Unity Home Health Providers, Inc.

“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 perform an assessment of a right jugular dialysis perm-catheter (a special tunneled central line used for hemodialysis, featuring two internal tubes to draw blood out and return cleaned blood to the body), during a visit, in accordance with the plan of care for one of five sampled patients’ (Patient 12). This deficient practice had the potential to result in Patient 12’s perm-catheter to malfunction from occlusion and for the skin site to become infected. During a review of Patient 12’s undated “Patient Information”, the “Patient Information” indicated Patient 12’s start of care (SOC) date was on 6/9/2025, with a primary diagnosis of enterocolitis (inflammation of both the small intestine and the colon). During a review of Patient 12’s Home Health Certification and Plan of Care (POC) for the re-certification period starting from 12/6/2025 to 2/3/2026, the POC included a physician order for the skilled nurse (SN) frequency of visits of twice a week for eight weeks, once a week for one week, for the skilled nurse (SN) to perform right jugular dialysis perm-catheter access site assessment/monitoring on every visit and to report to physician for any signs and symptoms of infection and complications. On 12/18/2025, at 10 a.m., a home visit was conducted at Patient 12’s residence with registered nurse (RN 1). Patient 12 was observed sitting on a couch with a right upper chest perm-catheter intact covered by a clean transparent dressing. On 12/18/2025, at 10:30 a.m., during an interview with RN 1, she stated Patient 12 has a right upper chest perm-catheter for dialysis and RN 1 assessed the catheter site to check for skin redness and for potential bleeding during her visits. A review of Patient 12’s Skilled Nursing Visit Notes dated 12/5, 12/9 and 12/12/2025, indicated there was no documented evidence that the visiting nurse was assessing the right jugular perm-catheter site for Patient 12. On 12/19/2025, at 12 p.m., during an interview with the Director Of Patient Care Services (DPCS), she stated the visiting nurse should be assessing Patient 12’s right jugular perm-catheter site on every visit to ensure the catheter and site does not get infected. During a review of the HHA’s undated policies and procedures (P&P)“Ongoing Assessments”, the policy indicated on each home visit, the clinician will re-evaluate the patient according to the problems identified and will re-assess the patient for skin integrity.”

“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 meet the Condition of Participation (COP, the term healthcare organizations must meet in order to participate in federally funded healthcare programs) for Reporting Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) information as follows: The HHA failed to ensure 12 of 968 OASIS for the last 12 months were submitted within 30 days of completing the assessments. This failure had the potential to result in inaccurate or delayed assessment of the patient’s needs and may affect timely interventions and continuity of care for patients. (Refer to G372). This cumulative practice resulted in systemic failure of the Home Health Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Reporting OASIS information of patients certified to receive home health benefits.”

“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 meet the Condition of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) for Care Planning, Coordination of Services, and Quality of Care was met as follows: 1. Patient 6’s diabetic ulcer (an open wound that develops in people with diabetes) of the right plantar (sole of the right foot) and right second toe (second toe on a person’s right foot) was photographed on initial assessment in accordance with the facility’s policy and procedure (P&P). 2. Patient 6’s diabetic ulcer of the right plantar and right second toe assessment included wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound (skin and tissue surrounding a wound) by Licensed Vocational Nurse 4 (LVN 4) from 6/4/2025 to 9/20/2025. 3. The “Daily Visit Notes,” for Patient 6 were completed and submitted by LVN 4 to indicate that wound assessments and wound care treatments were provided from 9/21/2025 to 10/2/2025, in accordance with Patient 6’s plan of care and the facility’s P&P. This deficient practice resulted in the delay in providing the care services ordered by the physician that could affect the health status and quality of life of these patients. (Refer to G592). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation for Care planning, Coordination, and Quality of Care to ensure highest quality of care are provided to patients certified to receive home health. The facility failed to: 2. Include the updated wound care orders to one of six sampled patients’ (Patient 4) plan of care. This failure had the potential to result in wound treatment errors to Patient 4 that may lead to delay healing or worsening of current wounds. (Refer to GTag 570) 3. Ensure plans of care for four of eight sampled patients (Patient 2, Patient 3, Patient 4 and Patient 6) were reviewed by the physician who is responsible for the home health plan of care when Patient 2’s, Patient 3’s, Patient 4’s and Patient 6’s “Home Health Recertifications and Plans of Care” (POC) did not have physician signatures. This failure had the potential to result in lack of coordination between the interdisciplinary team and the lack of physician review of the established plan of care. (Refer to GTag 588) 4. Ensure communication with the physician regarding Plans of Care. This failure had the potential to jeopardize patient care and patient safety. (Refer GTag 602) 5. Ensure the medication list for two of eight sampled patients (Patient 1 and Patient 2) was written in plain language when Patient 1’s and Patient 2’s “Medication Profiles” contained medical abbreviations. This failure had the potential to result in lack of patient understanding, medication errors, and possible missed medication doses, which could lead to possible hospitalization and contribute to an avoidable, traumatic death. (Refer GTag 616) 1. The HHA failed to include the updated wound care orders for one of six sampled patients (Patient 4) plan of care. This failure had the potential to result in wound treatment errors to Patient 4 that may lead to delay healing or worsening of current wounds. (Refer to G576). 2. The HHA failed to ensure timely and complete wound assessments were documented for one of eight sampled patients (Patient 6) in accordance with the facility’s policy and procedure (P&P) titled, “Wound Care Policy,” dated 9/1/2023, when the facility failed to: a. Photographed Patient 6’s diabetic ulcer (an open wound that develops in people with diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]) of the right plantar (sole of the right foot) and right second toe (second toe on a person’s right foot) on initial assessment in accordance with the facility’s P&P titled “Wound Care Policy,” dated 9/1/2023, that indicated each wound will be photographed. b. Ensure Licensed Vocational Nurse (LVN) 4 documented Patient 6’s wound assessment that included wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound (skin and tissue surrounding a wound) for Patient 6’s diabetic ulcer of the right plantar and right second toe from 6/4/2025 to 9/20/2025. c. Ensure LVN 4 completed and submitted Patient 6’s “Daily Visit Notes,” to indicate that wound assessments and wound care treatments were provided from 9/21/2025 to 10/2/2025, in accordance with Patient 6’s plan of care and the facility’s P&P titled “Ongoing Assessment,” undated, that indicated the clinician will re-assess the patient for skin integrity. These failures placed Patient 6 at risk placed for suffering complications such as wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization or death. (Refer to G592). 3. The HHA failed to ensure the Plan of Care (POC) was reviewed and signed by a physician for four of eight sampled patients (Patient 2, Patient 3, Patient 4 and Patient 6). This failure had the potential to result in lack of coordination between the interdisciplinary team (a group of professionals from different fields who collaborate to work on a common goal) and the lack of physician review of the established plan of care, which could lead to delayed or inappropriate treatment for Patient 2, Patient 3, Patient 4 and Patient 6. (Refer to G588). 4. The Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to patients in their homes to help with illness, rehabilitation, or to maintain health and independence) failed to ensure the physician was made aware when one of nine sampled patients (Patient 3) blood pressure and heart rate was not within normal range. This failure had the potential to put Patient 3 at risk for complications of low blood pressure and low heart rate such as dizziness, fainting and potentially life-threatening organ damage. (Refer G590). 5. The HHA failed to ensure the medication profile for one of eight sampled patients (Patient 1) has written instructions on how to administer the medications via gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential to result in lack of patient understanding, medication errors, and possible missed medication doses, which could lead to possible hospitalization and contribute to an avoidable, traumatic death. (Refer G616). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation for Care planning, Coordination, and Quality of Care to ensure highest quality of care are provided to patients certified to receive home health.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. 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 quality assessment and performance improvement (QAPI) of patients was met as follows: 1. The HHA failed to document how they measured, analyzed, and tracked, measurable improvement in QAPI (Quality Assessment and Performance Improvement) indicators for wound care and documentation. This failure had the potential for decrease quality of care and increased risk to patient safety for 42 of 42 patients. (Refer to G642) 2. The HHA QAPI program failed to address patients’ concern with wound care and assessment. This failure resulted in Patient 6’s assessment of diabetic ulcer (an open wound that develops in people with diabetes) of the right plantar (sole of the right foot) and right second toe (second toe on a person’s right foot) not being documented that could affect lack of treatment, wound healing and comfort, which could lead to the wounds worsening, becoming injured, and bacteria being introduced for 42 of 42 patients. (Refer to G656). 3. The HHA failed to document QAPI projects for the year 2025. This failure had the potential for increased risk to 42 of 42 patient safety, higher costs of preventable errors, increased operating costs, and potential sanctions or penalties from Centers for Medicare & Medicaid Services (CMS, a federal agency that runs the Medicare and Medicaid programs). (Refer to G658). 4. The HHA failed to ensure that the HHA’s Governing Body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) demonstrate and provide evidence of their GB knowledge and involvement in the agency’s Quality Assessment Performance Improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to ensure ongoing quality improvement and patient safety to Patient 6. This failure resulted in Patient 6 did not have timely and complete wound assessments, which placed Patient 6 at risk for suffering complications such as wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization or death. (Refer to G660) The cumulative effect of these practices resulted in the systemic failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Quality Assessment and Performance Improvement are provided to patients certified to receive home health benefits.