A & M Miracle Home Health Care, Inc.

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to properly assess the continuing need for home care services for two of four sampled patients (Patient 9 and Patient 10). This deficient practice resulted in the continued provision of home health services to the patients who no longer need skilled nursing services. b. During a review of Patient 10’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period from 5/10/2026 to 7/8/2026, the POC indicated Patient 10 was admitted to the HHA on 1/10/2026 with a primary diagnosis of atherosclerotic heart disease (he narrowing or stiffening of the heart’s arteries caused by the buildup of fatty plaques) of native coronary artery (original blood vessels you were born with that supply oxygen-rich blood to your heart muscle) without angina pectoris (chest pain or discomfort that occurs when your heart muscle does not receive enough oxygen-rich blood) and a secondary diagnosis of essential hypertension (high blood pressure). The POC indicated that Patient 10 was to receive one skilled nurse (SN, a licensed nurse in general) visit for nine weeks. The POC goal indicated Patient 10 will be free of any falls, injuries, medication complications, and preventable emergency room visits. The POC goal also indicated Patient 10 will demonstrate compliance with prescribed medications and treatments. During a joint home visit, 6/10/2026 at 10:05 a.m. in Patient 10’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 10 was observed lying in bed. LVN 1 took Patient 10’s vital signs, including blood pressure, temperature, oxygen saturation, and heart rate. LVN 1 stated Patient 10’s vital signs were stable. Patient 10 was awake and alert to self, time, situation, and place. Patient 10 was ambulatory with a rollator walker (a wheeled mobility aid featuring handlebars, hand brakes, and usually a built-in seat) and had no wounds or medical lines. During an interview on 6/10/2026 at 10:52 a.m. with LVN 1, LVN 1 stated Patient 10 lives in a board and care facility with very capable caregivers that manage Patient 10’s care and medications. LVN 1 stated Patient 10 has not had any recent hospitalizations. During an interview on 6/10/2026 at 1:25 p.m. with the Administrator/Director of Patient Care Services Designee (ADM/DPCS Designee), the ADM/DPCS Designee stated Patient 10’s vital signs were stable, is eating all her meals and drinking fluids appropriately, and has not had any changes in medications. The ADM/DPCS Designee stated Patient 10 has also not had any recent hospitalizations. The ADM/DPCS Designee stated Patient 10 does not need home health services and would be discharged at the end of the current recertification period. Findings: a. During a review of Patient 9’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 1/10/2026, with a diagnoses that includes essential hypertension (high blood pressure), pain in the left knee, and other chronic pain. During a review of Patient 9’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) document for the certification period starting from 3/11/2026 to 5/9/2026, the POC included an order for the skilled nurse (SN) to visit Patient 9 once a week for 9 weeks to perform skilled assessment (a detailed, holistic evaluation of a patient’s physical, mental, emotional, and social health conducted by a licensed nurse ,usually a registered nurse), monitor vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), to assess pain and teach symptom control. The POC goal indicated Patient 9’s blood pressure will be stable and patient/pcg (patient caregiver) will verbalize and demonstrate pain control measures. The discharge plan indicated to discharge Patient 9 once the patient’s stated goals are achieved, medical condition stabilizes, and capable of remaining at home with assistance from the primary caregiver or under supervision of the primary physician. During a joint home visit, on 6/10/2026 at 10:45 a.m., at Patient 9’s residence with the licensed vocational nurse (LVN 1), Patient 9 was observed lying in a hospital bed, awake, alert, oriented x 3 (to person, place and time), and was accompanied by her caregiver (PCG 1). Patient 9 was observed with no wounds, and had no medical lines or catheters (thin, flexible tubes inserted into the body to deliver fluids, medication, nutrition, or to drain fluids like urine). During an interview, PCG 1 stated Patient 9 had no wounds, no recent falls or hospitalizations, took her medications daily, and had stable blood pressure. During a review of Patient 9’s Nursing Progress Note, from 4/1/2026 to 5/8/2026, the Nursing Progress Notes indicated Patient 9 had normal vital signs, had no wounds, no falls, no hospitalization, and no skilled nursing needs. During a concurrent interview and record review, on 6/10/2026 at 2:00 p.m., with the Administrator/Director of Patient Care Services Designee (ADM/DPCS Designee), the ADM/DPCS Designee reviewed Patient 9’s Recertification assessment (a mandatory, comprehensive assessment conducted every 60 days to evaluate a patient’s continued need for services, update their plan of care, and determine ongoing Medicare payment) dated 5/8/2026, and Nursing Progress Notes from 4/1/2026 to 5/8/2026. The ADM/DPCS Designee stated Patient 9 had no recent hospitalizations, falls, wound care, had stable vital signs, and had no documented evidence of the need for skilled nursing care. The ADM/DPCS Designee stated Patient 9 home health goals had been met but was recertified for another 60 days of continuous skilled nursing services. During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria and Process, revised December 2025, the P&P indicated services will be terminated when the patient meets one or more of the discharge criteria: if appropriate, the physician (or allowed practitioner) and the organization agree that the goals of home care have been attained or are no longer attainable. The Clinical Supervisor or designee is accountable for the decision and the required documentation.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to obtain a physician’s order for the visiting nurse to take vital signs (clinical measurements that indicate the state of a body’s essential functions) for one of four sampled patients (Patient 10). This failure had the potential to place the patient at risk for adverse medical effects. Findings: During a review of Patient 10’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support that an individual needs to meet their healthcare goals) for the certification period from 5/10/2026 to 7/8/2026, the POC indicated Patient 10 was admitted to the HHA on 1/10/2026 with a primary diagnosis of atherosclerotic heart disease (he narrowing or stiffening of the heart’s arteries caused by the buildup of fatty plaques) of native coronary artery (original blood vessels you were born with that supply oxygen-rich blood to your heart muscle) without angina pectoris (chest pain or discomfort that occurs when your heart muscle does not receive enough oxygen-rich blood) and a secondary diagnosis of essential hypertension (high blood pressure). The POC indicated that Patient 10 was to receive one skilled nurse (SN, a licensed nurse in general) visits for nine weeks. During a review of Patient 10’s “Nursing Progress Note,” dated 5/26/2026, the Nursing Progress Note indicated Patient 10’s “vital signs remained stable and within baseline parameters.” There was no documented evidence of vital signs results. During a review of Patient 10’s Nursing Progress Note,” dated 6/2/2026, the Nursing Progress Note indicated Patient 10’s vital signs were taken and recorded and measured within normal limits. There was no documented evidence of vital signs results. During a joint home visit, 6/10/2026 at 10:05 a.m. in Patient 10’s residence, with Licensed Vocational Nurse (LVN) 1, Patient 10 was observed lying in bed. LVN 1 took Patient 10’s vital signs, including blood pressure, temperature, oxygen saturation, and heart rate. During a concurrent interview and record review on 6/10/2026 at 1:04 p.m. with LVN 1, Patient 10’s POC was reviewed. The POC did not indicate physician’s order for the skilled nurse to take vital signs. LVN 1 stated there was no physician order to take vital signs on Patient 10. LVN 1 stated all nursing interventions should have a physician order. During an interview on 6/10/2026 at 1:38 p.m. with the Administrator/Director of Patient Care Services Designee (ADM/DPCS Designee), the ADM/DPCS Designee stated all nursing interventions should have a physician order, especially vital signs. During a record review of the agency’s policy and procedure (P&P) titled, “Verification of Physician Orders,” revised 12/2025, the P&P indicated, “Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients.””

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1.The HHA failed to ensure four of five sampled patients (Patient 4, Patient 9, Patient 10, and Patient 11) clinical records were accurate and contained all required documentation. This deficient practice resulted in incomplete and inaccurate clinical records, which had the potential to affect continuity of care and the ability of healthcare providers to make informed clinical decisions. (Refer to G1012). 2. The HHA failed to ensure patient care records were properly authenticated for five of five sampled patients (Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice resulted in patients’ medical records that contained entries without required signatures, which prevented verification of the individual responsible for the documentation and compromised the integrity and reliability of the clinical record. (Refer to G1024). The cumulative effect of these systemic practices resulted in failure of the HHA to deliver statutorily (written law) mandated Federal (government) regulations for Clinical Records to ensure the provision of quality health care in a safe environment.”

