Interim Healthcare of Pueblo

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure staff followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 2 patient observed receiving wound care during a home visit (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/1/25. The plan of care for the certification period dated 10/31/25 to 12/29/25 revealed a start of care date of 10/31/25; diagnoses included cellulitis of the right lower limb and hypertension. Plan of care orders included skilled nurse (SN) visits two times weekly and as needed (PRN) for assessment, education, and management of wound care and hypertension. Wound care orders on the plan of care, dated 10/31/25, were to cleanse with wound cleaner, apply moisture barrier to periwound, please antimicrobial pigmented foam dressing such as Hydrofera Blue or equivalent to wound bed, cover with absorbent dressing, and apply 3-layer compression dressing. a) Observations showed Licensed Practical Nurse (LPN) #4 failed to utilize appropriate infection control procedures during the provision of wound care for Patient #1. A home visit was conducted on 12/1/25 at 2:00 p.m. for Patient #1. The surveyor observed LPN #4 providing wound care to Patient #1’s right lower extremity wound. A paper barrier was placed on a bed and then Patient #1 right lower extremity was placed on top of the barrier. The paper barrier was retrieved by LPN #4 from a foot stool that was used from past wound changing visits. The paper barrier had pet hair and stains. LPN #4 then provided the care to the wound that was stated in the plan of care. During an interview on 12/1/25 at 2:48 p.m., LPN #4 stated she had been with the agency since June 2025. She stated she trained with the clinical medical director on infection prevention standards and wound care management. She stated her wound care process including sanitizing her hands, getting the patient on the bed with a paper barrier under the wound, getting all supplies ready, removing old bandages, and going through the wound care orders step by step. When asked if she reuses paper barriers she states she has always used the same one and did not know that they should be thrown away after each visit. During an interview on 12/2/25 at 12:58 p.m., the Director of Nurse (DON) stated that their policy for paper barriers is to be thrown away after every wound change and to never be reused. The DON stated that the LPN needed to be reeducated on proper infectious disease standards and the agency’s policy on paper barriers.”

“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 agency failed to ensure a comprehensive assessment was completed no later than five calendar days after each patient’s start of care for 1 of 7 patient records reviewed (Patient #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 12/2/25. The Plan of Care for the certification period dated 4/7/25 to 6/5/25, revealed a start of care date of 3/26/25; diagnoses included Parkinson’s disease without dyskinesia, without mention of fluctuations. Plan of Care orders included physical therapy two times weekly for four weeks. a) The agency failed to ensure the Physical Therapist (PT) completed a comprehensive assessment within five calendar days of Patient #7’s start of care date of 3/26/25. Record review of a referral dated 3/26/25 revealed Patient #7 was to receive physical therapy two times weekly for four weeks starting immediately. The comprehensive assessment was completed by a PT on 4/7/25, 12 days after the start of care was to begin. During an interview on 12/2/25 at 1:14 p.m., the Director of Nursing (DON) and the Administrator stated that they do not know why the PT did not go out to do a comprehensive assessment within the 5 day timeframe. They stated that they did not have a delay of service order from the physician and the start of care should not have been 12 days behind.”

“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 record review and interview, the agency failed to ensure the comprehensive assessment included all required elements. Specifically, for 1 of 7 sample patients, the agency did not ensure the comprehensive assessment included a review of the medications the patient was currently using (Patient #2). Findings include: The clinical record for Patient #2 was reviewed on 12/2/25. Plan of care orders for the certification period dated 11/5/25 to 1/3/26 revealed a start of care date of 5/14/24; diagnoses included lymphedema and venous insufficiency. Plan of care orders included skilled nursing visits twice per week for wound care. a) The agency failed to ensure a review of medications was included in the comprehensive assessment. 1. During a home visit interview with Patient #2 at 3:30 p.m. on 12/1/25, Patient #2 stated he was taking medications for pain and high blood pressure. 2. Review of the comprehensive assessment completed for the most recent 60-day recertification period, dated 11/3/25, revealed it did not include medications or a review of medications. Further review revealed no medication review had been completed since the comprehensive assessment for the 60-day recertification period beginning 5/5/25. 3. Review of the agency’s Comprehensive Assessment policy revealed the following: “The comprehensive assessment is completed to accurately reflect the individual’s status at the time of the assessment. The comprehensive assessment must include a medication review and reconciliation.” 4. During an interview with director of nursing (DON) at 1:43 p.m. on 12/2/25, the DON acknowledged the comprehensive assessments for Patient #2 had not included a medication review since May 2025. The DON stated the medication review may have been missing due to a change in the electronic medical records system the agency had put into place mid-year. The DON stated the medication review should have been completed and placed in the comprehensive assessment.”