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. 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 skilled professional services of patients was met as follows: 1. The HHA failed to ensure clinical visit notes were completed for three of eight sampled patients (Patient 2, Patient 4, and Patient 6) when Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 4, and LVN 5 did not document skilled nursing visit notes. This failure had the potential to result in lack of coordination between the interdisciplinary team that could result in delayed or inappropriate treatment that could put Patient 2, Patient 4 and Patient 6’s health at risk or health condition worsens. (Refer to G716) 2. The HHA failed to ensure the Physical Therapy Assistant providing services for two of three sampled patients (Patient 1 and Patient 3) were supervised by a Physical Therapist. This failure had the potential for Patient 1 and Patient 3 to decline or delay progress with functional status (person’s capacity to move safely and independently to perform activities of daily living like walking, standing or bending). (Refer G728). These practices resulted in the systemic failure of the Home Health Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for skilled professional services to ensure the quality of care were provided to patients certified to receive home health benefits.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on 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 meet the Condition of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) for Clinical Records of patients as follows: 1. The HHA failed to ensure clinical visit notes were completed for three of eight sampled patients (Patient 2, Patient 4, and Patient 6) when Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 4, and LVN 5 did not document skilled nursing visit notes. This failure had the potential to result in lack of coordination between the interdisciplinary team (a group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) that could result in delayed or inappropriate treatment that could put Patient 2, Patient 4 and Patient 6’s health at risk or health condition worsens. (Refer to G1012). 2. The HHA failed to ensure the Skilled Nursing Visit Notes for two of six sampled patients (Patient 2 and Patient 4) reflect the actual date when the visit notes were entered. This failure had the potential for Patient 2 and Patient 4’s delay in care coordination and inadequate monitoring which may lead to patients’ worsening condition and hospitalization. (Refer to G1024). This cumulative practice resulted in the systemic failure of the Home Health Agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Clinical Records to ensure the quality of care 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 12 of 968 Outcome and Assessment Information Set (OASIS, a standardized data collection tool used by HHA to measure patient outcomes, quality improvement and reimbursement rate) for the last 12 months were submitted within 30 days of completing the assessments. This failure had the potential to result in inaccurate or delayed assessment of the patient’s needs and may affect timely interventions and continuity of care for patients that could result in decline in patient condition, hospitalization or death. Findings: During an interview on 10/6/2025 at 9:21 am with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated OASIS data exported to Centers for Medicare & Medicaid Services (CMS, a federal agency that runs the Medicare and Medicaid programs), includes initial and comprehensive assessments (a thorough, foundational evaluation of a patient’s overall health status when they first enter a healthcare setting), discharges (a document that summarizes a patient’s facility stay and outlines their post-discharge care plan to ensure continuity of care and patient safety), and transfer assessments (an evaluation of a patient’s physical and mental status to ensure a safe and effective move to another unit, facility, or level of care). The ADM/DPCS stated the agency tried to submit OASIS data every week. During a concurrent interview and record review on 10/6/2025 at 9:45 am with the ADM/DPCS. The “HHA Error Summary Report” dated 10/6/2025, was reviewed. The ADM/DPCS stated there were 12 assessments within the last 12 months that received an error for “Record Submitted Late”. The ADM/DPCS stated the error “Record Submitted Late” were indicated when the assessment was exported to CMS past 30 days. The ADM/DPCS was unable to provide a report to indicate who were the patients affected by the late submission. The ADM/DPCS stated she does not know why the 12 assessments were submitted, and the person responsible for submitting the OASIS data was on vacation. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection,” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to patients in their homes to help with illness, rehabilitation, or to maintain health and independence) failed to document how they measured, analyzed, and tracked, measurable improvement in QAPI (Quality Assessment and Performance Improvement) indicators for wound care and documentation. This failure had the potential for decreased quality of care and increased risk to patient safety for 42 of 42 patients. Findings: During a review of Patient 6’s “Patient Information”, the “Patient Information” indicated Patient 6’s start of care (SOC) date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a review of Patient’ 6’s “Licensed Practical Nurse (LPN)/LVN – Skilled Nursing Visit” notes, authored by Licensed Vocational Nurse (LVN) 4 from 6/4/2025 to 9/20/2025, the LPN/LVN – Skilled Nursing Visit notes did not indicate wound assessments (wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound) of Patient 6’s right plantar and right second toe wounds. During a concurrent interview and record review on 10/6/2025 at 10:19 am with Administrator/Director of Patient Care Services (ADM/DPCS), the QAPI binder, dated 2025, was reviewed. The QAPI binder indicated no documents for tracking or improving data indicators for wound care assessment and documentation. The ADM/DPCS stated we have a QAPI plan, but it was not available because only the Consultants have access to it, they are on vacation, and I don’t know when they will return. We do not have a QAPI policy and procedure (P&P). During a review of the facility’s policy and procedure (P&P) titled, “Wound Care Policy,” dated 9/1/2023, indicated each wound will be photographed. During a review of the P&P titled “Ongoing Assessment,” undated, that indicated the clinician will re-assess the patient for skin integrity.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, a Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to patients in their homes to help with illness, rehabilitation, or to maintain health and independence) failed to document QAPI (Quality Assessment and Performance Improvement) projects for the year 2025 This failure had the potential for increased risk to patient safety, higher costs of preventable errors, increased operating costs, and potential sanctions or penalties from Centers for Medicare & Medicaid Services (CMS, a federal agency that runs the Medicare and Medicaid programs). Findings: During a concurrent interview and record review on 10/6/2025 at 1:25 pm with Administrator/Director of Patient Care Services (ADM/DPCS), the QAPI binder, dated 2025 was reviewed. The QAPI binder indicated, no performance improvement project, only CMS printouts of national statistics for handwashing and falls. The ADM/DPCS stated the agency does not have paper copies of the QAPI plan, monitoring or evaluation.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on interview and record review, the Governing Body of a Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to patients in their homes to help with illness, rehabilitation, or to maintain health and independence) failed to ensure that the HHA’s Governing Body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) demonstrate and provide evidence of their GB knowledge and involvement in the agency’s Quality Assessment Performance Improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to ensure ongoing quality improvement and patient safety to Patient 6. This failure resulted in Patient 6 did not have timely and complete wound assessments, which placed Patient 6 at risk for suffering complications such as wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization or death. Findings: During a review of Patient 6’s “Patient Information,” “Patient Information” indicated Patient 6’s start of care (SOC) date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a review of Patient’ 6’s “Licensed Practical Nurse (LPN)/LVN – Skilled Nursing Visit” notes, authored by LVN 4 from 6/4/2025 to 9/20/2025, the LPN/LVN – Skilled Nursing Visit notes did not indicate wound assessments (wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound) of Patient 6’s right plantar and right second toe wounds. During an interview on 10/6/2025 at 10:19 am with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated wound assessment and documentation was not identified as a QAPI project because they prioritized the other three projects (falls, infection, and late notes), there was no specific Policy & Procedure regarding QAPI, and QAPI projects were selected based on the facility’s percentage of occurrences compared with CMS national averages. During a review of HHA Facility Quarterly QAPI meeting for 2nd quarter 2025, the meeting minutes indicated that the facility has no concerns with Quality of Care for Month 1 (April 2025), Month2 (May 2025) and Month 3 (June 2025) did not have issues with quality of care. During a concurrent interview and record review on 10/7/2025 at 1:52 pm with Co-CEO, Governing Body Binder, dated 2025 was reviewed. The Governing Body Binder indicated no documentation of QAPI discussions beyond January 2025. The Co-CEO stated that the Governing Body January 2025 meeting minutes did not specify what was discussed regarding QAPI projects. The Co-CEO stated there was no other documentation for Governing Body meetings since January 2025.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, a Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Skilled Nursing Visit Notes for two of six sampled patients (Patient 2 and Patient 4) reflect the actual date when the visit notes were entered. This failure had the potential for lack of communication between healthcare teams, that could result in delay in care coordination for Patient 2 and Patient 4’s, inadequate monitoring which may lead to patients’ worsening condition and hospitalization. Findings: 1. During a review of Patient 2’s “Patient Information” (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was on 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 2:49 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s “LVN (Licensed Vocational Nurse) – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN – Skilled Nursing Visits were blank. The ADM/DPCS stated the visit notes were blank and has asked LVN 5 repeatedly to document her assessments from the patient visits on 9/10/2025 and 9/12/2025. The ADM/DPCS stated nurses are expected to chart their visits in the patient’s electronic health record within seven days. The ADM/DPCS stated if their visits are not documented, they did not do it. The ADM/DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician. During an interview on 10/2/2025 at 11:52 am with the ADM/DPCS, the ADM/DPCS stated the date the staff sign “LVN – Skilled Nursing Visit” note should reflect the date the note was completed. During a review of Patient 2’s “LVN – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN - Skilled Nursing Visits indicated LVN 5 “digitally signed,” the notes on 9/10/2025 and 9/12/2025. During an interview on 10/2/2025 at 2:31 pm with LVN 5, LVN 5 stated she was the visiting nurse for Patient 2. LVN 5 stated visit notes are expected to be completed on the same day of the visit. LVN 5 stated she completed her visit notes from 9/10/2025 and 9/12/2025 on 9/26/2025. LVN 5 stated timely documentation was important so other staff members can see the patients’ progress. During an interview on 10/2/2025 at 2:44 pm with the ADM/DPCS, the ADM/DPCS stated a report called “Task Detail Report (a comprehensive overview of tasks to monitor documentation and track progress)” would indicate the date and the name of the person that completed the visit notes. During a concurrent interview and record review on 10/2/2025 at 2:50 pm with the ADM/DPCS, Patient 2’s “Task Detail Report,” dated 9/10/2025 and 9/12/2025 indicated LVN 5 submitted the visit notes on 10/1/2025. The ADM/DPCS stated LVN 5 did not submit any notes on 9/26/2025 because it would reflect on the Task Detail Report. The ADM/DPCS stated the visit notes from 9/10/2025 and 9/12/2025 were submitted late on 10/1/2025. 2. During a review of Patient 4’s “Patient Information,” undated. The “Patient Information” indicated Patient 4, a 74 year-old female, SOC date was on 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/2/2025 at 11:26 am with Registered Nurse (RN) 1. Patient 4’s “Episode Manager: Nursing”, for the certification period 8/13/2025 to 10/11/2025 was reviewed. The “Episode Manager: Nursing” indicated the RN-skilled nursing visit assigned to RN 1 on 9/6, 9/9, 9/13, 9/16, 9/20, 9/23, 9/27 with the visit note status as “Not Started”. RN 1 stated the visit notes should be completed in 2-3 days after the date of visit, and she was aware that she has been behind with her notes. RN 1 stated she will work on her late notes tonight (10/2/2025). During an interview on 10/2/2025 at11:52 am with the DPCS, the DPCS stated the date the staff sign the visit note should reflect the date the note was completed. During an interview on 10/2/2025 at 2:44 pm with the DPCS, the DPCS stated a report called “Task Detail Report” would indicate the date and the name of the person that completed the visits notes. During a concurrent interview and record review on 10/6/2025 at 11:19 am with the DPCS, Patient 4’s “RN-Skilled Nursing Visit Note”, dated 9/13, 9/16, 9/20, 9/22 and 9/27 was reviewed. The “RN-Skilled Nursing Visit Note” was signed and dated by RN 1 that the notes were completed on the same date the visit was completed. The DPCS stated the visit notes should be signed on the date it was entered. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit” (a comprehensive overview of tasks to monitor documentation and track progress), dated 9/13/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on 10/3/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/16/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on 10/2/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/20/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on10/2/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/22/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on n 10/3/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/27/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on 10/3/2025. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided… Amendments, correction or late entries within an electronic health record must: Distinctly identify ant amendment, correction or late entry Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification.” 1 Findings: 1. During a review of Patient 2’s “Patient Information” (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was on 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 2:49 pm, Patient 2’s “LVN (Licensed Vocational Nurse) – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN – Skilled Nursing Visits were blank. The ADM/DPCS stated the visit notes were blank and had asked LVN 5 repeatedly to document her assessments from the patient visits on 9/10/2025 and 9/12/2025. The Administrator/Director of Patient Care Services (ADM/DPCS) stated nurses were expected to chart their visits in the patient’s electronic health record within seven days. The ADM/DPCS stated if their visits were not documented, they did not do it. The ADM/DPCS stated missing and late documentation could jeopardize (to put one’s health at risk or in danger) the patients’ care and result in a lack of communication with their physician. During an interview on 10/2/2025 at 11:52 am with the ADM/DPCS, the ADM/DPCS stated the date the staff sign “LVN – Skilled Nursing Visit” note should reflect the date the note was completed. During a review of Patient 2’s “LVN – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN - Skilled Nursing Visits indicated LVN 5 “digitally signed,” the notes on 9/10/2025 and 9/12/2025. During an interview on 10/2/2025 at 2:31 pm with LVN 5, LVN 5 stated she was the visiting nurse for Patient 2. LVN 5 stated visit notes are expected to be completed on the same day of the visit. LVN 5 stated she completed her visit notes from 9/10/2025 and 9/12/2025 on 9/26/2025. LVN 5 stated timely documentation was important so other staff members can see the patients’ progress. During an interview on 10/2/2025 at 2:44 pm with the ADM/DPCS, the ADM/DPCS stated a report called “Task Detail Report (a comprehensive overview of tasks to monitor documentation and track progress)” would indicate the date and the name of the person that completed the visit notes. During a concurrent interview and record review on 10/2/2025 at 2:50 pm with the ADM/DPCS, Patient 2’s “Task Detail Report,” dated 9/10/2025 and 9/12/2025 indicated LVN 5 submitted the visit notes on 10/1/2025. The ADM/DPCS stated LVN 5 did not submit any notes on 9/26/2025 because it would reflect on the Task Detail Report. The ADM/DPCS stated the visit notes from 9/10/2025 and 9/12/2025 were submitted late on 10/1/2025. 2. During a review of Patient 4’s “Patient Information,” undated. The “Patient Information” indicated Patient 4, SOC date was on 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/2/2025 at 11:26 am with Registered Nurse (RN) 1. Patient 4’s “Episode Manager (refers to the documentation created and maintained by a home health agency to manage a patient’s entire episode of care. The document helps track all services provided during a specific timeframe to address a patient’s medical condition): Nursing”, for the certification period 8/13/2025 to 10/11/2025 was reviewed. The “Episode Manager: Nursing” indicated the RN-skilled nursing visit assigned to RN 1 on 9/6/2025, 9/9/2025, 9/13/2025, 9/16/2025, 9/20/2025, 9/23/2025, 9/27/2025 with the visit note status as “Not Started”. RN 1 stated the visit notes should be completed in two to three days after the date of visit, and she was aware that she has been behind with her notes. RN 1 stated she will work on her late notes tonight (10/2/2025). During an interview on 10/2/2025 at11:52 am with the DPCS, the DPCS stated the date the staff sign the visit note should reflect the date the note was completed. During an interview on 10/2/2025 at 2:44 pm with the DPCS, the DPCS stated a report called “Task Detail Report” would indicate the date and the name of the person that completed the visits notes. During a concurrent interview and record review on 10/6/2025 at 11:19 am with the DPCS, Patient 4’s “RN-Skilled Nursing Visit Note”, dated 9/13/2025, 9/16/2025, 9/20/2025, 9/22/2025 and 9/27/2025 was reviewed. The “RN-Skilled Nursing Visit Note” was signed and dated by RN 1 that the notes were completed on the same date the visit was completed. The DPCS stated the visit notes should be signed on the date it was entered. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit” (a comprehensive overview of tasks to monitor documentation and track progress), dated 9/13/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on 10/3/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/16/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on 10/2/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/20/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on10/2/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/22/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on n 10/3/2025. During a review of Patient’s “Task Detail: RN - Skilled Nursing Visit”, dated 9/27/2025. The “RN - Skilled Nursing Visit” indicated RN 1 completed and submitted the visit note for review on 10/3/2025. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided… Amendments, correction or late entries within an electronic health record must: Distinctly identify ant amendment, correction or late entry Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each record modification.””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to include the updated wound care orders for one of six sampled patients’ (Patient 4) plan of care. This failure had the potential to result in wound treatment errors to Patient 4 that may lead to delay healing or worsening of current wounds. Findings: During a review of Patient 4’s “Patient Information”, undated. The “Patient Information” indicated Patient 4 start of care (SOC) date was on 8/24/2023, with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 4’s “Plan of Care”, dated 8/12/2025. The “Plan of Care” indicated the following: 1. On right perineum (area between genitals and anus) pressure injury and left sacrum (area at the base of the spine) pressure injury - to apply Medihoney (a medical grade honey to promote wound healing) daily and as needed 2. On right posterior ischium (lower back part of the right hipbone) pressure injury– to apply Skin Graft (a skin substitute to treat non-healing wounds) and to change dry dressing above adaptic dressing (a mesh dressing with petroleum to prevent adhesion) daily. During a review of Patient 4’s “Progress Notes”, dated 9/4/2025. The “Progress Notes” indicated Patient 4 has the following pressure injuries: 1. Right perineum stage 3 pressure injury (full thickness loss of skin. Dead and black tissue may be visible) with plan to apply Santyl (an ointment used for removing dead tissue on pressure injury) daily. 2. Right thigh stage 3 pressure injury with plan to apply Santyl daily. 3. Right ischium stage 4 pressure injury (Full thickness skin and tissue loss with exposed muscle tendon, ligament, cartilage or bone) with plan to apply Skin Graft and may change dressing above adaptic dressing (a medical wound dressing that prevents sticking) as needed. During an interview on 10/2/2025 at 10:34 am with the Director of Patient Care Services (DPCS), the DPCS stated the plan of care was created at the beginning of the certification period (the duration a patient is considered eligible to received HHA services), and updates or changes on plan of care will be seen on patient’s medication profile (a comprehensive record of a patient’s current and historical medication and treatment record) to supplement the plan of care. During a concurrent interview and record review on 10/2/2025 at 10:54 am with the DPCS, Patient 4’s “Medication Profile” dated 8/13/2025 to 10/11/2025 was reviewed. The DPCS stated the “Medication Profile” did not reflect the changes with wound treatment orders for right perineum and right thigh. The DPCS stated the plan of care should be updated as soon as new wound treatment order was received. The DPCS stated not updating the plan of care may result in treatment errors and lead to Patient 4’s wound worsening or delaying healing. During a review of HHA’s policies and procedures (P&P), titles “Care Planning Process”, undated. The P&P indicated the following: 1. The care planning process will be documented on the plan of care, clinical notes and medication profile. 2. The plan of care will be based upon the physician’s orders and will encompass the equipment, supplies and services required to meet the patient’s needs.”

