contracted Services 1 (CS 1), CS 1 stated Patient 12’s PT referral was received from the facility on 12/31/2024 via email sent by Intake 1. CS 1 stated due to holiday the referral was entered into their system on 1/3/2025 and that PT will be available to evaluate Patient 12 on 1/10/2025. CS 1 stated the facility was made aware via email sent to Intake 1 on 1/3/2025. CS 1 stated Intake 1 responded on 1/6/2025 (3 days after the email was sent on 1/3/2025) indicating “to proceed” with PT eval on 1/10/2025 (14 days after the PT referral order was received). During a review of the “Agreement” ((Agreement – a negotiated and typically legally binding arrangement between parties as to a course of action), undated. The “Agreement” indicated an agreement between Contracted Rehabilitation Agency 1 (RA 1) and the HHA was started on 5/18/2023. The “Agreement” indicated “WHEREAS, SERVICE PROVIDER is engaged in the business of maintaining, conducting, and providing physical, occupational, and speech (hereinafter referred to as therapy services)”. 3. A review of Patient 14’s “Patient Information” undated, indicated Patient 14’s Start of Care (SOC) of 11/29/2023, had a primary diagnosis of atherosclerosis heart disease other diagnosis including but not limited to cerebral vascular accident and hypertension. A review of “Patient Grievance Tracking Log” undated, indicated on 12/12/2023, the facility received a call from Patient 14’s insurance regarding a complaint received by the insurance from Patient 14’s mother that the facility was not able to provide ST due to staffing, “Vocalized that we do not have a direct in house ST so we have to send the referral out to multiple contractors to staff. Although ST’s are hard to staff we had one company state they can do the Eval early next week but that the ST will be out for Christmas vacation…” A review of Patient 14’s “Physician Order”, dated 11/29/2023, indicated Patient 14 was referred to HHA for speech therapy (ST) to assist with swallowing skills for dysphagia and speech exercise therapy. A review of Patient 14’s “CMS 485” dated 11/29/2023 indicated, “ST: evaluate.” A review of Patient 14’s “ST Initial Evaluation,” dated 12/18/2023, indicated Patient 14 was evaluated for dysphagia (difficult swallowing), impaired verbal expression, and impaired short-term memory. (19 days after the ST referral order was received). During a concurrent interview and record review on 10/21/2025 at 11:09 a.m., with the DPCS, the DPCS stated Patient’s 14’s delayed ST evaluation was due to staffing issue. The DPCS stated it is unacceptable to have a reason for delayed services. The DPCS stated when the facility receives ST referral for the patient, it is expected for the patient to be evaluated by ST within two to three days after receiving the referral order. The DPCS stated Patient 14’s delayed ST evaluation could result in patient injury and prevent the patient from reaching his goals. During a concurrent interview and record review on 10/20/2025 at 11:58 am, with the Register Nurse Quality Assurance (RNQA), Patient 14’s “Plan Of Care” indicated Patient 14 needs to be evaluated by ST. The RNQA stated that once the order for referral was received, the patient should be evaluated within two days. The RNQA stated Patient 14’s ST referral was placed on 11/29/2023 and Patient 14 was seen by ST on 12/18/2023 (19 days after the order was received). The RNQA stated there was no clear communication between the facility and the contracted agencies regarding coordination of Patient 14’s ST evaluation. The RNQA stated a delay in ST services can potentially cause the patient to have poor nutrition, incident of choking or hospitalization. During an interview on 10/21/2025 at 1:31 pm, with Contracted Services 2 (CS 2), CS 2 stated ST referral was received via email from the facility on 12/11/2023 (12 days after the ST referral order was received by the facility). CS 2 stated the referral request received from the facility indicated Patient 14’s availability for ST evaluation was 12/18/2023. CS 2 stated ST was scheduled and evaluated Patient 14 on 12/18/2023. A review of “Service Contract,” undated, indicated CS 2’s contract commence on 6/7/2022, “The necessity to conform to all applicable company policies including personnel qualifications and the responsibility for participating in developing plans of treatments.” During review of HHA’s policies and procedure (P&P), titled “Care/Service Coordination”, undated. The P&P indicated the following: “Each patient will be assigned a case manager upon admission” “Care coordination will include... integration of services, whether the 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.” “When the patient requires more than one service from the organization, the Case Manager will be responsible for cooperative care planning in order to assure that