“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, the HHA failed to ensure patient care records were authenticated for five of five sampled patients (Patient 4, Patient 8, Patient 9, Patient 10, and Patient 11). This deficient practice resulted in patients’ medical records missing signatures of authentication reflecting who completed the documents. a. During a record review of Patient 9’s “Home Health Certification and Plan of Care” for the certification period starting from 1/10/2026 to 3/10/2026, indicated a start of care date of 1/10/2026 with diagnoses of essential hypertension (high blood pressure), chronic pain, pain to the left knee, insomnia (unable to sleep) and cough. During a review of Patient 9’s “Nursing Progress Note” dated 2/12/2026, 2/18/2026 and 2/27/2026, the “Nursing Progress Note” indicated that LVN 2 did not sign and date the notes. b. During a record review of Patient 10’s “Home Health Certification and Plan of Care” for the certification period starting from 1/10/2026 to 3/10/2026, indicated a start of care date of 1/10/2026 with a diagnoses of chronic obstructive pulmonary disease (COPD - lung disease that makes it hard to breathe), type 2 diabetes (blood sugar levels are too high), muscle weakness, essential hypertension and iron deficiency anemia (body doesn’t get enough iron or loses too much iron). During a review of Patient 10’s “Nursing Progress Note” dated 2/12/2026, 2/18/2026 and 2/27/2026, the “Nursing Progress Note” indicated that LVN 2 did not sign and date the notes. c. During a record review of Patient 11’s “Home Health Certification and Plan of Care” for the certification period starting from 1/11/2026 to 3/11/2026, indicated a start of care date of 1/11/2026 with a diagnoses of essential hypertension (high blood pressure), urinary tract infection (infection in any part of the urinary system) and chronic pain. During a review of Patient 9’s “Nursing Progress Note” dated 2/13/2026, the “Nursing Progress Note” indicated that LVN 3 did not sign and date the notes. During a concurrent interview and record review, on 3/4/2026 at 11:40 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that Patient 9, Patient 10, and Patient 11 skilled nursing notes were not signed and dated by the nurses. ADM/DPCS stated that it is important to sign and date the notes to make sure that nurses verify the visit and notes are completed. During a review of the agency’s policy and procedure (P&P) titled, “Contents of Clinical Record”, dated 12/2025, the P&P indicated that the purpose of the clinical records is to outline the requirements and components of a clinical record. The P&P indicated that the following information will be available in the clinical records for patients receiving skilled care: …N. signed and dated progress notes for each discipline… a. During a record review of Patient 4’s medical record indicated Patient 4’s SOC date was 1/2/2026, with a diagnosis that includes pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine), essential hypertension (high blood pressure), low back pain, and senile degeneration of the brain (Involves progressive, irreversible damage 2 brain cells, causing cognitive decline beyond normal aging, loss of memory, confusion, and behavioral changes). During a record review of Patient 4’s electronic medical record nursing notes, LVN 2 submitted a nursing notes without a signature, dated 1/31/2026, 2/3/2026, 2/12/2026, 2/19/2026, and 2/27/2026. b. During a record review of Patient 8’s medical record indicated Patient 8’s SOC date was 11/17/2025, with a diagnosis that includes Alzheimer’s disease, (Involves progressive, irreversible damage two brain cells, causing cognitive decline beyond normal aging, loss of memory, confusion, and behavioral changes), hypertensive heart disease (high blood pressure), atherosclerotic heart disease (a condition affected the heart that leads to build up of plague in the arteries leading to blockage), and muscle weakness. During a record review of Patient 8’s electronic medical record nursing notes, LVN 2 submitted a nursing notes without a signature, dated 1/31/2026, 2/3/2026, 2/12/2026, 2/19/2026, and 2/27/2026. During a concurrent interview and record review, on 3/4/2026 at 12:34 p.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 4’s and Patient 8’s nursing notes dated 1/31/2026 to 2/27/2027 confirmed none of the nursing notes were authenticated by LVN 2. ADM/DPCS stated, “our nurses have 3 to 5 days to complete and sign the nursing notes, it wasn’t done for Patient 4 and Patient 8. This is important because that’s how we know who entered the note and that its complete so we can track patient progress.” When asked for a policy regarding time frame for staff authentication in the clinical record, ADM/DPCS stated they don’t have it.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Comprehensive Assessment of Patients as follows: Findings: 1. The HHA failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within five days of admission for one of seven sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520). 2. The HHA nursing staff failed to perform a completed pressure wound assessment for one of seven sampled patients (Patient 4), who had an open wound on the sacral region (a triangular bone at the base of the spine). This deficient practice can lead to inadequate treatment and longer healing times causing patient’s discomfort and/or pain. (Refer to G528). 3. The HHA failed to maintain an accurate, current medication profile for three of seven sampled patients (Patient 3, Patient 5, and Patient 6). This failure had the potential to place the patients at risk for medication errors and adverse drug reactions. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Comprehensive Assessment of patients to ensure the highest quality of care were being provided to patients certified to receive home health care and services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Care Planning, Coordination of Services and Quality of Care as follows: A. The HHA failed to ensure that six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 receiving home health services without an individualized, written plan of care that included management of their medical conditions and/or diagnosis that could lead to serious harm and hospitalization of the patients. (Refer to G572). B. The HHA failed to ensure the individualized POC included patient-specific interventions and education for one of seven sampled patients (Patient 5) by failing to: Ensure there are nursing interventions and patient/caregiver education related to patient’s primary diagnosis of essential hypertension.Ensure the HHA’s visiting nurses provided teaching to Patient 5 and the family member and/or caregiver regarding the importance of checking the blood pressure prior to taking blood pressure lowering medications, potentially leading to hypotension (low blood pressure) and placing the patient at increased risk for falls As a result, Patient 5 was not receiving necessary care, such as being monitored for signs and symptoms of hypotension, which may lead to serious harm, hospitalization, and/or death. (Refer to G574). C. The HHA failed to ensure that patient wound care orders were recorded in the plan of care for three of seven sampled patients (Patient 3, Patient 4, and Patient 6). This failure had the potential to affect patient safety, impair continuity and coordination of care. (Refer to G576). D. The HHA failed to notify the physicians of two of seven sampled patients (Patient 3 and Patient 5) regarding the following: a. Patient 3’s black-colored gastrostomy tube catheter. b. Patient 5’s low blood pressure and multiple blood pressure medication This failure resulted in Patient 3’s tube feeding and Patient 5’s blood pressure not being properly monitored and the patients’ care plan not updated. (Refer to G602). E. The HHA failed to provide a copy of the POC to three of seven sampled patients (Patient 3, Patient 4, and Patient 5). This failure might result in the patients and their family members/caregivers not being able to be active participants in their care. (Refer to G612). F. The HHA failed to provide a copy of medication schedule/instructions that included medication name, dosage and frequency for one of seven sampled patients (Patient 5). This failure might result in medication noncompliance, adverse drug effects, and drug interactions. (Refer to G616). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with the Federal regulations for Care planning, Coordination of services, and Quality of care to ensure home health benefits and services were furnished in accordance with accepted standards of practice.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, agency providing care to a love one in the comfort of home) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Organization and Administration of Services was met as follows: The HHA failed to ensure the HHA’s Director of Patient Care Services provided oversight of all patient care services and personnel as follows: - Ensure that six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 receiving home health services without an individualized, written plan of care that included management of their medical conditions and/or diagnosis that could lead to serious harm and hospitalization of the patients. - Ensure a comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within five days of admission for one of seven sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G958). The cumulative effect of these systemic practices resulted in failure of the HHA to deliver statutorily (written law) mandated with Federal (government) regulations for Organization and Administration of Services to ensure patients’ care goal needs were met.”

“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, a public or private organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 receiving home health services without an individualized, written plan of care that included management of their medical conditions and/or diagnosis that could lead to serious harm and hospitalization of the patients. On 1/15/2026, at 3:03 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator/Director of Patient Care Services (ADM/DPCS) related to the agency’s failure to provide home health services that have a written, individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). On 1/16/2026, at 2:10 p.m., the HHA was unable to submit an IJ removal plan (IJRP-includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 1/16/2026, at 2:20 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM/DPCS, Office Manager, and the Licensed Vocational Nurse (LVN) case manager with the IJ not removed. Findings: a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1’s start of care (SOC) date was 11/7/2025, with diagnoses that include encounter for change or removal of nonsurgical wound dressing, pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, and pressure ulcer of left buttock. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 11/7/2025 to 1/5/2026, noted that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. b. During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC date was 1/2/2026, with a primary diagnosis of essential hypertension (high blood pressure that develops gradually over time with no single, identifiable cause). During a review of Patient 2’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, noted was that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review, on 1/15/2026 at 12:05 p.m., with the Administrator/DPCS (ADM/DPCS), Patient 1’s POC for the certification period starting from 11/7/2025 to 1/5/2026 and Patient 2’s POC for the certification period starting from 1/2/2026 to 3/2/2026 was reviewed. The ADM/DPCS stated there was no written plan of care developed for Patient 1 and Patient 2. The ADM/DPCS stated the patient’s (in general) POCs should have been completed within 24 to 48 hours from the patient’s SOC. The ADM/DPCS stated not having a complete POCs could result in nurses not performing needed interventions, which could result in harm to the patients. c. During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 12/2/2025, with a diagnosis that includes cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy status (the presence of a gastrostomy tube [GT], a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Patient 3’s Home Health Certification and Plan of Care for the certification period starting from 12/2/2025 to 1/30/2026, noted that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a joint home visit observation, on 1/14/2026 at 11:55 a.m., at Patient 3’s residence with the Registered Nurse 2 (RN 2), Patient 3 was observed laying in a hospital bed, awake, alert, oriented to person and place, accompanied by a caregiver (PCG 1). Observed RN 2 perform a head-to-toe assessment (full body assessment) to Patient 3 by checking vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), assessing pain levels, assessing and cleansing the patient’s GT site. Observed RN2 performed wound care treatment on Patient 3’s stage 2 pressure ulcer wound (partial-thickness loss of skin, presenting as a shallow open sore or wound) on the right buttock and coccyx area (refers to the tailbone, the small, triangular bone at the very bottom of your spine). During a concurrent interview and record review on 1/14/2026 at 12:42 p.m., with RN 2, RN 2 reviewed Patient 3’s POC for the certification period starting from 12/2/2025 to 1/30/2026. RN 2 stated she performed a full body assessment to Patient 3 by checking Patient 3’s vital signs, cleansing Patient 3’s GT site, performed wound care treatment, and educated Patient 3’s