“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 record review and interview, the agency failed to ensure the plan of care included all required elements. Specifically, for 1 of 7 sample patients, the agency did not ensure the plan of care included the patient’s medications (Patient #2). Findings include: The clinical record for Patient #2 was reviewed on 12/2/25. Plan of care orders for the certification period dated 11/5/25 to 1/3/26 revealed a start of care date of 5/14/24; diagnoses included lymphedema and venous insufficiency. Plan of care orders included skilled nursing visits twice per week for wound care. a) The agency failed to ensure Patient #2’s plan of care included a list of his medications. 1. During a home visit interview with Patient #2 at 3:30 p.m. on 12/1/25, Patient #2 stated he was taking medications for pain and high blood pressure. 2. Review of Patient #2’s plan of care revealed the plan of care did not include his medications. 3. Per the agency’s policy, Developing a Plan to Meet Patient/Client Needs, dated 4/2/21, all medications were to be included in the plan of care. 4. During an interview with director of nursing (DON) at 10:50 a.m. on 12/2/25, the DON acknowledged Patient #2’s plan of care did not include any medications. The DON stated the full list of medications should have been listed in the plan of care.”

“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 agency failed to ensure wound care treatments were administered by agency staff only as ordered by a physician for 1 of 3 patients reviewed who had wound care ordered (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/1/25. The plan of care for the certification period dated 10/31/25 to 12/29/25 revealed a start of care date of 11/3/25; diagnoses included cellulitis of the right lower limb and hypertension. Plan of care orders included skilled nurse (SN) visits two times weekly and as needed (PRN) for assessment, education, and management of wound care and hypertension. Wound care orders on the plan of care, dated 10/31/25, were to cleanse with wound cleaner, apply moisture barrier to periwound, place antimicrobial pigmented foam dressing such as Hydrofera Blue or equivalent to wound bed, cover with absorbent dressing, and apply 3-layer compression dressing. a) The agency failed to ensure wound care was provided only as ordered by the physician. Review of Patient #1 plan of care dated 10/31/25 to 12/29/25 revealed the following wound care orders: cleanse with wound cleaner, apply moisture barrier to periwound, place antimicrobial pigmented foam dressing such as Hydrofera Blue or equivalent to wound bed, cover with absorbent dressing, and apply 3-layer compression dressing. These orders were to be followed for the wound on Patient #1 right lower limb twice a week or as needed. Record review of the nursing notes dated 11/6/25 by RN #10 stated they cleansed the wound with wound cleaner, applied moisture barrier to periwound, placed antimicrobial pigmented foam dressing to the wound bed, covered with absorbent dressing, secured the absorbent dressing with medical tape to Patient #1 skin, and applied 3-layer compression dressing. On 11/14/25, 11/16/25, 11/19/25, and 11/23/15, RN #7 repeated using tape to secure the absorbent dressing to the skin of Patient #1. A home visit was conducted on 12/1/25 at 2:00 p.m. for Patient #1. The surveyor observed LPN #4 providing wound care to Patient #1’s right lower extremity wound. LPN #4 removed the old bandage, cleansed the wound with wound cleaner, applied moisture barrier to periwound, placed antimicrobial pigmented foam dressing to the wound bed, covered with absorbent dressing, secured the absorbent dressing with medical tape to Patient #1 skin, and applied 3-layer compression dressing. During an interview on 12/1/25 at 2:38 p.m. LPN #4 stated that she had read the plan of care and thought that securing the absorbent bandage to the skin was in the order. She stated that she has always secured the bandage to the skin with tape at every visit. LPN #4 had visited Patient #1 on 11/3/25, 11/26/25, 11/28/25, and 12/1/25. During interview on 12/2/25 at 12:58 p.m., the Director of Nursing (DON), Employee #3, stated that the nurses are supposed to follow all physician orders including wound care orders.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patient was advised of changes in the patient’s plan of care, prior to implementing changes in 1 of 3 active patients reviewed (Patient #2). Findings include: 1.The record for Patient #2 was reviewed on 4/16/24. The plan of care for the certification period, dated 3/20/24 to 5/04/24, revealed a start of care date of 6/4/21. Diagnoses include secretion of antidiuretic hormone (SIADH), causes the body to retain too much water, and unspecified obesity. Plan of care orders included a skilled nurse (SN) visit once a week for 60 days to perform medication management, and medication administration. a) The agency failed to ensure the patient was informed of the change in frequency of visits resulting in the patient not being able to consent to changes, or participate in their care. Record review revealed that the agency received new physician orders on 3/12/24 to reflect a change in frequency for SN visits once daily to once weekly. Further record review of SN visits between 3/14/24 to 4/11/24 revealed the agency followed physician orders and provided SN visits once weekly. During interview on 4/16/24 at 1:39 p.m., Patient #2 confirmed they were not notified of the change in the frequency of visits. They also stated they were the one to call the agency after the nurse did not arrive as per usual, and were notified during the phone call of the changes to the frequency. During an interview on 4/16/24 at 1:07 p.m., the director of nursing (DON) stated there was a breakdown in communication and she assumed Patient #2 was notified of the changes in frequency after requesting the field nurse communicate the change to Patient #2. The DON admitted she did not follow up after the nurse visited the patient.”

“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 interview and record review, the agency failed to ensure drugs and treatments were administered by agency staff only as ordered by a physician for 2 of 4 active patients reviewed (Patients #2 and #3). Findings include: 2. The clinical record for Patient #3 was reviewed on 4/16/24. The plan of care for the certification period dated 2/27/24 to 4/26/24 revealed a start of care date of 2/27/24; diagnoses included orthostatic hypotension, unspecified diastolic (congestive) heart failure, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Plan of care orders included SN services twice for one week, once weekly for four weeks, and three as needed (PRN) visits for medication education, pressure relieve prevention, vital sign assessment, and infection risk assessment; certified nursing assistant (CNA) services once a week for one week, three times a week for three weeks, two visits a week for one week and three PRN visits for assistance with personal care, skilled transfers, and assistance with activities of daily living (ADL); physical therapy (PT) services once during the certification period for PT assessment and evaluation; and occupational therapy (OT) services once during the certification period for OT assessment and evaluation. a) The agency failed to provide a PT and OT evaluation for Patient #3 as ordered by the physician. Review of the clinical record on 4/17/24 revealed the agency provided a SN visit on 2/27/24 and 2/29/24, before Patient #3 was admitted to the hospital on 3/1/24. Following the patient’s release from the hospital on 3/5/24 the patient received the following new visit frequency orders; SN services twice weekly for two weeks, once a week for two weeks, and three PRN visits for the certification period for medication education, pressure relieve prevention, vital sign assessment, and infection risk assessment; CNA services three times a week for two weeks, twice a week for two weeks, once a week for one week, and three PRN visits for assistance with personal care, skilled transfers, and assistance with ADL; PT services once during the certification period for PT assessment and evaluation; and OT services once during the certification period for OT assessment and evaluation. Further review of the clinical record for Patient #3 revealed the patient discharged himself on 3/19/24. During the period between the discharge from the hospital on 3/5/24 and the self discharge on 3/19/24, the agency failed to provide an PT and OT evaluation as per the physician orders. During an interview on 4/16/24 at 2:02 p.m., the administrator and DON stated the reason the agency had not sent an PT or OT for evaluation to the home of Patient #3 was because they had not yet received the authorization from the insurance company. The administrator and DON also stated if the agency has not received insurance authorization from the insurance company they would explain to the patient that any costs would have to be paid out of pocket by the patient. During an interview on 4/16/24 at 2:32 p.m., the administrator and DON stated the agency had “dropped the ball”. The administrator and DON explained the agency had received the authorization for PT and OT services from the insurance company on 3/15/24, four days prior to the discharge of Patient #3. During an interview on 4/16/24 at 3:04 p.m., registered nurse (RN) #4 stated she was the RN who visited Patient #3. RN #4 stated the reason Patient #3 gave for wanting to be discharged is that the patient was afraid he would have to pay for further services, including the PT and OT services. RN #4 also stated she contacted the physician of Patient #3 to request another referral be sent out for Patient #3, as RN #4 believed the patient still required services. 1. The record for Patient #2 was reviewed on 4/16/24. The plan of care for the certification period, dated 3/20/24 to 5/04/24, revealed a start of care date of 6/4/21.Diagnoses include secretion of antidiuretic hormone(SIADH)(causes the body to retain too much water), and unspecified obesity. Plan of care orders included a skilled nurse (SN) visit once a week for 60 days to perform medication management and administration. a) The agency failed to administer the medication to Patient #2 as per physician orders. Record review of plan of care on 4/16/24 revealed physician orders of agency SN to administer Trulicity subcutaneous (SQ) injection one time weekly on Thursdays. Further record review showed the last administration of Trulicity was performed on 3/8/24. Patient #2 had not received administration of Trulicity SQ injection on 3/14/24, 3/21/24and 3/28/24 as ordered by the physician. During an Interview on 4/16/24 at 11:39 a.m. Patient #2 confirmed that the agency had stopped providing administration of the injection. The patient was not able to recall how long but that it had been for a few weeks. Interview on 4/16/24 beginning at 1:07 p.m. the director of nursing (DON) confirmed that after reviewing the record and speaking with the nurse on record, the physician’s orders were not being followed per the plan of care and the medication was not administered per the physician’s orders.”