“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 facility failed to ensure the Plan of Care (POC) was reviewed and signed by a physician for four of eight sampled patients (Patient 2, Patient 3, Patient 4 and Patient 6). This failure had the potential to result in lack of coordination between the interdisciplinary team (a group of professionals from different fields who collaborate to work on a common goal) and the lack of physician review of the established plan of care, which could lead to delayed or inappropriate treatment for Patient 2, Patient 3, Patient 4 and Patient 6. Findings: 1. During a review of Patient 2’s Patient Information (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a review of Patient 2’s “Home Health Certification and Plan of Care (POC, a required document that authorizes and outlines the specific medical services a patient will receive at home, typically on a 60-day basis),” for the recertification period from 8/4/2025 to 9/15/2025, the POC did not indicate a physician signature or date signed. 2. During a review of Patient 3’s “Patient Information”, undated, the “Patient Information,” indicated Patient 3, SOC date was 6/22/2025 with primary diagnosis of chronic thromboembolic pulmonary hypertension (high blood pressure in the lungs) and secondary diagnosis of chronic pulmonary embolism (blood clots in the lungs). During a concurrent interview and record review on 10/1/2025 at 1:50 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 3’s “Home Health Certification and Plan of Care”, for recertification periods 6/22/2025 to 8/20/2025 and recertification period 8/21/2025 to 10/19/2025 were reviewed. Patient 3’s POC did not indicate a physician signature or date signed. The ADM/DPCS stated she was aware they [the facility] have a problem with physicians not signing documents. 3. During a review of Patient 4’s “Patient Information”, undated. The “Patient Information” indicated Patient 4 SOC date was on 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Patient 4’s “Home Health Certification and Plan of Care”, dated 6/13/2025. The POC was for the certification period 6/14/2025 to 8/12/2025. The POC was signed by Patient 4’s attending physician on 7/22/2025. During a review of Patient 4’s “Home Health Certification and Plan of Care”, dated 8/12/2025. The POC was for the certification period 8/13/2025 to 10/11/2025. The POC did not indicate a physician signature. The most recent plan of care signed by the physician was more than 2 months ago). During an interview on 10/1/2025 at 1:50 pm with the DPCS. The DPCS stated once the plan of care is completed it is sent to the patient’s attending physician and will be returned to the HHA once signed via fax. The DPCS stated the plan of care should be signed by the attending physician (a fully licensed doctor who is responsible for a patient’s overall care). The DPCS stated she is aware the HHA have concerns on physicians not signing the plan of are on time. 4. During a review of Patient 6’s Patient Information, the Patient Information indicated Patient 6’s SOC date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a review of Patient 6’s “Home Health Certification and POC,” for the recertification period from 7/18/2025 to 9/15/2025, the POC did not indicate a physician signature or date signed. During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection,” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided... A clinical/service record will be initiated and maintained for each patient receiving care or services... and will include at a minimum...Signature authorization of clinical/service documentation will include the staff member’s name and credentials.” During a review of HHA’s P&P, titled “Physician Participation of Plan of Care”, undated. The P&P indicated “The attending physician recertification will be obtained in intervals of at least every 60 days when the patient’s plan of care is reviewed.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to patients in their homes to help with illness, rehabilitation, or to maintain health and independence) failed to ensure the physician was made aware when one of nine sampled patient’s (Patient 3) blood pressure and heart rate was not within normal range. This failure had the potential to put Patient 3 at risk for complications of low blood pressure, low heart rate such as dizziness, fainting and potentially life-threatening organ damage. Findings: During a review of Patient 3’s “Patient Information”, undated, the “Patient Information,” indicated Patient 3’s start of care (SOC) date was 6/22/2025 with primary diagnosis of chronic thromboembolic pulmonary hypertension (high blood pressure in the lungs) and secondary diagnosis of chronic pulmonary embolism (blood clots in the lungs). During a concurrent interview and record review on 10/1/2025 at 2:52 pm with Administrator/Director of Patient Care Services (ADM/DPCS), the Skilled Nursing Visits, dated 6/26/2025- 9/24/2025 were reviewed. The Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated the following vital signs were documented on Resident 3’s “Skilled Nursing Visits” were not within normal ranges as follows: 9/24/2025: Blood pressure (BP) 97/52 millimeters of mercury (mmHg, unit of measurement). Reference range: A BP of less than 100/80 mmHg is low, BP of 120-129/80 mmHg is elevated, and 130/80 and above is considered high. Pt 3’s pulse 54 beats per minute (bpm, unit of measurement) normal reference range 60-100 bpm. 9/22/2025: BP 101/57 mmHg, pulse 54 bpm 9/19/2025: pulse 54 bpm 8/29/2025: BP 107/47 mmHg, pulse 54 8/27/2025: BP 98/55 mmHg, pulse 54 bpm 8/22/2025: BP 89/54 mmHg, pulse 54 bpm 8/20/2025: BP 96/54 mmHg, pulse 58 bpm 7/30/2025: BP 96/47 mmHg 7/27/2025: BP 100/54 mmHg 7/25/2025: BP 104/59 mmHg 7/18/2025: BP 100/54 mmHg 7/11/2025: BP 100/52, pulse 57 bpm 6/25/2025: BP 99/40 mmHg During a concurrent interview and record review on 10/1/2025 at 2:52 pm with Administrator/Director of Patient Care Services (ADM/DPCS), the Skilled Nursing Visits, dated 6/26/2025- 9/24/2025 were reviewed. The Skilled Nursing Notes did not indicate the physician was notified when Patient 3’s blood pressure and heart rates were not within normal limits. The ADM/DPCS stated, if the nurse’s notes on the Skilled Nursing Visits did not indicate the physician was notified, then it did not happen (the physician was not notified). The ADM/DPCS stated not communicating a patient’s blood pressure and pulses that were not within reference range to the physician could lead to lack of oxygen to the brain and other organs, resulting in dizziness, fainting and potentially life-threatening organ damage. During a review of the facility’s policy and procedures (P&P) titled, “Ongoing Assessments, Policy No. 4-019.1,” undated indicated, “7. The Physician will be notified to verify any changes …. and treatment/interventions that require physician approval.””