caregiver regarding skin care, medications, and precautions. RN 2 stated that RN 2 was unable to confirm all the care and services that RN 2 provided to Patient 3 because it was not written in Patient 3’s plan of care. RN 2 stated all patient care, treatment, and services should be based in the patient’s plan of care (in general), but Patient 3 did not have a written plan of care. d. During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/2/2026, with a diagnosis that includes encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, it indicated there was no care plan developed that identifies patient-specific measurable outcomes, goals and interventions for the patient’s treatment, skilled care and services. During a joint home visit observation on 1/14/2026 at 10:30 a.m., at Patient 4’s residence with Registered Nurse 3 (RN 3), Patient 4 was observed awake, alert, confused and ambulatory while being accompanied by a caregiver (PCG 2). During an observation, RN 3 performed head-to-toe assessment to Patient 4 by checking vital signs, assessing pain level, and performing wound care treatment on Patient 4’s stage 4 pressure ulcer wound on the sacral region. During a concurrent interview and record review on 1/14/2026 at 11:12 a.m., with RN 3, RN 3 reviewed Patient 4’s POC for the certification period starting from 1/2/2026 to 3/2/2026. RN 3 stated she performed full body assessment to Patient 4, by checking Patient 4’s vital signs, performing wound care treatment, and educating Patient 4’s caregiver regarding wound care, medications and safety precautions. RN 3 stated that there was no written plan of care developed for Patient 4. RN 3 stated she conducted the comprehensive assessment on admission for Patient 4 on 1/2/2026 but has not completed and submitted her notes. RN 3 stated Patient 4’s plan of care would have been generated once she (RN3) completed the comprehensive assessment. RN 3 stated all patient care (in general), treatment and services should be based in the patient’s plan of care, but Patient4 did not have a written plan of care. RN 3 could not state and remained quiet when asked how the care provided to Patient4 when there was no written POC. During a concurrent interview and record review, on 1/15/2026 at 11:50 am, with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s POC for the certification period starting from 12/2/2025 to 1/30/2026 and Patient 4’s POC for the certification period starting from 1/2/2026 to 3/2/2026. The ADM/DPCS stated and acknowledged there were no written plans of care developed for Patient 3 and Patient 4. The ADM/DPCS stated patient’s (in general) POC should have been completed within 24-48 hours from the patient’s start of care. The ADM/DPCS stated it was important to complete patient’s POC timely because it would tell the nurse (in general) what medications, orders, and treatments were prescribed by the doctor and what to do during the home visit. The ADM/DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for serious harm in failure to properly care for the patient.” e. During a review of Patient 5’s Home Health Certification and Plan of Care (also known as the plan of care [POC]) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). There were no other pertinent diagnoses listed in the POC. The POC did not indicate the services and the frequency of each service the HHA was providing for Patient5. The POC did not identify the orders for discipline and treatment. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, patient helped write a measurable goal, understandable to all stakeholders…” The POC was not signed by a Registered Nurse and a physician. During a review of Patient5’s Nursing Progress Note, dated 1/2/2026, the blood pressure was 105/79 mmHg (millimeters of mercury, a unit of pressure, used primarily in medicine for blood pressure). There was no documentation on whether education on blood pressure monitoring was given. During a review of Patient5’s Nursing Progress Note, dated 1/13/2026, the blood pressure was 90/70 mmHg. There was no documentation on whether education on blood pressure monitoring was given. During a joint home visit on 1/14/2026 at 10:30 a.m., with Registered Nurse 1 (RN 1), at Patient 5’s residence, RN 1 stated Patient 5 was only receiving physical therapy from the HHA, and no nursing service was ordered. Patient 5 was observed awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was observed sitting on a couch. When RN 1 and the surveyor entered the home, Patient 5 was working with Occupational Therapist Assistant 1 (OTA 1). During an interview on 1/14/2026 at 10:30 a.m., with OTA 1, OTA1 stated Patient 5’s blood pressure was running low, with the systolic blood pressure (the top number in a blood pressure reading, measuring the pressure in the arteries when the heart beats and pushes blood out) in the 80s and the diastolic blood pressure (the second [bottom/lower] number; it measures the pressure the blood is pushing against the artery walls while the heart muscle rests between beats) in the 60s (the National Heart, Lung, and Blood Institute defined low blood pressure as blood pressure that is lower than 90/60 mmHg). OTA 1 stated that she had worked twice with Patient5 and her blood pressure had always been on the lower side. During a concurrent interview and record review with RN 1 on 1/14/2026 at 11:45 a.m., RN 1 reviewed Patient 5’s POC for the certification period of 1/2/2026 to 3/2/2026. RN 1 stated the POC was lacking interventions, such as parameters for blood pressure medications and for physician notification. RN 1 stated that he had never seen Patient 5’s POC until now, so he was not aware that Patient 5 was receiving nursing services and physical therapy services, or that the POC was missing interventions. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 1/15/2026 at 11 a.m., the ADM/DPCS reviewed Patient’s 5 POC for the certification period of 1/2/2026 to 3/2/2026. The ADM/DPCS stated, “It’s not done.” The ADM/DPCS stated the POC did not have physician orders, interventions, parameters, patient education, and individualized goals. When the ADM/DPCS was asked about the purpose of a plan of care, the ADM/DPCS stated that POC provided guide for staff, so they know what to do for the patient. The ADM/DPCS stated, “The POC is a care that you should follow.” f. During a review of Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026, the POC indicated that Patient 6 was admitted to the HHA on 11/7/2025 with diagnoses that included encounter for other postprocedural aftercare, pressure ulcer (a localized skin and tissue injury caused by prolonged pressure, friction, or shear, typically over bony areas like the tailbone, hips, or heels, which restricts blood flow, leading to tissue damage and potentially deep wounds, and is common in immobile individuals) of sacral (related to the sacrum [a triangular bone in the lower back]), pressure ulcer of left buttock, and pressure ulcer of right heel. The POC indicated Patient 6 was to receive daily skilled nurse (a licensed nurse in general) for 7 days, and then Patient 6 would be reassessed. The POC did not identify the orders for (nursing) discipline and treatments. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, agreed to and identified actions/interventions…” During a review of Patient 6’s Nursing Progress Note, dated 1/7/2026, the Nursing Progress Note indicated that Licensed Vocational Nurse (LVN 2) performed wound treatment as follows to the stage 4 pressure ulcer (the most severe type of pressure ulcer, involving full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone become exposed and damaged, creating deep, crater-like wounds) on the sacral region: Wound cleansed with wound cleanser, Medi Honey (a brand of medical-grade honey dressing, primarily made from sterilized Leptospermum/Manuka honey, used to promote healing in various wounds like burns, ulcers, and surgical sites) and Calcium Alginate (a type of wound dressing that absorbs drainage and creates a moist healing environment) applied to wound bed, followed by collagen powder (a supplement to support skin, joints, bones, and hair). Covered with abdominal pad (a highly absorbent, thick dressing used for large wounds) and Mepilex (a brand of wound dressing made of soft silicone foam) dressing. For the pressure ulcer on the right hip and stage 3 pressure ulcer (full-thickness skin loss, showing a deep crater where fat tissue is visible but muscle, bone, or tendon aren’t exposed) on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a review of Patient 6’s Nursing Progress Note, dated 1/8/2026, the Nursing Progress Note indicated that LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer on the sacral region: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with abdominal pad and Mepilex dressing. For the pressure ulcers on the right hip and stage 3 pressure ulcer on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a review of Patient 6’s Nursing Progress Note, dated 1/9/2026, the Nursing Progress Note indicated that LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer on the sacral region: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with abdominal pad and Mepilex dressing. For the pressure ulcers on the right hip and stage 3 pressure ulcer on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a review of Patient 6’s Nursing Progress Note, dated 1/10/2026, the Nursing Progress Note indicated that LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer on the sacral region: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with abdominal pad and Mepilex dressing. For the pressure ulcers on the right hip and stage 3 pressure ulcer on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a telephone interview with Patient 6 on 1/14/2026 at 1:51 p.m., Patient 6 stated that LVN 2 had been visiting him 6 days a week. Patient 2 stated there was another personnel who visited him once a week, Nurse Practitioner 1 (NP 1). Patient 6 stated, “I think NP 1 is a wound specialist.” Patient 6 stated that LVN 2 and NP 1 visited him for daily wound dressing change. During a concurrent interview and record review with the ADM/DPCS on 1/16/2026 at 11:59 a.m., the ADM/DPCS reviewed Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026 and Skilled Progress Notes dated 1/7/2026, 1/8/2026, 1/9/2026, and 1/10/2026. The ADM/DPCS confirmed the POC did not have interventions, physician orders, and goals. When the ADM/DPCS was asked how LVN 2 knew what she needed to do for Patient 6’s wounds if there were no interventions and physician orders in the POC, the ADM/DPCS stated that LVN 2 performed the wound care based on the orders from Wound Clinic 1 (WC 1). Per ADM/DPCS, NP 1 was a wound specialist from WC 1 who evaluated Patient 6 weekly and wrote the order for Patient 6’s wound care. The ADM/DPCS stated that the wound care orders from WC 1 needed to be transcribed into the HHA’s POC for Patient 6. The ADM/DPCS acknowledged the HHA staff had been providing care to Patient 5 and Patient 6 without a guide and without orders, which could cause patient harm. During a review of the agency’s policy and procedure (P&P) titled, Care Planning Process, dated April 2018, the P&P indicated a written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised within five working days of initiation or of the reassessment of the patient. All clinicians including the physician involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. 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.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation and interview, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to provide a copy of the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) to three of seven sampled patients (Patient 3, Patient 4, and Patient 5). This failure might result in the patients and their family members/caregivers not being able to be active participants in their care. a. During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 12/2/2025, with diagnoses that included cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy status (the presence of a gastrostomy tube [GT], a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period starting from 12/2/2025 to 1/30/2026, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 1 week, two times a week for 2 weeks, and then once a week for 6 weeks. The POC did not indicate and identify any orders for (nursing) discipline and treatments. During a joint home visit, on 1/14/2026 at 11:55 a.m., at Patient 3’s residence with the registered nurse (RN 2), Patient 3 was observed lying in a hospital bed, awake, alert, oriented to person and place, accompanied by a caregiver (CG 3). During a review of the HHA’s folder located at the Patient 3’s home, RN 2 stated and confirmed there was no copy of the current POC at the patient’s home. b. During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/2/2026, with diagnoses that included encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, the POC included an order for the skilled nurse to visit the patient twice a week for 3 weeks, then once a week for 8 weeks. The POC did not indicate and identify any orders for (nursing) discipline and treatments. During a joint home visit, on 1/14/2026 at 10:30 a.m., at Patient 4’s residence with the registered nurse (RN 3), Patient 4 was observed awake, alert, confused and ambulatory, accompanied by a caregiver (CG 2). During a review of the HHA’s folder located at the Patient 4’s home, RN 3 stated and confirmed there was no copy of the current POC at the patient’s home. c. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated that Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure [BP] with no single, identifiable cause, developing gradually over time, often linked to genetics, aging, diet, and lifestyle). During a joint home visit observation on 1/14/2026 at 10:30 a.m., with Registered Nurse 1 (RN 1) at Patient 5’s residence, observed Patient 5 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was observed sitting on a couch. During an interview on 1/14/2026 at 11:30 a.m., with Caregiver 1 (CG)1, CG 1 stated that Patient 5 lived with her (CG 1) and she (CG 1) acted as Patient 5’s primary caregiver. CG 1 stated that she (CG1) prepared and administered Patient 5’s medications. During the joint home visit, Patient 5’s home health folder was reviewed with RN 1. It was noted that there was no copy of the POC in the home health folder. The home health folder only contained signed consent forms. During an interview with RN 1 on 1/14/2026 at 11:45 a.m., RN 1 stated that he was not aware that home health patients needed to be provided with a copy of the POC. RN 1 stated he had never seen Patient 5’s care plan before. RN 1 stated that since the patient did not have a copy of the POC, they would not know what the plan and goals are for her. During an interview, on 1/16/2026 at 12:18 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated a copy of the plan of care should be provided at the patient’s home. The ADM/DPCS stated the importance of providing the patient and/or their family with a copy of the care plan to ensure their involvement in the patient’s care and their understanding of the intended plan. During a review of the HHA’s policy and procedure (P & P), titled “Care Planning Process,” updated April 2018, the P & P indicated the patient and family/caregiver would participate in decisions regarding the plan of care whenever possible.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that a Director of Patient Care Services provided oversight of all patient care services and personnel as follows: a. Ensure that six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) received home health services that are written in an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a physician to address the management of health status of the patients. This failure resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 receiving home health services without an individualized, written plan of care that included management of their medical conditions and/or diagnosis that could lead to serious harm and hospitalization of the patients. b. Ensure a comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within five days of admission for one of seven sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1’s start of care (SOC) date was 11/7/2025, with diagnoses that include encounter for change or removal of nonsurgical wound dressing, pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, and pressure ulcer of left buttock. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 11/7/2025 to 1/5/2026, noted that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. b. During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC date was 1/2/2026, with a primary diagnosis of essential hypertension (high blood pressure that develops gradually over time with no single, identifiable cause). During a review of Patient 2’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, noted was that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review, on 1/15/2026 at 12:05 p.m., with the Administrator/DPCS (ADM/DPCS), Patient 1’s POC for the certification period starting from 11/7/2025 to 1/5/2026 and Patient 2’s POC for the certification period starting from 1/2/2026 to 3/2/2026 was reviewed. The ADM/DPCS stated he was not aware there was no written plan of care developed for Patient 1 and Patient 2. The ADM/DPCS stated the patient’s (in general) POCs should have been completed within 24 to 48 hours from the patient’s SOC. The ADM/DPCS stated not having a complete POCs could result in nurses not performing needed interventions, which could result in harm to the patients. c. During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 12/2/2025, with a diagnosis that includes cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy (a surgical procedure to create an opening in the abdomen, leading directly into the stomach, for a gastrostomy tube [G-tube] to deliver food, fluids, and medicine when someone cannot eat or drink enough by mouth) status. During a review of Patient 3’s Home Health Certification and Plan of Care for the certification period starting from 12/2/2025 to 1/30/2026, noted that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. d. During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/2/2026, with a diagnosis that includes encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, it indicated there was no care plan developed that identifies patient-specific measurable outcomes, goals and interventions for the patient’s treatment, skilled care and services. During a review of Patient 4’s Comprehensive Assessment/OASIS (or Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 1/2/2026, the comprehensive assessment indicated the admitting registered nurse (RN 3) failed to complete the entire form. During an interview with RN 3, on 1/14/2026 at 11:12 a.m., RN 3 stated she conducted the comprehensive assessment on admission for Patient 4 on 1/2/2026 but has not completed and submitted her (RN 3) notes. RN 3 stated according to the agency’s policy, patient’s OASIS comprehensive assessment should be completed within 7-10 days. During a concurrent interview and record review, on 1/15/2026 at 11:50 am, with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s POC for the certification period starting from 12/2/2025 to 1/30/2026 and Patient 4’s POC for the certification period starting from 1/2/2026 to 3/2/2026. The ADM/DPCS stated and acknowledged he was not aware there was no written plan of care developed for Patient 3 and Patient 4. The ADM/DPCS stated patient’s (in general) POC should have been completed within 24-48 hours from the patient’s start of care. The ADM/DPCS stated it was important to complete patient’s POC timely because it would tell the nurse (in general) what medications, orders, and treatments were prescribed by the doctor and what to do during the home visit. The ADM/DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for serious harm in failure to properly care for the patient.” During a concurrent interview and record review, on 1/16/2026 at 12:18 p.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 4’s Comprehensive OASIS assessment dated 1/2/2026. The ADM/DPCS stated and acknowledged Patient 4’s comprehensive assessment was incomplete and not signed by the admitting nurse. The ADM/DPCS stated comprehensive assessment should be signed and completed within 5 days from the start of care to comply with regulations, and facilitating quality patient care. e. During a review of Patient 5’s Home Health Certification and Plan of Care (also known as the plan of care [POC]) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). There were no other pertinent diagnoses listed in the POC. The POC did not indicate the services and the frequency of each service the HHA was providing for Patient 5. The POC did not identify the orders for discipline and treatment. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, patient helped write a measurable goal, understandable to all stakeholders…” The POC was not signed by a Registered Nurse and a physician. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 1/15/2026 at 11 a.m., the ADM/DPCS reviewed Patient’s 5 POC for the certification period of 1/2/2026 to 3/2/2026. The ADM/DPCS stated, “It’s not done.” The ADM/DPCS stated the POC did not have physician orders, interventions, parameters, patient education, and individualized goals. When the ADM/DPCS was asked about the purpose of a plan of care, the ADM/DPCS stated that POC provided guide for staff, so they know what to do for the patient. The ADM/DPCS stated, “The POC is a care that you should follow.” f. During a review of Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026, the POC indicated that Patient 6 was admitted to the HHA on 11/7/2025 with diagnoses that included encounter for other postprocedural aftercare, pressure ulcer (a localized skin and tissue injury caused by prolonged pressure, friction, or shear, typically over bony areas like the tailbone, hips, or heels, which restricts blood flow, leading to tissue damage and potentially deep wounds, and is common in immobile individuals) of sacral (related to the sacrum [a triangular bone in the lower back]), pressure ulcer of left buttock, and pressure ulcer of right heel. The POC indicated Patient 6 was to receive daily skilled nurse (a licensed nurse in general) for 7 days, and then Patient 6 would be reassessed. The POC did not identify the orders for (nursing) discipline and treatments. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, agreed to and identified actions/interventions…” During a concurrent interview and record review with the ADM/DPCS on 1/16/2026 at 11:59 a.m., the ADM/DPCS reviewed Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026. The ADM/DPCS confirmed the POC did not have interventions, physician orders, and goals. The ADM/DPCS acknowledged the HHA staff had been providing care to Patient 5 and Patient 6 without a guide and without orders, which could cause patient harm. During a review of the agency’s job description for job title/position: Clinical Director/Director of Patient Care Services, revised April 2020, the job description summary indicated the Clinical Director/Director of Patient Care Services is responsible for the overall direction of home health clinical services. The Clinical Director/Director of Patient Care Services establishes, implements and evaluates goals and objectives for home health services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Director also serves as the Clinical Manager for the purpose of meeting the Medicare Conditions of Participation. During a review of the agency’s policy and procedure (P&P) titled, Care Planning Process, dated April 2018, the P&P indicated a written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised within five working days of initiation or of the reassessment of the patient. All clinicians including the physician involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. 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. During a review of the agency’s P&P titled, Initial and Comprehensive Assessment, dated April 2018, the P&P indicated a comprehensive patient assessment will be completed within five (5) days of the start of care. The assessment will be patient-specific and comprehensive to include patient’s need for home health care, rehabilitative care, social services, and discharge planning.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence)) failed to ensure a comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) was completed within five days of admission for one of seven sampled patients (Patient 4). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. Findings: During a review of Patient 4’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 4’s start of care (SOC) date was 1/2/2026, with a diagnosis that includes encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, the POC included an order for the skilled nurse to visit the patient twice a week for 3 weeks, then once a week for 8 weeks. The POC did not indicate and identify any orders for (nursing) discipline and treatments. During a review of Patient 4’s Comprehensive Assessment/OASIS (or Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 1/2/2026, the comprehensive assessment indicated the admitting registered nurse (RN 3) failed to complete the entire form. During an interview with RN 3, on 1/14/2026 at 11:12 a.m., RN 3 stated she conducted the comprehensive assessment on admission for Patient 4 on 1/2/2026 but has not completed and submitted her (RN 3) notes. RN 3 stated according to the agency’s policy, patient’s OASIS comprehensive assessment should be completed within 7-10 days. During a concurrent interview and record review, on 1/16/2026 at 12:18 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 4’s Comprehensive OASIS assessment dated 1/2/2026. The ADM/DPCS stated and acknowledged Patient 4’s comprehensive assessment was incomplete and not signed by the admitting nurse. The ADM/DPCS stated comprehensive assessment should be signed and completed within 5 days from the start of care to comply with regulations, and facilitating quality patient care. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2018, the P&P indicated a comprehensive patient assessment will be completed within five (5) days of the start of care. The assessment will be patient-specific and comprehensive to include patient’s need for home health care, rehabilitative care, social services, and discharge planning.