St Anthony Regional Hospital and Nursing Home

“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 home observation visits, patient interview, staff interviews, clinical record reviews and agency policy review, the agency failed to perform a complete and accurate drug regimen review with each comprehensive assessment for 1 of 3 sampled patients with a home observation visit (Patient #2). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Ongoing Assessments, dated 8/2025, a comprehensive assessment should include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy. During interview on 8/11/2026 at 2:41 PM, Staff B, Clinical Manager, identified a drug regimen review (DRR) is done at admission, at recertification, resumption of care and discharge. Patient #2 had a start of care date of 1/12/23. Clinical record review revealed: a. The Plan of Care (POC), dated 6/25/26 to 8/23/26, identified the patient had a primary diagnosis of cerebral infarction and included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 6/23/26, completed by Staff H, Registered Nurse (RN), identified a DRR was completed and no changes were made to medications. c. During a home observation visit on 8/11/26 at 9:00 AM with Staff H, RN, the surveyor observed Staff H to set up the patient’s medication in a medication planner. The following medication discrepancies were identified: 1) The agency medication list identified the patient takes glucose 4 gram oral chewable tablets with instructions to take 1-4 tablets as needed for low blood sugar. The patient reported not taking this medication and not having the medication available in the home for greater than 2 months. 2) The agency medication list identified the patient takes famotidine (acid reducer) 20 milligram (mg) oral tablets with instructions to take 1 tablet every 48 hours as needed. The surveyor identified the bottle of famotidine in the home expired on 1/25/25. 3) The surveyor observed a bottle of loratadine 10 mg tablets with instructions to take 1 tablet as needed for a runny nose. The medication was last filled on 2/26/26. The patient stated he/she takes the medication as needed. The POC lacked documentation of an order for loratadine. The RN failed to ensure all medications reviewed at the time of the DRR were current and accurate. The above findings were reviewed with the Administrator and Clinical Manager.”

“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 home observation visits, patient interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care (POC), including all medical supplies/equipment, all medications, and treatments used by the patient for 2 of 3 sampled patients with home visits (Patients #1 and #3). Failure to maintain complete and accurate POCs with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #1 had a start of care date of 6/26/26. Clinical record review revealed: a. The POC, dated 6/26/26 to 8/24/26, identified the patient had a primary diagnosis of acute embolism and thrombosis of right femoral vein and included physician orders for medications and treatments. b. The occupational therapist (OT) visit note, dated 7/8/26, completed by Staff E, OT, identified the patient had gauze to the left lower extremity that was stuck secondary to bleeding from wound. Staff E, OT, documented using saline to wet the gauze and remove and then applied sterile antimicrobial gel to the wound. The agency failed to include all medications and treatments on the POC, including wound care orders. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Physician Orders/Plan of Care, dated 6/2025, the contecnts of the diagnostic and therapeutic orders should include a description of equipment, if any, necessary in the provision of care and a description of current medication, including name, dose, frequency and route of each medication. 1.Patient #3 had a start of care date of 7/20/26. Clinical record review revealed: a. The POC, dated 7/20/26 to 9/17/26, identified the patient had a primary diagnosis of a fractured left femur and included physician orders for medical supplies/equipment used by the patient. The POC included the following medical supplies/equipment used by the patient: walker, shoer chair/bench, scale, pill box and handheld shower. b. During a home observation visit on 8/11/26 at 9:00 AM with Staff C, Registered Nurse (RN), the surveyor identified the patient utilized a lifeline pendant. During an interview during the same home visit, the patient stated they had the call light for several years. The agency failed to include all medical supplies/equipment on the patient’s POC, including a lifeline pendant.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on staff interview, agency policy review and clinical record review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services (Patient #3). The agency reported 10 patients who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: According to the policy, titled Home Care Aide, dated 3/2025, the home care aide should follow an individualized care plan for each patinet and should follow the assigned duties. During an interview on 8/11/26 at 2:41 PM, the Clinical Manager, reported the admit nurse develops the aide care plan. Patient #3 had a start of care date of 7/20/26. Clinical record review revealed: a. The Plan of Care, dated 7/20/26 to 9/17/26, included primary diagnosis of fractured left femur and included physician orders for skilled nursing and home health aide services. b. The Home health aide assignment, dated 7/21/2, directed the aides to assist the patient with personal bath-shower, assist with dressing-upper and lower body, assist with per brush/comb hair, shampoo/condition and apply non medicated lotion to arms, back, chest and legs. c. The home health aide visit notes, dated 7/21/26 and 7/23/26, Staff G, Home Health Aide, documentation the patient refused a shower and staff gave a sponge bath. The aide visit notes addressed the sponge bath but this task was not on the aide assignment. The home health aide failed to follow the home health aide assignment as directed by the RN. The findings were reviewed with the Administrator and Clinical Manager.”

“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 staff interview, clinical record review and agency policy review, the agency failed to provide a complete wound assessment on a weekly basis per agency policy for 1 of 1 sampled patient with a wound (Patient #1). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: According to the agency’s policy titled Wound Care, dated 3/2025, wound care should be ordered by a physician and wounds should be pictured, assessed, and measured (length, width and depth) on a weekly basis and as needed with wound care. On 8/11/26 at 2:41 PM, Staff B, Clinical Manager stated patient wounds are to be assessed, pictured and measured weekly. The information is documented in the patient’s electronic medical record. Patient #1 had a start of care date of 6/26/26. Clinical record review revealed: a. The Plan of Care (POC), dated 6/26/26 to 8/24/26, identified the patient had a primary diagnosis of acute embolism and thrombosis of right femoral vein and included physician orders for skilled nursing services one time a week. b. The occupational therapist (OT) visit note, dated 7/8/26, completed by Staff E, OT, identified the patient had gauze to the left lower extremity that was stuck secondary to bleeding from wound. c. The skilled nurse visit, dated 7/8/26, completed by Staff C, Registered Nurse (RN), failed to include documentation of an assessment including measurements for the left lower extremity wound. d. The skilled nurse visit note, dated 8/3/26, completed by Staff D, RN, identified the RN removed a non-adherent wound dressing from patient’s left lower leg and a small amount of drainage present on the dressing. The RN failed to include documentation of an assessment including measurements for the left lower extremity wound. The agency nurses failed to obtain complete weekly wound assessments and measurements per agency policy. The above findings were reviewed with the Administrator and Clinical Manager.”