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. 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 timely and complete wound assessments were documented for one of eight sampled patients (Patient 6) in accordance with the facility’s policy and procedure (P&P) titled, “Wound Care Policy,” dated 9/1/2023, when the facility failed to: 1. Photographed Patient 6’s diabetic ulcer (an open wound that develops in people with diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]) of the right plantar (sole of the right foot) and right second toe (second toe on a person’s right foot) on initial assessment in accordance with the facility’s P&P titled “Wound Care Policy,” dated 9/1/2023, that indicated each wound will be photographed. 2. Ensure Licensed Vocational Nurse (LVN) 4 documented Patient 6’s wound assessment that included wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound (skin and tissue surrounding a wound) for Patient 6’s diabetic ulcer of the right plantar and right second toe from 6/4/2025 to 9/20/2025. 3. Ensure LVN 4 completed and submitted Patient 6’s “Daily Visit Notes,” to indicate that wound assessments and wound care treatments were provided from 9/21/2025 to 10/2/2025, in accordance with Patient 6’s plan of care and the facility’s P&P titled “Ongoing Assessment,” undated, that indicated the clinician will re-assess the patient for skin integrity. These failures placed Patient 6 at risk placed for suffering complications such as wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization or death. On 10/3/2025 at 1:51 pm, while onsite at the facility, the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident), in the presence of the Administrator/Director of Patient Care Services (ADM/DPCS) and the ADM Designee related to the HHA failure to ensure timely and complete wound assessments were documented for Patient 6, which placed Patient 6 at risk for suffering complications such as wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization or death. Findings: 1. During a review of Patient 6’s Patient Information (admission record), Patient Information indicated Patient 6’s Start of Care (SOC) date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a review of Patient 6’s OASIS (Outcome and Assessment Information Set) Transfer form (a standardized health assessment used in home healthcare for patients being transferred from one agency to another, or from home to a hospital) dated 5/20/2025, the OASIS Transfer form indicated Patient 6 was transferred to General Acute Care Hospital (GACH 1) on 5/20/2025 for evaluation of diabetic right foot infection. During a review of Patient 6’s OASIS Resumption of Care (OASIS ROC) an assessment type that home health agencies use when a patient returns to their care after a break in services), dated 6/3/2025, the OASIS ROC indicated Patient 6 was discharged from GACH 1 on 6/2/2025 for right foot infection. The OASIS ROC indicated Patient 6 had the following diabetic wounds: Patient 6’s right plantar wound had irregular edges, scant serosanguineous drainage (minimal amount of pink, watery fluid from a wound), macerated (skin that has softened and broken down due to excessive moisture) surrounding tissue, and measured 2 centimeters (cm, a unit of measurement) by 1.3 cm by 0.2 cm. Patient 6’s right second toe had attached edges, no drainage, erythema (abnormal redness) in the surrounding tissue, and measured 1 cm by 1 cm by 0.2 cm. During a review of Patient 6’s OASIS ROC dated 6/3/2025, the OASIS ROC did not include photographs of Patient 6’s diabetic wounds. During a review of Patient 6’s OASIS Recertification (a follow-up assessment conducted in the last five days of each 60-day home health certification period to ensure they still meet eligibility requirements), dated 9/12/2025, the OASIS Recertification did not include photographs of Patient 6’s diabetic wounds. During an interview on 10/1/2025 at 4:06 pm with the ADM/DPCS, the ADM/DPCS stated she called Patient 6 to determine if the Department would be able to conduct a home visit and interview with him. The ADM/DPCS stated Patient 6 declined and stated he did not want any home visitors and did not want to speak with anyone from the Department, including over the phone. During an interview on 10/2/2025 at 12:01 pm with LVN 4, LVN 4 stated he was the assigned LVN for Patient 6 and does Patient 6’s wound care treatment daily. LVN 4 stated he was aware that Patient 6’s wound should be assessed and photographed during each visit. LVN 4 stated it was important to photograph wounds during each visit to ensure members of the interdisciplinary team (a group of professionals from different fields who collaborate to work on a common goal) can visually see Patient 6’s wounds’ progression and identify if they were worsening. During an interview on 10/2/2025 at 3:29 pm with the ADM/DPCS, the ADM/DPCS stated LVN 4 was supposed to have wound assessments, including photos of the wounds, documented in Patient 6’s record. The ADM/DPCS stated if it was not documented, then it was not done. During a review of the facility’s P&P titled, “Wound Care Policy,” dated 9/1/2023, the P&P indicated the following: “Each wound will be photographed and digitally sent to the Case Manager for approval of the wound image, assessment of the wound and ordered treatment and coordination with the wound care specialist if assigned. Wound digital images are used as an adjunct to electronic/written documentation.” During a review of the facility’s P&P titled, “Photo Documentation,” undated, the P&P indicated, “the photo documentation purpose is to: - Document the initial condition of the client’s skin upon admission, - Document clear, accurate status of skin conditions, - Document clear objective images of the outcomes of treatment plan - Facilitate communication between the treatment team and prescribing physician.” 2. During a review of Patient 6’s “Home Health Certification and Plan of Care (a standardized patient assessment used by home health agencies to plan care),” for the recertification period from 7/18/2025 to 9/15/2025, the Home Health Certification and Plan of Care indicated for the skilled nurse to “Assess/monitor site during visit; report signs/symptoms of infection to Doctor of Medicine (MD).” During a review of Patient 6’s “Frequency Order,” dated 7/20/2025, the Frequency Order indicated for the skilled nurse to visit “once daily for 27 days, then reassess.” During a review of Patient 6’s “Licensed Practical Nurse (LPN)/LVN – Skilled Nursing Visit” notes, authored by LVN 4 from 6/4/2025 to 9/20/2025, the LPN/LVN – Skilled Nursing Visit notes did not indicate assessments (wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound) of Patient 6’s right plantar and right second toe wounds. During an interview on 10/2/2025 at 10:10 am with the ADM/DPCS, the ADM/DPCS stated all patient wounds should be measured at least every seven days by the licensed nurse assigned to visit the patient. The DPCS stated Patient 6’s physician manages Patient 6’s care and that the licensed nurses should follow the physician’s order. During an interview on 10/2/2025 at 12:01 pm with LVN 4, LVN 4 stated he was the assigned LVN for Patient 6 and does Patient 6’s wound care treatment daily. LVN 4 stated he was aware that Patient 6’s wound should be assessed and measured with each visit. LVN 4 stated he forgot to document Patient 6’s wound assessment and wound measurements in his notes (from 6/4/2025 to 9/20/2025). LVN 4 stated it was important to document wound assessments after each visit to ensure members of the interdisciplinary team can see Patient 6’s wounds’ progression and identify if they were worsening. During an interview on 10/2/2025 at 3:29 pm with the ADM/DPCS, the ADM/DPCS stated LVN 4 was supposed to have wound assessments documented in Patient 6’s record. The ADM/DPCS stated if it was not documented, then it was not done. The ADM/DPCS stated LVN 4 calls the HHA to give updates after each visit with Patient 6 and has instructed LVN 4 to document the information in Patient 6’s visit notes. The ADM/DPCS stated the HHA does not keep a log of LVN 4’s verbal reports and has instructed LVN 4 to document his assessments in his visit notes. During an interview on 10/2/2025 at 3:32 pm with the ADM/DPCS, the ADM/DPCS stated all staff were aware of the facility’s wound care policies. The ADM/DPCS stated the patient’s wound assessment that includes wound measurement, peri wound, and wound tissue appearance helps determine if the patient’s wound is getting worse or improving. During a review of the facility’s P&P titled, “Wound Care Policy,” dated 9/1/2023, the P&P indicated the following: At each visit the patient’s skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition…At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present.” During a review of the facility’s P&P titled, “Application of Dry Dressing”, undated, the P&P indicated, “the purpose of applying a dry dressing is to protect the wound from injury, prevent introduction of bacteria, reduce discomfort, and assist with healing.” During a review of the facility’s P&P titled, “Application of Dry Dressing”, undated, the P&P indicated, “Document in the clinician record the following: - Appearance, odor and size of wound. - Amount and characteristics of drainage.” 3. During an interview on 10/1/2025 at 2:49 pm with the ADM/DPCS, the ADM/DPCS stated late, or missing documentation could result in a lack of communication between interdisciplinary teams, which could result in jeopardized (to put someone into a situation in which there is a danger of loss, harm, or failure) patient care. During an interview on 10/2/2025 at 12:03 pm with LVN 4, LVN 4 stated he did not complete Patient 6’s visit notes from 9/21/2025 to 10/2/2025 because he forgot. stated it was important to ensure timely documentation of patient visits so other interdisciplinary team members can see the patient’s progress. During a review of the facility’s P&P titled, “Ongoing Assessment,” undated, the P&P indicated, “Using the standards of care identified by the organization the clinician will re- assess the patient for skin integrity.” During a review of the facility’s P&P titled, “Care Planning Process,” undated, the P&P indicated the following: Purpose - To provide clinician directions to the clinicians providing direct patient care. The patients’ plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries.””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure the medication profile for one of eight sampled patients (Patient 1) has written instructions on how to administer the medications via gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential to result in lack of patient understanding, medication errors, and possible missed medication doses, which could lead to possible hospitalization and contribute to an avoidable, traumatic death. Findings: 1. During a review of Patient 1’s “Patient Information,” undated, the “Patient Information” indicated Patient 1, a 75 year-old male, start of care (SOC) was on 11/13/2024 with diagnoses including but not limited to pneumonia (an infection/inflammation in the lungs) and management of ventricular assist device (VAD, mechanical pump surgically placed to help weakened heart to circulate blood). During Patient 1’s home visit with Licensed Vocational Nurse (LVN) 3 on 10/2/2025 at 9:00 am. Patient 1’s “Medication Profile”, for the certification period of 9/9/2025 to 11/07/2025 was reviewed. The “Medication Profile” indicated the following medications to be administered via gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems): furosemide (used to treat fluid retention and high blood pressure), Zyrtec (used to treat allergy symptoms), gabapentin (used to relieve nerve pain), fludrocortisone acetate (used to replace certain hormones the body does not produce enough), omeprazole (used to reduce the amount of acid the stomach produces), atorvastatin (used to lower cholesterol (a fat-like substance found in the body) in the blood), amantadine (used to treat Parkinson’s disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)), sertraline (used to treat depression), entacapone (used to treat Parkinson’s disease), polyethylene glycol (used to treat or prevent constipation), clopidogrel bisulfate (used to prevent blood clots), tamsulosin (used to treat symptoms such as enlarged prostate that makes it difficult to urinate), alfuzosin (used to treat symptoms such as enlarged prostate that makes it difficult to urinate), aspirin (used to prevent blood clots), carbidopa-levodopa-entacapone used to treat Parkinson’s disease) and trazodone (used to treat depression). The “Medication Profile” did not indicate instructions on how to administer the medication through G-tube. During an interview on 10/3/2025 at 2:46 pm with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated medications administered through G-tube should include detailed instructions on how to administer the medication, if it needed to be crushed and/or mixed with water or applesauce. The DPCS Designee stated if the instruction is not clear on how to administer the medication may result in patient and family members lack of understanding on how to correctly administer the medication. 2. During a review of Patient 2’s Patient Information (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 10:28 pm with Patient 2, Patient 2’s “Medication Profile,” for the recertification period from 8/4/2025 to 10/2/2025, was reviewed. The Medication Profile indicated physician orders containing medical jargon (including Latin abbreviations and technical terms to indicate dosage, frequency, and administration). During an interview on 10/3/2025 at 2:46 pm with the ADM/DPCS Designee, the ADM/DPCS Designee stated medication lists should be in a form and manner that patients and family members are able to understand. The ADM/DPCS Designee stated medication lists should not include medical jargon such as abbreviations. The ADM/DPCS stated patients might not take their prescribed medications if they do not have an accurate medication list. During a review of the facility’s P&P titled, “Medication Profile”, undated, the P&P indicated, “Each patient will receive appropriate written material for specific medications he/she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications the patient should be aware of, and any special instructions when taking the specific medication.” 1 Findings: During a review of Patient 1’s “Patient Information,” undated, the “Patient Information” indicated Patient 1, start of care (SOC) was on 11/13/2024 with diagnoses including but not limited to pneumonia (an infection/inflammation in the lungs) and management of ventricular assist device (VAD, mechanical pump surgically placed to help weakened heart to circulate blood). During a concurrent interview and record review on 10/2/2025 at 9 am. Patient 1’s “Medication Profile”, for the certification period of 9/9/2025 to 11/7/2025 was reviewed. The “Medication Profile” indicated the following medications to be administered via G-tube and did not indicate instructions on how to administer the medication through G-tube. Furosemide (used to treat fluid retention and high blood pressure) oral 40 mg (milligram, unit of measurement) once daily via G-tube with start date of 8/24/2025. Zyrtec (used to treat allergy symptoms), oral 10 mg once daily via G-tube with a start date of 7/1/2025. Gabapentin (used to relieve nerve pain), oral 300 mg once daily at bedtime via G-tube with a start date of 4/9/2025. Fludrocortisone acetate (used to replace certain hormones the body does not produce enough), oral 0.1 mg once daily via G-tube for 180 days with a start date of 3/26/2025. Omeprazole (used to reduce the amount of acid the stomach produces), oral 40 mg twice daily via G-tube with a start date of 3/26/2025. Atorvastatin (used to lower cholesterol (a fat-like substance found in the body) in the blood), oral 40 mg once daily at bedtime via G-tube with a start date of 3/26/2025. Amantadine (used to treat Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)), oral 100 mg at 0700, 1100, and 1500 via G-tube with a start date of 3/26/2025. Sertraline (used to treat depression), entacapone (used to treat Parkinson’s disease), oral 50 mg once daily via G-tube at night with a start date of 3/26/2025. Entacapone (used to treat Parkinson’s disease), oral 200 mg four times a day via G-tube with a start date of 11/13/2024. Vitamin B-12 (used to support healthy nerve cells), oral 2500 mg once daily via G-tube with a start date of 11/13/2024. Polyethylene glycol (used to treat or prevent constipation), clopidogrel bisulfate (used to prevent blood clots), oral 100 mg at 0700, 1100, and 1500 via G-tube with a start date of 3/26/2025, Clopidogrel bisulfate (used to prevent blood clots), oral 75 mg once daily via G-tube with a start date of 11/13/2024. Tamsulosin (used to treat symptoms such as enlarged prostate that makes it difficult to urinate), oral 0.4 mg once daily via G-tube with a start date of 11/13/2024, Alfuzosin (used to treat symptoms such as enlarged prostate that makes it difficult to urinate), oral 10 mg once daily via G-tube with a start date of 11/13/2024. Aspirin (used to prevent blood clots), oral 81 mg once with meal daily via G-tube with a start date of 11/13/2024, Carbidopa-levodopa-entacapone used to treat Parkinson’s disease), oral 500-200-200 mg four times a day via G-tube with a start date of 11/13/2024, Trazodone (used to treat depression), oral 150 mg once daily at bedtime via G-tube with a start date of 11/13/2024. During an interview on10/3/2025 at 2:46 pm with the Director of Patient Care Services Designee (DPCS Designee), the DPCS Designee stated medications administered through G-tube should include detailed instructions on how to administer the medication, if it needed to be crushed and/or mixed with water or applesauce. The DPCS Designee stated if the instruction was not clear on how to administer the medication may result in patient and family members lack of understanding on how to correctly administer the medication. During a review of the facility’s P&P titled, “Medication Profile”, undated, the P&P indicated, “Each patient will receive appropriate written material for specific medications he/she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications the patient should be aware of, and any special instructions when taking the specific medication.””

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on interview and record review, a Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to patients in their homes to help with illness, rehabilitation, or to maintain health and independence) QAPI (Quality Assessment and Performance Improvement) program failed to address patient’s concern with wound care and assessment. This failure resulted in Patient 6’s assessment of diabetic ulcer (an open wound that develops in people with diabetes) of the right plantar (sole of the right foot) and right second toe (second toe on a person’s right foot) not being documented that could affect lack of treatment, wound healing and comfort, which could lead to the wounds worsening, becoming injured, and bacteria being introduced. Findings: During a review of Patient 6’s “Patient Information,” “Patient Information” indicated Patient 6’s start of care (SOC) date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a review of Patient’ 6’s “Licensed Practical Nurse (LPN)/LVN – Skilled Nursing Visit” notes, authored by LVN 4 from 6/4/2025 to 9/20/2025, the LPN/LVN – Skilled Nursing Visit notes did not indicate wound assessments (wound measurement, wound bed, wound drainage, signs and symptoms of infection, and peri wound) of Patient 6’s right plantar and right second toe wounds. During an interview on 10/6/2025 at 10:19 am with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated wound assessment and documentation was not identified as a QAPI project because they prioritized the other three projects (falls, infection, and late notes), there was no specific Policy & Procedure regarding QAPI, and QAPI projects were selected based on the facility’s percentage of occurrences compared with Centers for Medicare & Medicaid Services (CMS, a federal agency that runs the Medicare and Medicaid programs) national averages. During a review of HHA Facility Quarterly QAPI meeting for 2nd quarter 2025, the meeting minutes indicated that the facility had “No issues” with Quality of Care and Patient Safety for Month 1 (April 2025), Month 2 (May 2025) and Month 3 (June 2025).”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure clinical visit notes were completed for three of eight sampled patients (Patient 2, Patient 4, and Patient 6) when Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 4, and LVN 5 did not document skilled nursing visit notes. This failure had the potential to result in lack of coordination between the interdisciplinary teams that could result in delayed or inappropriate treatment that could put Patient 2, Patient 4 and Patient 6’s health at risk or health condition worsens. Findings: 1. During a review of Patient 2’s Patient Information (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 2:49 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s “LVN – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN – Skilled Nursing Visits were blank. The ADM/DPCS stated the visit notes were blank and has asked LVN 5 repeatedly to document her assessments from the patient visits on 9/10/2025 and 9/12/2025. The ADM/DPCS stated nurses are expected to chart their visits in the patient’s electronic health record within seven days. The ADM/DPCS stated if their visits are not documented, they did not do it. The ADM/DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician. During an interview on 10/2/2025 at 2:31 pm with LVN 5, LVN 5 stated she was the visiting nurse for Patient 2. LVN 5 stated her visit notes from 9/10/2025 and 9/12/2025 were blank. During a review of LVN 5’s “Job Description Summary,” dated 3/29/2024, the Job Description Summary indicated, “Essential Job Functions/Responsibilities… Provides accurate and timely documentation consistent with the plan of care.” 2. During a review of Patient 4’s “Patient Information”, undated. The “Patient Information” indicated Patient 4, a 74 year-old female, start of care (SOC) date was on 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/2/2025 at 11:26 am with Registered Nurse (RN) 1. Patient 4’s “Episode Manager: Nursing”, for the certification period 8/13/2025 to 10/11/2025 was reviewed. The “Episode Manager: Nursing” indicated the RN-skilled nursing visit assigned to RN 1 on 9/6, 9/9, 9/13, 9/16, 9/20, 9/23, 9/27 with the visit note status as “Not Started”. RN 1 stated the visit notes should be completed in 2-3 days after the date of visit, and she was aware that she has been behind with her notes. RN 1 stated she will work on her late notes tonight (10/2/2025). RN 1 stated when the visit notes are not documented, the visit did not happen. 3. During a review of Patient 6’s Patient Information, the Patient Information indicated Patient 6’s SOC date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a concurrent interview and record review on 10/2/2025 at 11:35 am with the ADM/DPCS, Patient 6’s “LVN – Skilled Nursing Visits,” for the recertification period from 9/16/2025 to 10/1/2025 authored by LVN 4 were reviewed. The LVN – Skilled Nursing Visits indicated missing notes from 9/21/2025 to 10/1/2025. The ADM/DPCS stated the notes from 9/21/2025 to 10/1/2025 were missing. The ADM/DPCS stated late documentation has been an ongoing issue and frequently reminds visiting nurses to document their notes in the patients’ electronic health record within seven days. During an interview on 10/2/2025 at 12:01 pm with LVN 4, LVN 4 stated he was the assigned LVN for Patient 6 and does Patient 6’s wound care treatment daily. LVN 4 stated he did not complete Patient 6’s visit notes from 9/21/2025 to 10/2/2025 because he forgot and had “some issues at home.” LVN 4 stated it was important to ensure timely documentation of patient visits so other interdisciplinary team members can see the patient’s progress. During a review of LVN 4’s “Job Description Summary,” dated 1/20/2025, the Job Description Summary indicated, “Essential Job Functions/Responsibilities… Provides accurate and timely documentation consistent with the plan of care.” During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.” 1 Findings: 1. During a review of Patient 2’s Patient Information (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 2:49 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s “LVN – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The ADM/DPCS stated LVN 5 visit notes were blank. The ADM/DPS stated she and had asked LVN 5 repeatedly to document her assessments from the patient visits on 9/10/2025 and 9/12/2025. The ADM/DPCS stated nurses were expected to chart their visits in the patient’s electronic health record within seven days. The ADM/DPCS stated if their visits were not documented, they did not do it. The ADM/DPCS stated missing and late documentation could result in a lack of communication with their physician and could jeopardize (to put one’s health at risk or in danger) the patients’ care. During an interview on 10/2/2025 at 2:31 pm with LVN 5, LVN 5 stated she was the visiting nurse for Patient 2. LVN 5 stated her visit notes from 9/10/2025 and 9/12/2025 were blank. During a review of LVN 5’s “Job Description Summary,” dated 3/29/2024, the Job Description Summary indicated, “It is the LVN’s Responsibility to provide accurate and timely documentation consistent with the plan of care.” 2. During a review of Patient 4’s “Patient Information”, undated. The “Patient Information” indicated Patient 4 had a start of care (SOC) date of 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/2/2025 at 11:26 am with Registered Nurse (RN) 1. Patient 4’s “Episode Manager (refers to the documentation created and maintained by a home health agency to manage a patient’s entire episode of care. The document helps track all services provided during a specific timeframe to address a patient’s medical condition): Nursing”, for the certification period 8/13/2025 to 10/11/2025 was reviewed. The “Episode Manager: Nursing” indicated the RN-skilled nursing visit assigned to RN 1 on 9/6/2025, 9/9/2025, 9/13/2025, 9/16/2025, 9/20/2025, 9/23/2025, and 9/27/2025 with the visit note status as “Not Started”. RN 1 stated the visit notes should be completed in two to three days after the date of visit, and she was aware that she has been behind with her notes. RN 1 stated she will work on her late notes tonight (10/2/2025). 3. During a review of Patient 6’s Patient Information, the Patient Information indicated Patient 6’s SOC date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a concurrent interview and record review on 10/2/2025 at 11:35 am with the ADM/DPCS, Patient 6’s “LVN – Skilled Nursing Visits,” for the recertification period from 9/16/2025 to 10/1/2025 authored by LVN 4 were reviewed. The LVN – Skilled Nursing Visits indicated missing notes from 9/21/2025 to 10/1/2025. The ADM/DPCS stated the notes from 9/21/2025 to 10/1/2025 were missing. The ADM/DPCS stated late documentation has been an ongoing issue and frequently reminds visiting nurses to document their notes in the patients’ electronic health record within seven days. During an interview on 10/2/2025 at 12:01 pm with LVN 4, LVN 4 stated he was the assigned LVN for Patient 6 and does Patient 6’s wound care treatment daily. LVN 4 stated he did not complete Patient 6’s visit notes from 9/21/2025 to 10/2/2025 because he forgot. LVN 4 stated it was important to ensure timely documentation of patient visits so other interdisciplinary team members can see the patient’s progress. During a review of LVN 4’s “Job Description Summary,” dated 1/20/2025, the Job Description Summary indicated, “It is the LVN’s Responsibility to provide accurate and timely documentation consistent with the plan of care.” During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.””

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on interview and record review, (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the Physical Therapy Assistant providing services for two of three sampled patients (Patient 1 and Patient 3) were supervised by a Physical Therapist. This failure had the potential for Patient 1 and Patient 3 to decline or delay progress with functional status (person’s capacity to move safely and independently to perform activities of daily living like walking, standing or bending). Findings: 1. During a review of Patient 1’s “Patient Information”, undated. The “Patient Information” indicated Patient 1 start of care (SOC) was on 11/13/2024 with diagnoses including but not limited to pneumonia (an infection/inflammation in the lungs) and management of ventricular assist device (VAD, mechanical pump surgically placed to help weakened heart to circulate blood). During a review of Patient 1’s “Physical Therapy – Re-Assessment”, dated 3/7/2025. The “Physical Therapy – Re-Assessment” indicated the evaluation was signed by Physical Therapist (PT) 1. During a review of Patient 1’s “Episode Manager (refers to the documentation created and maintained by a home health agency to manage a patient’s entire episode of care. The document helps track all services provided during a specific timeframe to address a patient’s medical condition)” for the certification period of 11/13/2024 to 1/11/2025. The “Episode Manager” indicated Physical Therapy Assistant (PTA) 1 provided physical therapy service visits to Patient 1 on 11/25/2024, 11/25/2024, 11/27/2024, 12/2/2024, 12/5/2024, 12/9/2024, 12/12/2024, and 12/16/2024. The “Episode Manager” indicated PT 1 provided physical therapy service visit to Patient 1 on 11/20/2024 and 12/18/2024. During a review of Patient 1’s “Episode Manager”, for the certification period of 3/13/2025 to 5/11/2025. The “Episode Manager” indicated PTA 1 provided physical therapy service visits to Patient 1 on 3/13/2025, 3/17/2025, 3/20/2025, 3/14/2025, 3/27/2025, 4/1/2025 and 4/4/2025. The “Episode Manager” indicated PT 1 provided physical therapy service visit to Patient 1 on 4/7/2025. During a review of Patient 1’s “Episode Manager”, for the certification period of 5/12/2025 to 7/10/2025. The “Episode Manager” indicated PTA 1 provided physical therapy service visits to Patient 1 on 5/15/2025, 5/20/2025, 5/22/2025, 5/27/2025, 5/29/2025 and 6/2/2025. The “Episode Manager” indicated PT 1 provided physical therapy service visit to Patient 1 on 5/12/2025 and 6/5/2025. During an interview on 10/3/2025 at 2:10 pm with PT 1. PT 1 stated patients were evaluated and assessed by physical therapists for initial certification, recertification and discharge, while the physical therapy assistants complete the follow-up visits. PT 1 stated he never visits a patient with physical therapy assistant. PT 1 stated physical therapy assistants were self-sufficient and can provide the services to patients on their own. PT 1 stated he trusted the physical therapy assistants enough to follow the plan of care he created for patients. PT 1 stated he did not evaluate PTA 1 providing services to Patient 1. PT 1 stated patients may plateau or decline with functional status when physical therapy assistants were not being supervised if they were following the plan of care. During a review of Physical Therapy Agency (PT Agency) 1’s policies and procedures (P&P) titled “Therapy Supervision Policy for PTAs and OTAs”, undated. The P&P indicated the following: a. “All therapy services provided by PTAs shall be completed under the supervision, direction and plan of care of a qualified and currently licensed PT” b. “A supervisory visit must occur at least every 30 calendar days or every 12th visit, whichever comes first” c. “Each supervisory visit must be documented in the clinical record” During a review of PT 1’s “Physical Therapist - Job Description”, dated 2/20/2022. The “Physical Therapist - Job Description” indicated other essential responsibilities includes “Supervises physical therapy assistants according to organization policy and state regulations” 2. During a review of Patient 3’s “Patient Information”, undated, the “Patient Information,” indicated Patient 3, start of care (SOC) date was 6/22/2025 with primary diagnosis of chronic thromboembolic pulmonary hypertension (high blood pressure in the lungs) and secondary diagnosis of chronic pulmonary embolism (blood clots in the lungs). During a concurrent interview and record review on 10/3/2025 at 2:52 pm with PT 2, “Physical Therapy – 30 Day Re-eval,” dated 9/22/2025, and “Physical Therapy – Re-Assessments,” dated 8/20/2025 and 8/6/2025 were reviewed. The “Physical Therapy – 30 Day Re-eval” and “Physical Therapy – Re-Assessment”, indicated, no name for the PTA who was evaluated. PT 2 stated, the name of the PTA being evaluated should be on the evaluation and reassessment forms. PT 2 stated it is very bad if the names of the PTA being evaluated are not on the forms, and we are not meeting Medicare regulations. During a review of PT Priority’s (Physical Therapy Agency) policy and procedure (P&P) titled, “Supervision Policy, Physical Therapy Assistants/Occupational Therapy Assistants” undated, the P&P indicated the following: a. “Purpose - To guarantee that PTAs and OTAs provide therapy services under the supervision and direction of a qualified Physical Therapist (pt)… that is consistent with Medicare Conditions of Participation…” b. “All therapy services provided by PTAs shall be completed under the supervision, direction and plan of care of a qualified and currently licensed PT c. “Supervision must meet the standards of federal, state, or accrediting bodies.” During a review of PT Priority’s Physical Therapist Job Description, undated, the “Essential Job Functions/Responsibilities” indicated other essential job functions/responsibilities includes “Supervises Physical Therapy Assistants according to organization policy and state regulations.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on 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 clinical visit notes were completed for three of eight sampled patients (Patient 2, Patient 4, and Patient 6) when Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 4, and LVN 5 did not document skilled nursing visit notes dated 9/6/2025, 9/9/2025, 9/10/2025, 9/12/2025, 9/13/2025, 9/16/2025, 9/20/2025, 9/21/2025, 9/23/2025, 9/27/2025, and 10/1/2025. This failure had the potential to result in lack of coordination between the interdisciplinary team (a group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) that could result in delayed or inappropriate treatment that could put Patient 2, Patient 4 and Patient 6’s health at risk or health condition worsens. Findings: 1. During a review of Patient 2’s Patient Information (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 2:49 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s “LVN – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN – Skilled Nursing Visits were blank. The ADM/DPCS stated the visit notes were blank and has asked LVN 5 repeatedly to document her assessments from the patient visits on 9/10/2025 and 9/12/2025. The ADM/DPCS stated nurses are expected to chart their visits in the patient’s electronic health record within seven days. The ADM/DPCS stated if their visits are not documented, they did not do it. The ADM/DPCS stated missing and late documentation could jeopardize the patients’ care and result in a lack of communication with their physician. During an interview on 10/2/2025 at 2:31 pm with LVN 5, LVN 5 stated she was the visiting nurse for Patient 2. LVN 5 stated her visit notes from 9/10/2025 and 9/12/2025 were blank. During a review of LVN 5’s “Job Description Summary,” dated 3/29/2024, the Job Description Summary indicated, “Essential Job Functions/Responsibilities… Provides accurate and timely documentation consistent with the plan of care.” 2. During a review of Patient 4’s “Patient Information”, undated. The “Patient Information” indicated Patient 4, a 74 year-old female, start of care (SOC) date was on 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/2/2025 at 11:26 am with Registered Nurse (RN) 1. Patient 4’s “Episode Manager: Nursing”, for the certification period 8/13/2025 to 10/11/2025 was reviewed. The “Episode Manager: Nursing” indicated the RN-skilled nursing visit assigned to RN 1 on 9/6, 9/9, 9/13, 9/16, 9/20, 9/23, 9/27 with the visit note status as “Not Started”. RN 1 stated the visit notes should be completed in 2-3 days after the date of visit, and she was aware that she has been behind with her notes. RN 1 stated she will work on her late notes tonight (10/2/2025). RN 1 stated when the visit notes are not documented, the visit did not happen. 3. During a review of Patient 6’s Patient Information, the Patient Information indicated Patient 6’s SOC date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a concurrent interview and record review on 10/2/2025 at 11:35 am with the ADM/DPCS, Patient 6’s “LVN – Skilled Nursing Visits,” for the recertification period from 9/16/2025 to 10/1/2025 authored by LVN 4 were reviewed. The LVN – Skilled Nursing Visits indicated missing notes from 9/21/2025 to 10/1/2025. The ADM/DPCS stated the notes from 9/21/2025 to 10/1/2025 were missing. The ADM/DPCS stated late documentation has been an ongoing issue and frequently reminds visiting nurses to document their notes in the patients’ electronic health record within seven days. During an interview on 10/2/2025 at 12:01 pm with LVN 4, LVN 4 stated he was the assigned LVN for Patient 6 and does Patient 6’s wound care treatment daily. LVN 4 stated he did not complete Patient 6’s visit notes from 9/21/2025 to 10/2/2025 because he forgot and had “some issues at home.” LVN 4 stated it was important to ensure timely documentation of patient visits so other interdisciplinary team members can see the patient’s progress. During a review of LVN 4’s “Job Description Summary,” dated 1/20/2025, the Job Description Summary indicated, “Essential Job Functions/Responsibilities… Provides accurate and timely documentation consistent with the plan of care.” During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection” undated, the P&P indicated, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.” q Findings: 1. During a review of Patient 2’s Patient Information (admission record), the Patient Information indicated Patient 2’s Start of Care (SOC) date was 8/4/2025, with primary diagnosis of neuromuscular dysfunction of bladder (occurs when an injury or disease interrupts the electrical signals between your nervous system [a complex network of cells, tissues, and organs that work together to control and coordinate all bodily functions] and bladder [the organ that stores urine] function). During a concurrent interview and record review on 10/1/2025 at 2:49 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s “LVN – Skilled Nursing Visits,” dated 9/10/2025 and 9/12/2025 authored by LVN 5 were reviewed. The LVN – Skilled Nursing Visits were blank. The ADM/DPCS stated the visit notes were blank and has asked LVN 5 repeatedly to document her assessments from the patient visits on 9/10/2025 and 9/12/2025. The ADM/DPCS stated nurses were expected to chart their visits in the patient’s electronic health record within seven days. The ADM/DPCS stated if their visits were not documented, they did not do it. The ADM/DPCS stated missing and late documentation could cause lack of communication with their physicians that could jeopardize (to put one’s health at risk or in danger) the patients’ care. During an interview on 10/2/2025 at 2:31 pm with LVN 5, LVN 5 stated she was the visiting nurse for Patient 2. LVN 5 stated her visit notes from 9/10/2025 and 9/12/2025 were blank. During a review of LVN 5’s “Job Description Summary,” dated 3/29/2024, the Job Description Summary indicated, “It is the LVN’s Responsibility to provide accurate and timely documentation consistent with the plan of care.” 2. During a review of Patient 4’s “Patient Information”, undated. The “Patient Information” indicated Patient 4, start of care (SOC) date was on 8/24/2023 with primary diagnosis including but not limited to pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review on 10/2/2025 at 11:26 am with Registered Nurse (RN) 1. Patient 4’s “Episode Manager: Nursing”, for the certification period 8/13/2025 to 10/11/2025 was reviewed. The “Episode Manager: Nursing” indicated the RN-skilled nursing visit assigned to RN 1 on 9/6/2025, 9/9/2025, 9/13/2025, 9/16/2025, 9/20/2025, 9/23/2025, 9/27/2025 with the visit note status as “Not Started”. RN 1 stated the visit notes should be completed in 2-3 days after the date of visit, and she was aware that she has been behind with her notes. RN 1 stated she will work on her late notes tonight (10/2/2025). 3. During a review of Patient 6’s Patient Information, the Patient Information indicated Patient 6’s SOC date was 7/23/2024, with primary diagnosis of type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer. During a concurrent interview and record review on 10/2/2025 at 11:35 am with the ADM/DPCS, Patient 6’s “LVN – Skilled Nursing Visits,” for the recertification period from 9/16/2025 to 10/1/2025 authored by LVN 4 were reviewed. The LVN – Skilled Nursing Visits indicated missing notes from 9/21/2025 to 10/1/2025. The ADM/DPCS stated the notes from 9/21/2025 to 10/1/2025 were missing. The ADM/DPCS stated late documentation has been an ongoing issue and frequently reminds visiting nurses to document their notes in the patients’ electronic health record within seven days. During an interview on 10/2/2025 at 12:01 pm with LVN 4, LVN 4 stated he was the assigned LVN for Patient 6 and does Patient 6’s wound care treatment daily. LVN 4 stated he did not complete Patient 6’s visit notes from 9/21/2025 to 10/2/2025 because he forgot and had “some issues at home.” LVN 4 stated it was important to ensure timely documentation of patient visits so other interdisciplinary team members can see the patient’s progress. During a review of LVN 4’s “Job Description Summary,” dated 1/20/2025, the Job Description Summary indicated, “It is the LVN’s Responsibility to provide accurate and timely documentation consistent with the plan of care.” During a review of the facility’s policy and procedure (P&P) titled, “Clinical/Service Data Collection” undated, the P&P indicated, “Entries into the clinical record will be made on the day care/service is provided to the patient. All documentation will be turned into the office within seven calendar days.””