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) nursing staff failed to perform a completed pressure wound assessment for one of seven sampled patients (Patient 4), who had an open wound on the sacral region (a triangular bone at the base of the spine). This deficient practice can lead to inadequate treatment and longer healing times causing patient’s discomfort and/or pain. Findings: During a review of Patient 4’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 4’s start of care (SOC) date was 1/2/2026, with a diagnoses that included encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, the POC included an order for the skilled nurse to visit the patient twice a week for 3 weeks, then once a week for 8 weeks. The POC did not indicate and identify any orders for (nursing) discipline and treatments. During a joint home visit, on 1/14/2026 at 10:30 a.m., at Patient 4’s residence with the registered nurse (RN 3), Patient 4 was observed awake, alert, confused and ambulatory, accompanied by a caregiver (PCG 2). During an observation, RN 3 assessed Patient 4’s stage 4 sacral pressure ulcer, measuring its length and width but not its depth. During an interview with RN 3, on 1/14/2026 at 11:12 a.m., RN 3 stated she assessed and measured Patient 4’s stage 4 pressure ulcer but did not measure the depth of the wound. RN 3 stated she (RN 3) should have measured the depth of the wound to monitor wound healing. During an interview and record review, on 1/16/2026 at 12:18 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated a completed stage 4 pressure ulcer wound assessment included measuring the wound’s length, width and its depth. The ADM/DPCS stated it was essential to measure the wound depth to monitor the progress of wound healing and guide treatment orders. The HHA was unable to provide a policy on Assessment of Wound or Pressure Ulcer as requested by the survey team on 1/16/2026.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain an accurate, and current medication profiles for three of seven sampled patients (Patient 3, Patient 5, and Patient 6). This failure had the potential to place the patients at risk for medication errors and adverse drug reactions. a. During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 12/2/2025, with a diagnoses that included cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy status (the presence of a gastrostomy tube [GT], a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Patient 3’ physician Admission Order, dated 12/2/2025, the order indicated Patient 3 was admitted for skilled nursing observation, assessment and evaluation of all body systems, review of medications, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate) monitoring, and home safety evaluation. During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals)) for the certification period starting from 12/2/2025 to 1/30/2026, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 1 week, two times a week for 2 weeks, and then once a week for 6 weeks. During a joint home visit, on 1/14/2026 at 11:55 a.m., at Patient 3’s residence with the registered nurse (RN 2), Patient 3 was observed laying in a hospital bed, awake, alert, oriented to person and place, accompanied by a caregiver (CG2). During a review of Patient 3’s current medication with RN 2, there was a bottle of Loperamide (used to control and relieve the symptoms of diarrhea or loose stool) 2 milligrams (mg, a unit of measurement) 2 tablets via GT catheter on 1st loose stool, 1 tablet via GT after each loose stool, no more than 8 mg in 24 hours with a filled date of 1/1/2026 found at the patient’s room. However, Patient 3’s current medication list provided by the HHA indicated patient was not on this medication. During a concurrent interview with CG2, CG2 stated she (CG2) was still giving Loperamide to Patient 3 for loose stool as needed as ordered by Patient 3’s physician. b. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated that Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure [BP] with no single, identifiable cause, developing gradually over time, often linked to genetics, aging, diet, and lifestyle). During a review of Patient 5’s Patient Medication Profile, for the period of 1/2/2026 to 3/2/2026, the Patient Medication Profile indicated that Patient 5 was taking the following medications that could lower blood pressure: • Amiodarone (a medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias [abnormal heart rhythms that make the lower chambers of the heart twitch instead of pump; this can limit or stop the heart from supplying blood to the body]) 200 milligrams (mg- a unit measurement) tablet, one tablet daily. • Metoprolol Succinate (a medication used to treat high blood pressure) 100 mg tablet, one tablet twice daily. During a joint home visit observation on 1/14/2026 at 10:30 a.m., with Registered Nurse 1 (RN 1) at Patient 5’s residence, observed Patient 5 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was observed sitting on a couch. During a concurrent joint home visit observation and a record review on 1/14/2026 at 10:30 a.m., with RN 1, observed the medication furosemide (Lasix- a powerful diuretic, or “water pill,” that makes kidneys excrete excess salt and water, treating fluid buildup [edema] from heart, liver, or kidney conditions and managing high blood pressure) 20 mg tablet, one tablet twice daily at Patient 5’s home. The medication container indicated a dispense date of 9/17/2025. During a review of Patient 5’s medication profile, the medication profile did not include furosemide. During an interview on 1/14/2026 at 11:30 a.m., with Caregiver 1 (CG)1, CG 1 stated that Patient 5 lived with her (CG 1) and she (CG 1) acted as Patient 5’s primary caregiver. CG 1 stated that she (CG1) prepares and administers Patient 5’s medications. CG 1 stated that Patient 5 takes furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. During an interview with RN 1 on 1/14/2026 at 11:45 a.m., RN 1 stated that medication reconciliation needed to be done to make sure the patient had an updated medication list. RN 1 stated he was not sure how often medication reconciliation needed to be done. RN 1 stated, “Probably once a week.” c. During a review of Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026, the POC indicated that Patient 6 was admitted to the HHA on 11/7/2025 with diagnoses that included encounter for other postprocedural aftercare, pressure ulcer (a localized skin and tissue injury caused by prolonged pressure, friction, or shear, typically over bony areas like the tailbone, hips, or heels, which restricts blood flow, leading to tissue damage and potentially deep wounds, and is common in immobile individuals) of sacral (related to the sacrum [a triangular bone in the lower back]), pressure ulcer of left buttock, and pressure ulcer of right heel. During a review of Patient 6’s Patient Medication Profile, for the period of 1/6/2026 to 3/6/2026, the Patient Medication Profile only listed Hydrocodone 10 milligram (mg, a unit measurement) – Acetaminophen (a prescription medication to treat moderate to severe pain) 325 mg tablet, one tablet every 6 hours as needed for pain. During a review of Patient 6’s Nursing Progress Notes, dated 1/7/2026, 1/8/2026, 1/9/2026, and 1/10/2026, the Nursing Progress Notes indicated that Patient 6 had been receiving wound care from Licensed Vocational Nurse (LVN 2). LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer (the most severe type of pressure ulcer, involving full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone become exposed and damaged, creating deep, crater-like wounds) on the sacral region: Wound cleansed with wound cleanser, Medi Honey (a brand of medical-grade honey dressing, primarily made from sterilized Leptospermum/Manuka honey, used to promote healing in various wounds like burns, ulcers, and surgical sites) and Calcium Alginate (a type of wound dressing that absorbs drainage and creates a moist healing environment) applied to wound bed, followed by collagen powder (a supplement to support skin, joints, bones, and hair). Covered with abdominal pad (a highly absorbent, thick dressing used for large wounds) and Mepilex (a brand of wound dressing made of soft silicone foam) dressing. For the pressure ulcer on the right hip and stage 3 pressure ulcer (full-thickness skin loss, showing a deep crater where fat tissue is visible but muscle, bone, or tendon aren’t exposed) on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. During a concurrent interview and record review with the ADM/DPCS on 1/16/2026 at 11:59 a.m., the ADM/DPCS reviewed Patient 6’s Patient Medication Profile for the period of 1/6/2026 to 3/6/2026 and Skilled Progress Notes dated 1/7/2026, 1/8/2026, 1/9/2026, and 1/10/2026. The ADM/DPCS stated that wound cleanser, Medi Honey, Calcium Alginate, and collagen powder should have been in Patient 6’s medication profile. During an interview, on 1/16/2026 at 12:18 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated nursing staff need to review and reconcile the patient’s current medication on every nurse visit and update the medication profile in the patient’s clinical record right away for any changes in the patient’s medication. During a review of the agency’s policy and procedure (P&P) titled, Medication Profile, dated April 2018, the P&P indicated patient receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure the individualized plan of care (POC, a document where a doctor certifies that a patient needs home health services, outlining the specific skilled care [nursing, therapy], medical equipment, frequency of visits, and goals) included patient-specific interventions and education for one of seven sampled patients (Patient 5) by failing to: 1.Ensure there are nursing interventions and patient/caregiver education related to Patient 5’s primary diagnosis of essential hypertension (high blood pressure [BP] with no single, identifiable cause, developing gradually over time, often linked to genetics, aging, diet, and lifestyle). 2. Ensure the HHA’s visiting nurses provided teaching to Patient 5 and Patient 5’s family member and/or caregiver regarding the importance of checking the blood pressure prior to taking blood pressure lowering medications, potentially leading to hypotension and placing the patient at increased risk for falls. As a result, Patient 5 did not receive the necessary care, such as being monitored for signs and symptoms of hypotension (low blood pressure), which may lead to serious harm, hospitalization, and/or death. On 1/15/2026, at 2:18 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator/Director of Patient Care Services (ADM/DPCS) related to the home health agency (HHA) failure to ensure that the individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) included patient-specific interventions and education for one of seven sampled patients (Patient 5), related to Patient 5’s primary diagnosis of essential hypertension (high blood pressure) and ensuring that teaching was provider to Patient 5 and Patient 5’s caregiver regarding the importance of checking the blood pressure prior to administering blood pressure lowering medications. On 1/16/2026, at 2:10 p.m., the HHA was unable to submit an IJ removal plan (IJRP- includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) to remove the IJ. On 1/16/2026, at 2:20 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM/DPCS, Office Manager, and the Licensed Vocational Nurse (LVN) case manager with the IJ not removed. Findings: During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated that Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension. There were no other pertinent diagnoses listed in the POC. The POC indicated Patient 5 was at risk for hospitalization due to history of two or more falls or any fall with an injury in the past 12 months and was currently taking five or more medications. The POC did not indicate the services and the frequency of each service the HHA was providing for Patient 5. The POC did not identify the orders for discipline and treatment. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, patient helped write a measurable goal, understandable to all stakeholders…” The POC did not include physician notification parameters (specific clinical thresholds like vital signs [simple measurements of the body’s most basic functions {temperature, pulse, breathing, blood pressure} that show how well the body is working], laboratory results, or patient status changes that trigger an alert to the physician, ensuring timely intervention for critical conditions). The POC was not signed by a Registered Nurse and a physician. During a review of Patient 5’s Patient Medication Profile, for the period of 1/2/2026 to 3/2/2026, the Patient Medication Profile indicated that Patient 5 was taking the following medications that could lower blood pressure: • Amiodarone (a medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias [abnormal heart rhythms that make the lower chambers of the heart twitch instead of pump; this can limit or stop the heart from supplying blood to the body]) 200 milligrams (mg- a unit measurement) tablet, one tablet daily. • Metoprolol Succinate (a medication used to treat high blood pressure) 100 mg tablet, one tablet twice daily. Patient 5’s Patient Medication Profile did not have instructions to check Patient 5’s blood pressure prior to taking Amiodarone 200 mg and Metoprolol Succinate 100 mg. There were no hold parameters (specific, measurable safety rules [like blood pressure or heart rate numbers] that tell a caregiver exactly when to skip or delay a medication dose to prevent harming the patient) for both medications. During a review of Patient 5’s Nursing Progress Note, dated 1/2/2026, the note indicated that Patient 5 had a blood pressure reading of 105/79 millimeters of mercury (mmHg - a unit of pressure, used primarily in medicine for blood pressure). There was no documentation that education or that instructions were provided to Patient 5 and or Patient5’s caregiver for blood pressure monitoring. During a review of Patient 5’s Nursing Progress Note, dated 1/13/2026, the note indicated that Patient 5 had a blood pressure reading of 90/70 mmHg. There was no documentation that education or that instructions were provided to Patient 5 and or Patient5’s caregiver for blood pressure monitoring. During a joint home visit observation on 1/14/2026 at 10:30 a.m., with Registered Nurse 1 (RN 1) at Patient 5’s residence, observed Patient 5 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was observed sitting on a couch. When RN 1 entered the home, Patient 5 was working with Occupational Therapist Assistant 1 (OTA 1). During an interview on 1/14/2025 at 10:30 a.m. with OTA 1, OTA 1 stated that Patient 5’s blood pressure was running low, with the systolic blood pressure (the top number in a blood pressure reading, measuring the pressure in the arteries when the heart beats and pushes blood out) in the 80s and the diastolic blood pressure (the second [bottom/lower] number; it measures the pressure the blood is pushing against the artery walls while the heart muscle rests between beats) in the 60s. OTA 1 stated that she had worked twice with Patient 5 and her blood pressure has always been on the lower side. During a concurrent joint home visit observation and a record review on 1/14/2026 at 10:30 a.m., with RN 1, observed the medication furosemide (Lasix- a powerful diuretic, or “water pill,” that makes kidneys excrete excess salt and water, treating fluid buildup [edema] from heart, liver, or kidney conditions and managing high blood pressure) 20 mg tablet, one tablet twice daily at Patient 5’s home. The medication container indicated a dispense date of 9/17/2025. During a review of Patient 5’s medication profile, the medication profile did not include furosemide. During an interview on 1/14/2026 at 11:30 a.m., with Caregiver 1 (CG)1, CG 1 stated that Patient 5 lived with her (CG 1) and she (CG 1) acted as Patient 5’s primary caregiver. CG 1 stated that she (CG1) prepares and administers Patient 5’s medications. CG 1 stated that Patient 5 takes furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. When CG 1 was asked if she checks Patient 5’s blood pressure prior to administering furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. CG 1 stated that she does not check Patient 5’s blood pressure prior to administering the medications. CG 1 stated that no one informed CG 1 of the need to check Patient 5’s blood pressure prior to administering furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. CG 1 stated that Patient 5’s blood pressure has been running low. During a concurrent interview and record review on 1/14/2026 at 11:45 a.m., with RN 1, RN 1 reviewed Patient 5’s POC for the certification period of 1/2/2026 to 3/2/2026. RN 1 stated Patient 5’s POC was lacking interventions, such as parameters for blood pressure medications and for physician notification. RN 1 stated there were also no hold parameters for the blood pressure medications. RN 1 stated, “If the blood pressure is low, the blood pressure medications might need to be held.” RN 1 stated the home health nurse would need to let the physician know about Patient 5’s low blood pressure if it fell below parameters. RN 1 stated, “But there are no parameters.” During a concurrent interview and record review on 1/15/2026 at 11 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 5’s POC for the certification period of 1/2/2026 to 3/2/2026, Patient Medication Profile for episode period of 1/2/2026 to 3/2/2026, and Nursing Progress Notes dated 1/2/2026 and 1/13/2026. The ADM/DPCS stated that Patient 5’s POC was incomplete. The ADM/DPCS stated, “It’s not done.” The ADM/DPCS stated that Patient 5’s POC did not have physician orders, interventions, parameters, patient education, nor individualized goals. When the ADM/DPCS was asked about the purpose of a plan of care, the ADM/DPCS stated that POC provides a guide for staff, so that staff know what to do for the patient. The ADM/DPCS stated, “The POC is a care that you should follow.” The ADM/DPCS stated the incomplete POC could lead to patient harm, such as falls and hospitalization. The DPCS stated that for Patient 5, the incomplete POC could have negative outcomes such as the patient might not know the plan for her, and the patient might have a fall if the blood pressure was unmonitored. The ADM/DPCS stated patients (in general) need to have a plan of care that included diagnosis or problems, interventions including education, and goals within 24 to 48 hours after admission. The ADM/DPCS stated that education about the plan of care should be provided to patients and care givers (in general) and very important so the patient could achieve their goals. When the ADM/DPCS was asked what the “personal goals” of Patient 5 listed in the POC were, the ADM/DPCS stated that he could not interpret the goals based on those statements (listed in the POC, “personal goals”) The ADM/DPCS stated, “those are general, very broad statements, like a template.” The ADM/DPCS restated the POC lacked actual, individualized goals. During a record review and telephone interview on 1/15/2026 at 12:21 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that she (LVN1) conducted visits for Patient 5, on 1/13/2026 as indicated on the nursing progress notes. LVN 1 stated she (LVN1) was aware that Patient 5’s blood pressure was low 90/70 mmHg. LVN 1 stated she did not alert the physician regarding Patient 5’s low blood pressure. LVN 1 stated that since Patient 5’s blood pressure was consistently low, there was no need to alert the physician. LVN 1 stated that she did not know the blood pressure parameters for when it became necessary to alert the physician. During a review of the HHA’s policy and procedure (P & P), titled “Care Planning Process,” updated April 2018, the P & P indicated the following: A written plan of care will be initiated within 5 days of start of care and updated at least every 60 days, or as the patient’s condition warrants. The plan of care will include, but not be limited to: A. Identified patient problems and needs. B. Reasonable, measurable, and individualized goals. C. Specific services to be provided. D. Actions to be taken to meet the patient’s goals. E. Type, frequency, and duration of above actions. During a review of the HHA’s P & P, titled “Patient Education Process,” updated April 2018, the P & P indicated that patients and family/caregiver would receive education in verbal, visual, and written format, as appropriate. The scope of teaching would be determined by assessing the needs, abilities, learning preferences, and readiness to learn…as well as by the plan of care.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure patients wound care orders were recorded in the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for three of seven sampled patients (Patient 3, Patient 4, and Patient 6). This failure had the potential to affect patient safety, impair continuity and coordination of care. a. During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 12/2/2025, with diagnoses that included cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy status (the presence of a gastrostomy tube [GT], a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period starting from 12/2/2025 to 1/30/2026, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 1 week, two times a week for 2 weeks, and then once a week for 6 weeks. The POC did not indicate and identify orders to be provided for (nursing) discipline and treatments. During a joint home visit, on 1/14/2026 at 11:55 a.m., at Patient 3’s residence with the registered nurse (RN 2), Patient 3 was observed lying in a hospital bed, awake, alert, oriented to person and place, accompanied by a caregiver (CG 3). During an observation, RN 2 assessed and cleansed patient’s GT site, and performed wound care treatment on Patient 3’s stage 2 pressure ulcer wound (partial-thickness loss of skin, presenting as a shallow open sore or wound) on the right buttock and coccyx area (refers to the tailbone, the small, triangular bone at the very bottom of your spine) as follows: wound cleansed with wound cleanser, patted dry, applied Medi Honey, and covered with foam dressing. During a concurrent interview and record review with RN 2, on 1/14/2026 at 12:42 p.m., RN 2 reviewed Patient 3’s POC for the certification period starting from 12/2/2025 to 1/30/2026. RN 2 stated she cleansed Patient 3’s GT site and covered it with dry dressing and performed wound care treatment as ordered. RN 2 stated all patient care, treatment and services should be based in the patient’s plan of care but was unable to confirm all the care and services that she just provided was written in the patients’ plan of care. b. During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/2/2026, with diagnoses that includes encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, the POC included an order for the skilled nurse to visit the patient twice a week for 3 weeks, then once a week for 8 weeks. The POC did not indicate and identify orders to be implemented for (nursing) discipline and treatments. During a joint home visit, on 1/14/2026 at 10:30 a.m., at Patient 4’s residence with the registered nurse (RN 3), Patient 4 was observed awake, alert, confused and ambulatory, accompanied by a caregiver (CG 2). During an observation, RN 3 performed wound care treatment on Patient 4’s stage 4 pressure ulcer wound (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the coccyx area as follows: wound cleansed with wound cleanser, patted dry, applied Medi Honey, and covered with non-adhesive gauze dressing. During a concurrent interview and record review with RN 3, on 1/14/2026 at 11:12 a.m., RN 3 reviewed Patient 4’s POC for the certification period starting from 1/2/2026 to 3/2/2026. RN 3 stated she performed wound care treatment as ordered in the plan of care. RN 3 stated and confirmed there was no written plan of care developed for Patient 4 including wound care treatment on Patient 4’s pressure ulcer wound. RN 3 stated she conducted the comprehensive assessment on admission for Patient 4 on 1/2/2026 but has not completed and submitted her notes. RN 3 stated Patient 4’s plan of care will be generated once she completed her comprehensive assessment. RN 3 further stated all patient care, treatment and services should be based in the patient’s plan of care. During a concurrent interview and record review, on 1/15/2026 at 11:50 am, with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 3’s POC for the certification period starting from 12/2/2025 to 1/30/2026 and Patient 4’s POC for the certification period starting from 1/2/2026 to 3/2/2026. The ADM/DPCS stated and acknowledged there were no written plan of care developed for Patient 3 and Patient 4 including wound care treatment. The ADM/DPCS stated patient’s POC should have been completed within 24-48 hours from the patient’s start of care. The ADM/DPCS stated it was important to complete patient’s POC timely because it would tell the nurse (in general) what medications, orders, and treatments were prescribed by the doctor and what to do during the home visit. The ADM/DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for serious harm in failure to properly care for the patient.” c. During a review of Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026, the POC indicated that Patient 6 was admitted to the HHA on 11/7/2025 with diagnoses that included encounter for other postprocedural aftercare, pressure ulcer (a localized skin and tissue injury caused by prolonged pressure, friction, or shear, typically over bony areas like the tailbone, hips, or heels, which restricts blood flow, leading to tissue damage and potentially deep wounds, and is common in immobile individuals) of sacral (related to the sacrum [a triangular bone in the lower back]), pressure ulcer of left buttock, and pressure ulcer of right heel. The POC indicated that Patient 6 was to receive daily skilled nurse (a licensed nurse in general) for 7 days, and then Patient 6 would be reassessed. The POC did not identify the orders for (nursing) discipline and treatments. During a review of Patient 6’s Nursing Progress Note, dated 1/7/2026, the Nursing Progress Note indicated that Licensed Vocational Nurse (LVN 2) performed wound treatment as follows to the stage 4 pressure ulcer (the most severe type of pressure ulcer, involving full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone become exposed and damaged, creating deep, crater-like wounds) on the sacral region: Wound cleansed with wound cleanser, Medi Honey (a brand of medical-grade honey dressing, primarily made from sterilized Leptospermum/Manuka honey, used to promote healing in various wounds like burns, ulcers, and surgical sites) and Calcium Alginate (a type of wound dressing that absorbs drainage and creates a moist healing environment) applied to wound bed, followed by collagen powder (a supplement to support skin, joints, bones, and hair). Covered with abdominal pad (a highly absorbent, thick dressing used for large wounds) and Mepilex (a brand of wound dressing made of soft silicone foam) dressing. For the pressure ulcer on the right hip and stage 3 pressure ulcer (full-thickness skin loss, showing a deep crater where fat tissue is visible but muscle, bone, or tendon aren’t exposed) on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a review of Patient 6’s Nursing Progress Note, dated 1/8/2026, the Nursing Progress Note indicated that LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer on the sacral region: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with abdominal pad and Mepilex dressing. For the pressure ulcers on the right hip and stage 3 pressure ulcer on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a review of Patient 6’s Nursing Progress Note, dated 1/9/2026, the Nursing Progress Note indicated that LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer on the sacral region: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with