goals, actions...and to minimize the potential for missed or conflicting services” Written evidence of care coordination may be found in patient’s clinical record. During review of HHA’s P&P titled “Internal Referral Process”, undated. The P&P indicated the following: “All internal referrals to other disciplines will be documented within the clinical record” “The additional services needed will be communicated to clinical supervisors/nursing supervisor or scheduler who will assign the appropriate clinician.” During a review of HHA’s P&P titled “Intake Process”, undated. The P&P indicated “the Clinical Supervisor/Nursing supervisor will assign personnel and schedule an initial assessment visit. The initial assessment visit will be performed either within 48 hours or the referral or within 48 hours of a patient’s return home, or on the start of care date ordered by the physician.” During a review of the facility’s brochure indicated the facility provided, “Services: Physical Therapy. Occupational Therapy. Speech Therapy.” During a review of the facility’s license indicated an expiration date of 2/3/2026, had an “Approved Services: - Physical Therapy - Occupational Therapy - Speech Therapy””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element 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 therapeutic services to a patient’s personal residence) failed to ensure a copy of discharge summary for two of 14 sampled discharge patients (Patient 10 and Patient 11) was provided to their primary care physician. This failure had the potential for Patient 10 and Patient 11’s lapse with continuity of care and may result in patient deterioration and/or re-hospitalization. Findings: During a review of Patient 10’s “Patient Information”, dated 10/17/2025, indicated the Start of Care (SOC) of 9/26/2024, with the primary diagnosis of management of ventricular assist device (VAD, a mechanical pump that helps a weakened heart circulate blood) and other diagnosis including but not limited to chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and diverticulitis of the intestines (a condition where part of the intestine becomes inflamed or infected). During a review of Patient 10’s “DC Order” (Discharge order), dated 10/14/2025. The “DC Order” indicated Patient 10 will be discharged from home health services on 10/14/2024 due to patient will start outpatient intravenous therapy (administration of fluids, medications or nutrients directly into a vein) tomorrow (10/15/2025). During a concurrent interview and record review on 10/20/2025 at 3:53 pm., with the Director of Patient Care Services (DPCS). Patient 10’s “Episode Manager”, with service period 09/26/2024 to 10/14/2024 was reviewed. The DPCS stated Patient 10 did not have a discharge summary created for this period. The DPCS stated discharge summary indicates discussion regarding patient’s diagnoses, the treatment and services they received and the result, if patients’ goal are met or unmet. The DPCS stated the primary physician should receive a copy of the discharge summary, and without receiving a discharge summary may result in lapses of continuity of care and pose the risk of re-hospitalization. 2. During a review of Patient 11’s “Patient Information”, dated 10/20/2025, indicated the Start of Care (SOC) of 7/2/2024, with the primary diagnosis of malignant neoplasm of prostate (prostate cancer) and other diagnoses including but not limited to Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), benign prostatic hyperplasia (BPH, condition where the prostate gland enlarges, putting pressure on the urethra). During a review of Patient 11’s “OASIS-E Discharge”, dated 10/28/2025. The “OASIS-E Discharge” indicated Patient 10 were discharged from home health services after meeting goals in physical therapy. During a concurrent interview and record review on 10/20/2025 at 3:53 pm., with the Director of Patient Care Services (DPCS). Patient 11’s “Episode Manager”, with service period 8/31/2024 to 10/28/2024 was reviewed. The DPCS stated Patient 11 did not have a discharge summary created for this period. The DPCS stated discharge summary indicates discussion regarding patient’s diagnoses, the treatment and services they received and the result, if patients’ goal are met or unmet. The DPCS stated the primary physician should receive a copy of the discharge summary, and without receiving a discharge summary may result in lapses of continuity of care and pose the risk of re-hospitalization. During a review of HHA’s policies and procedures (P&P) titled “Discharge Summary”, undated. The P&P indicated the following: - “Each patient discharged from a service and from the organization will have a written discharge summary completed and field in the clinical record” -“A copy of the discharge summary will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge””