Better Living Home Health Care, Inc.

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary containing all essential medical information concerning the patient’s current disposition, diagnosed conditions for which care was being provided, treatment choices, and after discharge goals for care was provided to their primary care provider or receiving agency to guarantee the safe and effective change in care for 3 of 3 closed records reviewed (Patient #1, #2, and #3). Findings include: 1. The agency’s policy “CLIENT DISCHARGE AND TRANSFER POLICY” states planning for discharge or transfer from home health services begins at admission, the patient/caregiver/family should participate and is informed of the date and reason, the agency will continue to provide care or instructions for care when discharge or transfer is to take place, and the patients physician or receiving agency will be informed. 2. The clinical record for Patient #1 (SOC 09/26/2024, certification period of 05/24/2025 to 07/22/2025) documented a discharge date of 06/30/2024, a discharge/transfer note signed by the nurse on 07/14/2025, and a discharge order signed by the patient’s primary physician on 08/14/2025. The record failed to evidence a discharge and transfer summary with all required elements for the patient was completed and documentation it was sent to the primary care physician or receiving agency. 3. The clinical record for Patient #2, POC certification period of 09/11/2024 to 11/09/2024, documented a discharge date of 10/20/2024 with a discharge order written, signed and sent by the nurse case manager to the patient’s primary physician on 10/23/2024. The record failed to evidence a full discharge summary with all required elements for the patient was completed and documentation it was sent to the primary care physician or receiving agency. 4. The clinical record for Patient #3, POC certification period of 07/09/2025 to 09/06/2025, documented a discharge date of 09/05/2025 with a narrative of patient plan to move to structure family care program with caregiver, a communication note from the family caregiver indicating a move to structure family care program with patient and last date to work would be 09/02/2025, and another communication note on 09/04/2025 requesting a discharge from the agency due to receipt of approval for the structured family care program. The record failed to evidence a discharge and transfer summary with all required elements for the patient was completed and documentation it was sent to the primary care physician or receiving agency. 5. During an interview on 12/15/2025 at 2:15 PM, the Administrator and Director of Nursing (CM) indicated when a discharge or transfer occurs an OASIS assessment should be completed if a visit can be done, the physician is notified, and a communication note is put into the clinical record. The Director of Nursing (CM) did not verbalize a timeframe for when these items are supposed to be completed. The Administrator added discharge and/or transfer summaries should be completed for all patients that are discharging or transferring from the agency and this should be noted in the record and sent to the patient’s primary physician. 6. During an interview on 12/16/2025 at 9:45 AM, the Administrator indicated that after reviewing the records for the discharged/transferred patients in question, there was a note in the clinical record for the patient that was non-skilled, however it was not sent to the patient’s physician. For the other two patients, the Administrator indicated no completed summaries or notes to show they were sent to the physician in the clinical record. 17-13-2(a)(b)(9)”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete an initial assessment within 48 hours of a referral and failed to document the reason for the delayed start of care for 6 of 10 record reviews. (Patients #1, #2, #3, #8, #9, #10) Findings include: 1. Review of a policy titled “Initial Assessments” indicated but was not limited to, “…POLICY An initial client assessment will be performed within twenty-four (24) to forty-eight (48) hours of approved referral and documented in the client’s clinical record by the case manager/team leader…” 2. The clinical record for Patient #1 included a referral received on 08/26/2024 that had an initial nursing assessment completed on 09/10/2024 for the POC certification period of 05/24/2025 to 07/22/2025. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 3. The clinical record for Patient #2 included a referral received on 01/16/2020 that had an initial nursing assessment completed on 01/22/2024 for the POC certification period of 09/11/2024 to 11/09/2024. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 4. The clinical record for Patient #3 included a referral received on 02/03/2025 that had an initial nursing assessment completed on 02/28/2025 for the POC certification period of 07/09/2025 to 09/06/2025. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 5. The clinical record for Patient #8 had no referral at all but an initial nursing assessment completed on 06/01/2023 for the POC certification period of 10/14/2025 to 12/12/2025. The agency failed to provide evidence the initial assessment was completed within 48 hours of referral. 6.The clinical record for Patient #9 included a referral received on 06/24/2025 and evidenced an initial nursing assessment; however, the assessment date was illegible due to being cut off on the document. No additional documentation was found in the record for the POC certification period of 10/25/2025 to 12/23/2025 to verify when the assessment occurred. The agency failed to provide evidence that the initial assessment was completed within 48 hours of referral. 7. The clinical record for Patient #10 included a referral received on 05/28/2024 that had an initial nursing assessment completed on 06/21/2024 for the POC certification period of 10/14/2025 to 12/12/2025. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 8. During an interview on 12/10/2025 at 2:15 PM, the Administrator and Director of Nursing indicated they were not sure why the referral date and time the initial assessment wasn’t completed within the 48 hour window required as it is agency policy for this timeline to be met. The Administrator indicated discussions have occurred with the intake coordinators in the past but they have since been relieved of duty and the new intake coordinator is still in their 90 day window of hire and in training. The Administrator also indicated one thought for several of the patients are that they were receiving services from the PSA agency affiliated with the home health agency already and either the skilled care was requested by the patients themselves, during a supervisory visit, or at a recertification of services to check for qualification switch or add those services. 17-14-1(a)(1)(A)”

“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, record review, and interview, the agency failed to ensure patient orders were recorded in the plan of care that accurately reflected the type of treatment provided at each nursing visit for 1 of 4 home visit observations. (Patient #4) Findings include: The agency’s policy “Client Plan of Care” states that services are furnished under physician supervision and based on a plan of care that is established, periodically reviewed, and updated. The policy requires that changes in the plan of care be documented through written and signed modifications. The agency’s “Care Coordination” policy requires clinicians to update physician orders, update the plan of care, and communicate changes in orders or findings to supervisors and team members. The clinical record review for Patient #4 (SOC 03/04/2019; certification period 11/27/2025–01/25/2026) evidenced an active physician order dated 05/03/2024 directing enteral feedings via G‑tube pump (liquid nutrition delivered through a tube that goes directly into the stomach. via small electric pump controls how fast the formula goes in.) at 50 mL/hr, advancing as tolerated to 250 mL/hr, with 50 mL/hr of water between feeds. The POC dated (11/27/2025-01/25/2026) failed to include the pump, the formula, Nourish 6-8 oz via tube every 2-3 hours, and the MD order for tube feed administration failed to be specific. Review of the 12/10/2025 skilled nursing visit note showed the nurse administered the feeding via bolus push, not by pump as ordered. During an observation on 12/11/2025 at 8:59 AM, RN 1 administered a bolus (liquid nutrition given all at once) feeding of Nourish formula mixed with water using a syringe and extension set. RN 1 checked residuals and flushed the tube per routine bolus procedure. When interviewed, RN 1 stated the patient had temporarily used a pump during a stomach ulcer episode but had returned to bolus feedings once the ulcer healed. RN 1 was unaware that the pump order remained active in the clinical record and believed it had been discontinued. During an interview on 12/10/2025 at 3:30 PM, the Director of Nursing confirmed the patient receives bolus feedings and stated there is no pump in the home. The Director of Nursing was unaware an active pump order remained in the EMR and could not explain why it continued to appear despite being discontinued. 17-13-1(a)(1)(A)(B)(1-8)”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the nurse failed to ensure integration of all specialized doctors, therapists, specialty clinics, and/or agencies involved in care or treatment outside of the ordering physician and home health were communicated clearly through care coordination and the documentation included what actions were taken, how changes to the patient’s status occurred, and if orders and the POC were followed and/or affected for patients diagnosed with acute and chronic conditions for 7 of 7 skilled patients reviewed. (Pt #1, #2, #4, #5, #6, #7, and #9) Findings include: 1. The agency’s policy “Care Coordination” states the RN is responsible for utilizing comprehensive coordinated health care through communication with all