abdominal pad and Mepilex dressing. For the pressure ulcers on the right hip and stage 3 pressure ulcer on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a review of Patient 6’s Nursing Progress Note, dated 1/10/2026, the Nursing Progress Note indicated that LVN 2 performed wound treatment as follows to the stage 4 pressure ulcer on the sacral region: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with abdominal pad and Mepilex dressing. For the pressure ulcers on the right hip and stage 3 pressure ulcer on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a telephone interview with Patient 6 on 1/14/2026 at 1:51 p.m., Patient 6 stated that LVN 2 had been visiting him 6 days a week. Patient 2 stated there was another personnel who visited him once a week, Nurse Practitioner 1 (NP 1). Patient 6 stated, “I think NP 1 is a wound specialist.” Patient 6 stated that LVN 2 and NP 1 visited him for daily wound dressing change. During a review of a document from WC 1, dated 12/30/2025, the document indicated that Patient 6 had a chronic stage 4 pressure ulcer on the sacral region (wound #1), chronic stage 3 pressure ulcer on the left buttock (wound #7 – the document listed this wound as stage 3 pressure ulcer in one part, and listed it as chronic stage 3 non-pressure ulcer in other part), and wound on right hip (wound #2 – document did not mention if it was a pressure ulcer or not), and other non-pressure ulcer wounds. The wound treatment order for was as follows: For wound #1, change dressing daily and as needed for soilage or displacement, if dressing is soiled, cleanse with wound cleanser, apply Medi honey and collagen powder to wound bed, cover with abdominal pad and Mepilex dressing; For wound #2, cleanse with wound cleanser, apply calcium alginate to wound bed, cover with Mepilex dressing, perform wound care daily; For wound #7, cleanse with wound cleanser, gently pat dry, apply Medi honey and calcium alginate to wound bed, apply collagen powder, cover with Mepilex, change daily. During a concurrent interview and record review with the ADM/DPCS on 1/16/2026 at 11:59 a.m., the ADM/DPCS reviewed Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026 and Skilled Progress Notes dated 1/7/2026, 1/8/2026, 1/9/2026, and 1/10/2026. The ADM/DPCS confirmed the POC did not have interventions, physician orders, and goals. When the ADM/DPCS was asked how LVN 2 knew what she needed to do for Patient 6’s wounds if there were no interventions and physician orders in the POC, the ADM/DPCS stated that LVN 2 performed the wound care based on the orders from Wound Clinic 1 (WC 1). Per ADM/DPCS, NP 1 was a wound specialist from WC 1 who evaluated Patient 6 weekly and wrote the order for Patient 6’s wound care. The ADM/DPCS stated that the wound care orders from WC 1 needed to be transcribed into the HHA’s POC for Patient 6. According to the ADM/DPCS, all orders needed to be recorded in the POC to ensure staff were following the correct orders. During a review of the agency’s policy and procedure (P&P) titled, Care Planning Process, dated April 2018, the P&P indicated a written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to notify the physician for two of seven sampled patients (Patient 3 and Patient 5) regarding the following: a. Patient 3’s black-colored gastrostomy tube catheter. b. Patient 5’s low blood pressure and multiple blood pressure medication. This failure resulted in Patient 3’s tube feeding and Patient 5’s blood pressure not being properly monitored and the patients’ care plan not updated. a. During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 12/2/2025, with diagnoses that included cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy status (the presence of a gastrostomy tube [GT], a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Patient 3’ physician Admission Order, dated 12/2/2025, the order indicated Patient 3 was admitted for skilled nursing observation, assessment and evaluation of all body systems, review of medications, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse, and respiratory [breathing] rate) monitoring, and home safety evaluation. During a review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period starting from 12/2/2025 to 1/30/2026, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 1 week, two times a week for 2 weeks, and then once a week for 6 weeks. During a joint home visit, on 1/14/2026 at 11:55 a.m., at Patient 3’s residence with the registered nurse (RN 2), Patient 3 was observed lying in a hospital bed, awake, alert, oriented to person and place, accompanied by a caregiver (CG3). During the visit, it was observed Patient 5 had a black-colored GT catheter (normal color for GT catheter tubing is typically clear, transparent silicone). RN 2 stated patient’s physician was notified during admission and aware of the patient’s GT catheter condition and ordered to continue monitoring the site for blockage and signs of infection. During a concurrent interview and record review, on 1/16/2026 at 12:18 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 3’s physician orders and communication note. The ADM/DPCS stated and confirmed there was no documented evidence Patient 3’s physician was notified of black-colored GT catheter. The ADM/DPCS stated black-colored GT catheter tubing indicated staining from gastric contents and medications and patient’s physician should have been notified for evaluation for proper maintenance of the tube and to ensure safe and appropriate care for the patient. b. During a review of Patient 5’s Home Health Certification and Plan of Care (also known as the plan of care [POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals]) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated that Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure [BP] with no single, identifiable cause, developing gradually over time, often linked to genetics, aging, diet, and lifestyle). The POC indicated that Patient 5 was at risk for hospitalization due to history of 2 or more falls or any fall with an injury in the past 12 months and was currently taking 5 or more medications. During a review of Patient 5’s Patient Medication Profile, for the period of 1/2/2026 to 3/2/2026, the Patient Medication Profile indicated that Patient 5 was taking the following medications that could lower blood pressure: • Amiodarone (a medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias [abnormal heart rhythms that make the lower chambers of the heart twitch instead of pump; this can limit or stop the heart from supplying blood to the body]) 200 milligrams (mg- a unit measurement) tablet, one tablet daily. • Metoprolol Succinate (a medication used to treat high blood pressure) 100 mg tablet, one tablet twice daily. Patient 5’s Patient Medication Profile did not have instructions to check Patient 5’s blood pressure prior to taking Amiodarone 200 mg and Metoprolol Succinate 100 mg. There were no hold parameters (specific, measurable safety rules [like blood pressure or heart rate numbers] that tell a caregiver exactly when to skip or delay a medication dose to prevent harming the patient) for both medications. During a review of Patient 5’s Nursing Progress Note, dated 1/2/2026, the note indicated that Patient 5 had a blood pressure reading of 105/79 millimeters of mercury (mmHg - a unit of pressure, used primarily in medicine for blood pressure). There was no documentation that education or that instructions were provided to Patient 5 and or Patient5’s caregiver for blood pressure monitoring. During a review of Patient 5’s Nursing Progress Note, dated 1/13/2026, the note indicated that Patient 5 had a blood pressure reading of 90/70 mmHg. There was no documentation that education or that instructions were provided to Patient 5 and or Patient5’s caregiver for blood pressure monitoring. During a joint home visit observation on 1/14/2026 at 10:30 a.m., with Registered Nurse 1 (RN 1) at Patient 5’s residence, observed Patient 5 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was observed sitting on a couch. When RN 1 entered the home, Patient 5 was working with Occupational Therapist Assistant 1 (OTA 1). During an interview on 1/14/2025 at 10:30 a.m. , with OTA 1, OTA 1 stated that Patient 5’s blood pressure was running low, with the systolic blood pressure (the top number in a blood pressure reading, measuring the pressure in the arteries when the heart beats and pushes blood out) in the 80s and the diastolic blood pressure (the second [bottom/lower] number; it measures the pressure the blood is pushing against the artery walls while the heart muscle rests between beats) in the 60s. OTA 1 stated that she had worked twice with Patient 5 and her blood pressure has always been on the lower side. During a concurrent joint home visit observation and a record review on 1/14/2026 at 10:30 a.m., with RN 1, observed the medication furosemide (Lasix- a powerful diuretic, or “water pill,” that makes kidneys excrete excess salt and water, treating fluid buildup [edema] from heart, liver, or kidney conditions and managing high blood pressure) 20 mg tablet, one tablet twice daily at Patient 5’s home. The medication container indicated a dispense date of 9/17/2025. During a review of Patient 5’s medication profile, the medication profile did not include furosemide. During an interview on 1/14/2026 at 11:30 a.m., with Caregiver 1 (CG)1, CG 1 stated that Patient 5 lived with her (CG 1) and she (CG 1) acted as Patient 5’s primary caregiver. CG 1 stated that she (CG1) prepares and administers Patient 5’s medications. CG 1 stated that Patient 5 takes furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. When CG 1 was asked if she checks Patient 5’s blood pressure prior to administering furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. CG 1 stated that she does not check Patient 5’s blood pressure prior to administering the medications. CG 1 stated that no one informed CG 1 of the need to check Patient 5’s blood pressure prior to administering furosemide 20 mg, amiodarone 200 mg, and metoprolol succinate 100 mg. CG 1 stated that Patient 5’s blood pressure has been running low. During a concurrent interview and record review on 1/15/2026 at 11 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 5’s clinical records on the electronic health record platform. The ADM/DPCS stated there was no physician notification regarding Patient 5’s low blood pressure. The ADM/DPCS stated there should have been vital sign parameters for physician alert, so the HHA staff had a guideline. During a record review and telephone interview on 1/15/2026 at 12:21 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that she (LVN1) conducted visits for Patient 5, on 1/13/2026 as indicated on the nursing progress notes. LVN 1 stated she (LVN1) was aware that Patient 5’s blood pressure was low 90/70 mmHg. LVN 1 stated she did not alert the physician regarding Patient 5’s low blood pressure. LVN 1 stated that since Patient 5’s blood pressure was consistently low, there was no need to alert the physician. LVN 1 stated that she did not know the blood pressure parameters for when it became necessary to alert the physician. During a review of the HHA’s policy and procedure (P & P), titled “Monitoring Patient’s Response / Reporting to Physician,” updated April 2018, the P & P indicated that clinicians would establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. All conferences or attempts to communicate with the physician would be documented in the clinical record.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation and interview, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to provide a copy of medication schedule/instructions that included medication name, dosage and frequency for one of seven sampled patients (Patient 5). This failure might result in medication noncompliance, adverse drug effects, and drug interactions. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated that Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure [BP] with no single, identifiable cause, developing gradually over time, often linked to genetics, aging, diet, and lifestyle). During a joint home visit observation on 1/14/2026 at 10:30 a.m., with Registered Nurse 1 (RN 1) at Patient 5’s residence, observed Patient 5 awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). Patient 5 was observed sitting on a couch. During an interview on 1/14/2026 at 11:30 a.m., with Caregiver 1 (CG)1, CG 1 stated that Patient 5 lived with her (CG 1) and she (CG 1) acted as Patient 5’s primary caregiver. CG 1 stated that she (CG1) prepared and administered Patient 5’s medications. During the joint home visit, Patient 5’s home health folder was reviewed with RN 1. It was noted that there was no copy of the medication profile in the home health folder. There was a form that had columns for medication name, dosage, and frequency in the folder, but the form was blank. During an interview with RN 1 on 1/14/2026 at 11:45 a.m., RN 1 stated that he should have filled out the form with Patient 5’s medications, including the dose, frequency, and indication, upon admission. RN 1 stated that it was important to provide the patient with a copy of the medication list, so the patient/family members would be aware of what medications to take, when to take, and side effects. RN 1 stated the medication profile could also be used by the staff to provide teaching for patient. During a review of the HHA’s policy and procedure (P & P), titled “Patient Education Process,” updated April 2018, the P & P indicated, “Unless otherwise ordered by the physician, the patient and family/caregiver will receive verbal and, as appropriate, written instructions on: B. The medical regimen C. Medication management and administration D. Food and drug interactions”

