Entera Healthcare, Ltd.

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Program and staff interview, the Agency failed to establish policies and procedures based on the risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The “Hazard Vulnerability Assessment” (risk assessment) of the Emergency Preparedness Program was last updated with the date of “2025” and was reviewed on 02/09/26. The Assessment included the following possible events: “Ice Snow, Flooding, Earthquake, Hurricane, Hazardous Material Accident, Fire, Tornado, Volcano, Civil Disturbance, Mass Casualty Event, Terrorist Attacks, Pandemic/Infectious Disease, Electrical Failure, Communication Failure, Information Failure, Water Failure, Transportation Interruption, and Environment/Altered Air Quality Pollution”. As of 02/09/26, the Emergency Preparedness Plan lacked the policies and procedures indicated above. 2. On 02/10/26 at 10:30 AM, during an interview with the Director of Nursing/ Alternate Administrator, the above findings were confirmed.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Program and staff interview, the Agency failed update its Emergency Preparedness Program’s Communication Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Program’s Communication Plan was reviewed on 02/09/26 at 11:00 PM. The Communication Plan forms titled “Organization Chart” and “Emergency Command Structure” were signed by Administrator in “2022”. As of 02/09/26 at 1:00 PM, the Plan lacked up to date communication charts, and the names and the contact information for the patients’ physicians, the staff, and the volunteers. 2. On 02/10/26 at 10:30 AM, during an interview with the Director of Nursing/ Alternate Administrator, the above findings were confirmed.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Program and staff interview, the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Program dated 01/31/22 was reviewed on 02/09/2026 at 11:00 AM. The Program lacked documentation that the Agency conducted or participated in a tabletop, full-scale exercise, facility-based exercise, or activated the Agency’s Emergency Preparedness Program based on the Agency’s policies in 2023, 2024, and 2025 (as of 02/10/26). 2. On 02/10/26 at 10:30 AM, during an interview with the Director of Nursing/ Alternate Administrator, the above findings were confirmed.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 82 of 2039 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 01/01/25 to 12/31/25, was reviewed on 02/10/26. The report documented 82 of 2039 (4.02%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing/Alternate Administrator and Alternate Director of Nursing on 02/10/26 at 1:20 PM, the Administrative staff confirmed the above findings.”

“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 clinical record reviews and staff interview, for 4 of 13 (Pts. #1, 7, 9, and 10) clinical records reviewed, the Agency failed to ensure the services were provided as ordered in the PsOC. Findings include: 1. Pt. #1was admitted for home health services on 01/08/26 with the diagnoses of but not limited to Non-displaced Fracture of greater trochanter of left femur and Hypertensive Heart Disease with heart failure. The clinical record was reviewed on 02/10/25 and included a POC effective 01/08/26 which required, “SN to assess and evaluate patients’ vital signs and weigh every SN visit.” The record lacked documentation of Pt. #1’s weight on the SN notes dated, 01/03/26, 01/22/26 and 01/27/26. 2. Pt. # 7 was admitted to home health services on 12/26/25 with the diagnosis of Major Depressive Disorder. The clinical record was reviewed on 02/10/26. The clinical record included the POC effective 12/26/25 to 02/23/26, that required “….1wk1, 2wk2, 1wk6…” The clinical record included 2 SN visits dated 01/19/26 and 01/22/26 (week 5). There was no modification orders of SN frequency in the POC. The same POC required: “….Orders for Discipline and Treatment: Notify Physician of vital signs parameters out of range….Pain level: greater than (>) 6/10….” The clinical record included SN visits dated 01/07/26, 01/19/26 and 01/22/26, that lacked pain assessments as ordered in the POC. 3. Pt. #9 was admitted to Home Health Services on 11/17/25 with the diagnosis of Type 2 Diabetes Mellitus and Essential (primary) Hypertension. The clinical record was reviewed on 02/10/26. The clinical record included the PsOC effective 11/17/25 to 01/15/26 and 01/16/26 to 03/16/26 that required: “…. Orders for Discipline and Treatment: Notify Physician of vital signs parameters out of range…. Systolic Blood Pressure: greater than (>) 160 mmHg less than () 90 mmHg less than () 200 mg/dl....less than (4. Pt. #10 was admitted to home health services on 05/15/25 with the diagnosis of Type 2 diabetes mellitus with foot ulcer. The clinical record was reviewed on 02/09/26. The POC effective 05/15/25 required, “SN to check bs every visit, notify MD if fbs >200 mg/dl or 250 mg/dl or 5. During staff interview with the Director of Nursing (Alternate Administrator) and Alternate Director of Nursing on 02/11/26 at 10:15 AM, 11:00 AM and 12:15 PM, the above findings were confirmed.”

“Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA’s initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This Standard is not met as evidenced by: Based on document review and staff interview, the Agency failed to disclose Agency’s current management information to the State survey agency. Findings include: 1. During the entrance interview on 12/09/26 at 9:15 AM, the Director of Nursing/Alternate Administrator stated that the Agency had a change in Administrator in July of 2025. 2. A document request was made on 12/09/26 for the Agency’s disclosure of change of management information to the State Agency. 3. The “HHA Administrator Qualification review form” dated and signed 05/28/25 was presented for review on 02/10/26 at 11:54 AM. There was no documentation presented when the form was submitted to the Department for notification of change in management. 4. An email correspondence with the Department dated 02/10/26 11:39 AM, regarding change in management was presented for review on 02/10/26 at 2:00 PM and indicated “…. Not approved due to issues….” 5. During an interview with the Alternate Director of Nursing on 02/10/26 at 2:05 PM, it was stated that the Department was informed by email the same day of the interview on 02/10/26 at 11:00 AM. During the same interview with the Alternate Director of Nursing on 02/10/26 at 2:05 PM, the above findings were confirmed.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observation during home visit and staff interviews, for 10 of 13 (Pts. # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 13) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. 1. During the entrance interview with the Director of Nursing/Alternate Administrator on 02/09/26 at 9:15 AM, it was stated that a new administrator assumed the role, as of July 2025. 2. The Agency’s Pt. admission folder was reviewed on 02/09/26. The folder lacked the current Administrator’s name, address, and phone number to file a complaint and/or grievance. 3. The following home visits were conducted on 02/10/26. Pt. #1 SOC 01/08/26 Pt. #2 SOC 10/31/25 Pt. #3 SOC 12/30/25 Pt. #4 SOC 12/02/25 Pt. #5 SOC 07/28/25 During the home visits, the home folders were observed and lacked the current Administrator’s name and contact information. 4. The clinical records of the following Pts. were reviewed from 02/09/26 to 02/10/26: Pt. #1 SOC 01/08/26 Pt. #2 SOC 10/31/25 Pt. #3 SOC 12/30/25 Pt. #4 SOC 12/02/25 Pt. #5 SOC 07/28/25 Pt. #6 SOC 12/23/25 Pt. #7 SOC 12/26/25 Pt. #8 SOC 01/17/26 Pt. #9 SOC 11/17/25 Pt.# 13 SOC 11/15/25 The clinical records reviewed lacked documentation that the Pt./patient’s representative was provided with the name and contact of the current Administrator to file a complaint or grievance. 5. During an interview with the Director of Nursing on 02/11/26 at 11:40 AM, the Director of Nursing/Alternate Administrator and Alternate Director of Nursing, confirmed the above findings.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits and staff interviews, for 13 of 13 (Pts. #1, 2, 3, 4 , 5, 6, 7, 8, 9, 10, 11, 12 and 13) clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies. Findings include: 1. The Agency’s admission folder was reviewed on 02/09/26. The admission folder lacked documentation that the Agency provided Pts./representatives regarding the Agency’s transfer and discharge policies. 2. The following home visits were conducted on 02/10/26: Pt. #1 SOC 01/08/26 Pt. #2 SOC 10/31/25 Pt. #3 SOC 12/30/25 Pt. #4 SOC 12/02/25 Pt. #5 SOC 07/28/25 During the home visits, the home folders were observed and lacked information regarding the Agency’s transfer and discharge policies. 3. The following clinical records were reviewed from 02/09/26 to 02/10/26 and lacked documentation that the Agency provided Pts./representatives regarding the Agency’s transfer and discharge policies. Pt. #1 SOC 01/08/26 Pt. #2 SOC 10/31/25 Pt. #3 SOC 12/30/25 Pt. #4 SOC 12/02/25 Pt. #5 SOC 07/28/25 Pt. #6 SOC 12/23/25 Pt. #7 SOC 12/26/25 Pt. #8 SOC 01/17/26 Pt. #9 SOC 11/17/25 Pt. #10 SOC 05/15/25 Pt. # 11 SOC 05/09/25 Pt. #12 SOC 05/12/25 Pt. #13 SOC 11/15/25 4. During interviews with the Director of Nursing/ Alternate Administrator and Alternate Director of Nursing on 02/10/26 at 1:20 PM, the Administrative staff confirmed the above findings.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on clinical record reviews, Agency policy review and staff interview, for 10 of 13 (Pts. #1, 4, 5, 6, 7, 8, 9, 10, 11 and 12) clinical records reviewed, the Agency failed to ensure Pts. were assessed for need for Influenza and Pneumonia vaccination assessment. Findings include: 1. The following clinical records were reviewed from 02/09/26 to 02/11/26: Pt. #1 SOC 01/08/26 – lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 12/02/25 - lacked Influenza vaccination assessment. Pt. # 5 SOC 07/28/25 - lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 12/23/25 – lacked Influenza and Pneumonia vaccination assessment. Pt. #7 SOC 12/26/25 – lacked Influenza and Pneumonia vaccination assessment. Pt. #8 SOC 01/17/26 – lacked Influenza vaccination assessment. Pt. # 9 SOC 11/17/25 – lacked Pneumonia vaccination assessment. Pt. #10 SOC 05/15/25 - lacked Influenza and Pneumonia vaccination assessment. Pt. #11 SOC 05/09/25 - lacked Influenza and Pneumonia vaccination assessment. Pt. #12 SOC 11/15/25 - lacked Influenza and Pneumonia vaccination assessment. 2. The Agency’s vaccination policy was reviewed on 02/10/26 and required: “….1. Case manager or SOC nurse will assess the patient during the admission regarding vaccination preference and obtain consent for acceptance or refusal of the vaccine….5. Vaccination when given will be recorded in the medical record of the patient and patient response....” 3. During an interview with the Director of Nursing/Alternate Administrator and Alternate Director of Nursing on 02/11/26 between 9:15 AM and 12:30 PM, the Administrative staff confirmed the above findings.”