“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, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that clinical records included current comprehensive assessment, including all assessments from the most recent home health admission, clinical notes, plan of care, and physician or allowed practitioner orders for six of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This failure resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6 not having complete clinical records, placing patient safety at risk by increasing the chance of errors in medication, treatment, and diagnoses; increasing the risk for a lack in continuity of care, poor coordination between clinicians such as nurses and physicians, and affecting the patients’ care and services. a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1’s start of care (SOC) date was 11/7/2025, with diagnoses that include encounter for change or removal of nonsurgical wound dressing, pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of right buttock, and pressure ulcer of left buttock. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) for the certification period starting from 11/7/2025 to 1/5/2026, noted that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. b. During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC date was 1/2/2026, with a primary diagnosis of essential hypertension (high blood pressure that develops gradually over time with no single, identifiable cause). During a review of Patient 2’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, noted was that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. During a concurrent interview and record review, on 1/15/2026 at 12:05 p.m., with the Administrator/DPCS (ADM/DPCS), Patient 1’s POC for the certification period starting from 11/7/2025 to 1/5/2026 and Patient 2’s POC for the certification period starting from 1/2/2026 to 3/2/2026 was reviewed. The ADM/DPCS stated he was not aware there was no written plan of care developed for Patient 1 and Patient 2. The ADM/DPCS stated the patient’s (in general) POCs should have been completed within 24 to 48 hours from the patient’s SOC. The ADM/DPCS stated not having a complete POCs could result in nurses not performing needed interventions, which could result in harm to the patients. c. During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 12/2/2025, with a diagnosis that includes cerebrovascular disease (conditions that affect blood flow to your brain), dementia (a progressive state of decline in mental abilities), and gastrostomy (a surgical procedure to create an opening in the abdomen, leading directly into the stomach, for a gastrostomy tube [G-tube] to deliver food, fluids, and medicine when someone cannot eat or drink enough by mouth) status. During a review of Patient 3’s Home Health Certification and Plan of Care for the certification period starting from 12/2/2025 to 1/30/2026, noted that the POC was not signed by a physician and that there was no plan of care that identifies patient-specific measurable outcomes and goals for the patient’s treatment and care. d. During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/2/2026, with a diagnosis that includes encounter for change or removal of nonsurgical wound dressing, essential hypertension (high blood pressure), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a triangular bone at the base of the spine). During a review of Patient 4’s Home Health Certification and POC for the certification period starting from 1/2/2026 to 3/2/2026, it indicated there was no care plan developed that identifies patient-specific measurable outcomes, goals and interventions for the patient’s treatment, skilled care and services. During a review of Patient 4’s Comprehensive Assessment/OASIS (or Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 1/2/2026, the comprehensive assessment indicated the admitting registered nurse (RN 3) failed to complete the entire form. During an interview with RN 3, on 1/14/2026 at 11:12 a.m., RN 3 stated she conducted the comprehensive assessment on admission for Patient 4 on 1/2/2026 but has not completed and submitted her (RN 3) notes. RN 3 stated according to the agency’s policy, patient’s OASIS comprehensive assessment should be completed within 7-10 days. During a concurrent interview and record review, on 1/15/2026 at 11:50 am, with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s POC for the certification period starting from 12/2/2025 to 1/30/2026 and Patient 4’s POC for the certification period starting from 1/2/2026 to 3/2/2026. The ADM/DPCS stated and acknowledged he was not aware there was no written plan of care developed for Patient 3 and Patient 4. The ADM/DPCS stated patient’s (in general) POC should have been completed within 24-48 hours from the patient’s start of care. The ADM/DPCS stated it was important to complete patient’s POC timely because it would tell the nurse (in general) what medications, orders, and treatments were prescribed by the doctor and what to do during the home visit. The ADM/DPCS stated, “If we don’t have patient’s plan of care, we don’t know how to care for the patient, which has a potential for serious harm in failure to properly care for the patient.” During a concurrent interview and record review, on 1/16/2026 at 12:18 p.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 4’s Comprehensive OASIS assessment dated 1/2/2026. The ADM/DPCS stated and acknowledged Patient 4’s comprehensive assessment was incomplete and not signed by the admitting nurse. The ADM/DPCS stated comprehensive assessment should be signed and completed within 5 days from the start of care to comply with regulations, and facilitating quality patient care. e. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period of 1/2/2026 to 3/2/2026, the Home Health Certification and Plan of Care indicated that Patient 5 was admitted to the HHA on 1/2/2026 with a primary diagnosis of essential hypertension (high blood pressure [BP] with no single, identifiable cause, developing gradually over time, often linked to genetics, aging, diet, and lifestyle). The POC did not indicate the services and the frequency of each service the HHA was providing for Patient 5. The POC did not identify the orders for discipline and treatments. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, patient helped write a measurable goal, understandable to all stakeholders…” The POC was not signed by a Registered Nurse and a physician. During a joint home visit on 1/14/2026 at 10:30 a.m. with Registered Nurse 1 (RN 1) at Patient 5’s residence, Patient 5 was observed awake, alert, and oriented to person, place, and time (aware of own identity, location, and the current date and time). During a concurrent interview and record review with RN 1 on 1/14/2026 at 11:45 a.m., RN 1 reviewed Patient 5’s POC for the certification period of 1/2/2026 to 3/2/2026. RN 1 stated the POC was lacking interventions, such as parameters for blood pressure medications and for physician notification. RN 1 stated that he had never seen Patient 5’s POC until now, so he was not aware that Patient 5 was receiving nursing services and physical therapy services, or that the POC was missing interventions. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 1/15/2026 at 11 a.m., the ADM/DPCS reviewed Patient’s 5 POC for the certification period of 1/2/2026 to 3/2/2026. The ADM/DPCS stated, “It’s not done.” f. During a review of Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026, the POC indicated that Patient 6 was admitted to the HHA on 11/7/2025 with diagnoses that included encounter for other postprocedural aftercare, pressure ulcer (a localized skin and tissue injury caused by prolonged pressure, friction, or shear, typically over bony areas like the tailbone, hips, or heels, which restricts blood flow, leading to tissue damage and potentially deep wounds, and is common in immobile individuals) of sacral (related to the sacrum [a triangular bone in the lower back]), pressure ulcer of left buttock, and pressure ulcer of right heel. The POC indicated that Patient 6 was to receive daily skilled nurse (a licensed nurse in general) for 7 days, and then Patient 6 would be reassessed. The POC did not identify the orders for (nursing) discipline and treatments. The goals section indicated, “Patient agreed their personal goals was realistic based on the patient’s health status, agreed their personal goals needed to be modified based on the patient’s health status, agreed to and identified actions/interventions…” During a review of Patient 6’s Nursing Progress Notes, dated 1/7/2026, 1/8/2026, 1/9/2026, and 1/10/2026, the Nursing Progress Notes indicated that Licensed Vocational Nurse (LVN 2) performed wound treatment as follows to the stage 4 pressure ulcer (the most severe type of pressure ulcer, involving full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone become exposed and damaged, creating deep, crater-like wounds) on the sacral region: Wound cleansed with wound cleanser, Medi Honey (a brand of medical-grade honey dressing, primarily made from sterilized Leptospermum/Manuka honey, used to promote healing in various wounds like burns, ulcers, and surgical sites) and Calcium Alginate (a type of wound dressing that absorbs drainage and creates a moist healing environment) applied to wound bed, followed by collagen powder (a supplement to support skin, joints, bones, and hair). Covered with abdominal pad (a highly absorbent, thick dressing used for large wounds) and Mepilex (a brand of wound dressing made of soft silicone foam) dressing. For the pressure ulcer on the right hip and stage 3 pressure ulcer (full-thickness skin loss, showing a deep crater where fat tissue is visible but muscle, bone, or tendon aren’t exposed) on the left buttock, the following wound treatment was done as follows: Wound cleansed with wound cleanser, Medi Honey and Calcium Alginate applied to wound bed, followed by collagen powder. Covered with Mepilex dressing. The Nursing Progress Note indicated that wound care was performed “per the established plan of care.” During a concurrent interview and record review with the ADM/DPCS on 1/16/2026 at 11:59 a.m., the ADM/DPCS reviewed Patient 6’s POC for the certification period of 1/6/2026 to 3/6/2026 and Skilled Progress Notes dated 1/7/2026, 1/8/2026, 1/9/2026, and 1/10/2026. The ADM/DPCS confirmed the POC did not have interventions, physician orders, and goals. When the ADM/DPCS was asked how LVN 2 knew what she needed to do for Patient 6’s wounds if there were no interventions and physician orders in the POC, the ADM/DPCS stated that LVN 2 performed the wound care based on the orders from Wound Clinic 1 (WC 1). Per ADM/DPCS, NP 1 was a wound specialist from WC 1 who evaluated Patient 6 weekly and wrote the order for Patient 6’s wound care. The ADM/DPCS stated that the wound care orders from WC 1 needed to be transcribed into the HHA’s POC for Patient 6. The ADM/DPCS acknowledged the HHA staff had been providing care to Patient 5 and Patient 6 without a guide and without orders, which could cause patient harm. During a review of the agency’s policy and procedure (P&P) titled, “Entries Into The Clinical Record,” dated 2009, the P&P indicated: “A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: C. Physician orders and evidence of physician oversight activities. D. Changes to the plan of care. E. Dates, times, and types of interventions, assessments, and coordination of care. G. Current patient status and progress towards goals. H. Patient and family education.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that discharged patient had a discharge summary that physician responsible for the home health plan of care, reason for admission, type of services provided and frequency, medications at the time of discharge, patient outcomes, and post-discharge instruction for one of seven sampled patients (Patient 7). This deficient practice might impact continuity of care and patient safety post discharge. During a review of Patient 7’s Patient Profile, the Patient Profile indicated a start of care (SOC) date of 10/29/2025 and an end of care (EOC) date of 12/24/2025, with a primary diagnosis of type 2 diabetes mellitus (a chronic metabolic condition where the body either does not produce enough insulin [a hormone produced by the pancreas that regulates blood sugar/glucose] or becomes resistant to it, leading to high blood sugar [hyperglycemia]) without complications. During a review of Patient 7’s undated Discharge OASIS, the Discharge OASIS’ status indicated that it was in progress. The Discharge OASIS was not completed, was not signed and dated by the Registered Nurse who conducted the discharge assessment. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 1/16/2026 at 1:05 p.m., the ADM/DPCS reviewed Patient 7’s Discharge OASIS. The ADM/DPCS stated that it was incomplete. The ADM/DPCS stated the HHA did not have a discharge summary for Patient 7 because the discharge OASIS, which was the discharge assessment, was not completed. The ADM/DPCS stated that discharge summary was important because it summarized the patient’s care that was provided by the HHA and it ensured that patient and patient’s caregiver fully understood what to expect after patient had been discharged from home health. During a review of the agency’s policy and procedure (P&P) titled, “Discharge Summary,” updated April 2018, the P&P indicated the discharge summary and other relevant record documents would be completed and submitted within 72 hours of discharge.”