personnel involved with a patient, via a case conference if possible, and documentation in the clinical record about those changes/revisions/updates to any part of the care plan. 2. The clinical record for Patient #1 (SOC 09/26/2024, certification period of 05/24/2025 to 07/22/2025) included a POC that had orders for skilled nursing to setup patient’s medication weekly, monitor patient glucose levels, and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 05/19/2025 of the previous certification period (03/25/2025-05/23/2025) which indicated care and resources needed to help manage the patient’s past medical history that resulted in limited use of the right side of the body combined with multiple diagnosed conditions effecting several body systems, including mental illness and addiction that require more than five (5) medications regularly to treat and/or stabilize. The nurse states on the POC summary the patient is seeing three (3) specialists besides the ordering physician, has another agency providing assistance with instrumental activities of daily living, and no support system or involvement from family or friends in day-to-day life. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 3. The clinical record for Patient #2 (SOC 02/05/2020, certification period of 09/11/2024 to 11/09/2024) included a POC that had orders for skilled nursing to setup patient’s medication weekly, apply transdermal pain patch weekly, provide teaching about medications and management to attain compliance, and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 09/09/2024 of the previous certification period (07/13/2024-09/10/2024) which indicated the patient has physical deformities of both hands that make opening pill bottles or setting up a weekly planner independently very difficult, an extensive medical history with multiple diagnosed conditions effecting several body systems, including mental illness that require more than five (5) medications regularly to treat and/or stabilize. The nurse states on the POC summary the patient is seeing five (5) specialists, besides the ordering physician, two (2) different specialty clinics providing skilled care/treatment, physical therapy provided in home weekly, and has another agency providing assistance with instrumental activities of daily living. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 4. The clinical record for Patient #4 (SOC 03/04/2019; certification period 11/27/2025–01/25/2026) included a POC that had orders for skilled nursing to administer g-tube feedings and medications as ordered every visit; assess activity tolerance, cognitive and/or sensory limitations and impairments, motor function, pain levels their contributing factors and any relief modalities at every visit; assess patency and placement of g-tube prior to medication, hydration, and nutrition administration and the site and surrounding tissue (for complications, erythema, swelling, and purulent drainage); implement interventions to prevent skin breakdown; monitor vital signs and pulse oximetry as needed for respiratory distress; perform suctioning as needed throughout visit and mouth care every visit and as needed; check residual prior to each feeding and hold for 30 minutes if it is greater than 100 mL, then recheck within the hour and call the physician if the residual remains greater than 100 mL; may provide g-tube care and dressing changes upon family request; and provide activities of daily living every visit, The record included a summary dated 11/22/2025 of the previous certification period (09/28/2025-11/26/2025) which indicated the patient has had positive results from Deep Brain Stimulation (DBS-A surgical procedure using implanted electrodes and a pacemaker-like device to send electrical signals to the brain.) that decreased generalized spasticity and improved tone, Botox injections in the face and neck areas have been implemented to promote possible eating and speaking capabilities; continues to use wheeled walker as needed or walk independently with stand by assistance; and physical, occupational, speech, and craniosacral therapy moved locations but still working with the patient. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 5. The clinical record for Patient #5 (SOC 01/08/2015, certification period 11/11/2025-01/09/2026) included a POC that had orders for skilled nursing to administer medications when ordered and assess new/changed medications, side effects, and interactions; check Freestyle Libre system for blood sugar level and give sliding scale insulin as directed, fingerstick blood sugar check if needed in the absence of the Freestyle Libre system; and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 11/11/2025 of the previous certification period (09/12/2025-11/10/2025) which indicated the patient has triplegic cerebral palsy with some use of the right upper extremity, is non-ambulatory/non-weight bearing, confined to a bed/wheelchair with use of Hoyer lift for all transfers who lives with grandparents that provide all care. The nurse states on the POC summary the patient requires 24-hour supervision and is total care dependent as he/she suffers severe cognitive deficits, epilepsy secondary to hydrocephalus, vision impairment, complete incontinence of bowel and bladder, and is provided complete assistance with all activities of daily living. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 6. The clinical record for Patient #6 (SOC 08/19/2024, certification period 10/13/2025-12/11/2025) included a POC that had orders for skilled nursing to setup patient’s medication weekly and manage adherence to proper administration, assess and educate about medications ordered, any new or changed prescriptions, known side effects or possible interactions, and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 10/09/2025 of the previous certification period (08/14/2025-10/12/2025) which indicated the patient has right hemiplegia (paralysis or severe weakness affecting the right side of the body, typically from an injury to the left side of the brain (like a stroke) or the spinal cord, causing difficulty moving the arm, leg, and sometimes face on the affected side) that resulted from a cerebral infarct (stroke) along with several other diagnosed conditions that involve many body systems, including a mental health history, that requires more than five (5) medications regularly to treat, control, and/or stabilize. The nurse states on the POC summary the patient has at least three (3) specialists involved in care, other than ordering primary care physician, requires the use of DME to remain mobile within the home, requires the assistance of an aide to provide transfers, personal hygiene, meal prep, and reminders or prompts to complete tasks daily, and has another agency providing assistance with instrumental activities of daily living. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 7. The clinical record for Patient #8 (SOC 06/27/2023, certification period 10/14/2025-12/12/2025) included a POC that had orders for skilled nursing to setup patient’s medication weekly, manage adherence to proper administration, assess and educate about medications ordered, any new or changed prescriptions, known side effects or possible interactions and notify the physician if any are observed/reported or if non-compliance occurs. The record included a summary dated 10/13/2025 of the previous certification period (08/15/2025-10/13/2025) which indicated the patient has right hemiplegia due to late effect Cerebrovascular Accident (CVA or stroke) causing contracture of right hand and limited use of entire right side. The patient suffers from aphasia, mixed anxiety-depressive disorder, deficits with thought processing and memory, ambulation is slow with slouched gait that leans to the right, right foot drop and dragging of the right leg as a result of the CVA that causes difficulty with communication, mobility, and engagement with others that frustrates the patient and triggers outbursts and/or behaviors. The patient can no longer drive, cook or prepare meals, needs assistance to get to all activities/ appointments outside the home, requires help to complete all ADL’s and IADL’s, and has a very limited support system available. The patient takes more than five (5) medications regularly to treat and/or stabilize conditions or ailments. The nurse states on the POC summary the patient has another agency providing assistance with all ADL’s and IADL’s. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 8. The clinical record for Patient #9 (SOC 06/27/2025, certification period 10/25/2025-12/23/2025) included a POC that had orders for an aide to assist with personal hygiene, dressing, pet care, and preparation of meals as well as attend to IADL’s so patient is able to remain in home, and skilled nursing delegated/supervised interventions implemented to help the patient with identified areas of concern. The record included a summary dated 10/23/2025 of the previous certification period (08/26/2025-10/24/2025) which indicated the patient has a displaced fracture of the top end of the right upper arm and has been suffering from bilateral legs and back pain for which regular use of narcotic pain relief is used, a medical history with chronic conditions that have to be monitored and managed regularly and require more than five (5) medications taken regularly to treat and/or stabilize. The nurse states on the POC summary the patient wishes to include skilled nursing for help with management of medications and compliance which was started on 09/08/2025. The nurse failed to demonstrate how skilled care was used to coordinate the patient’s care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 9. During an interview on 12/15/2025 at 2:15 PM, the Administrator and Director of Nursing (CM) indicated documentation needs to give more information on how coordination is completed, why it is needed, who is involved and why, and what affects it has on the patient, orders and/or home health POC approved by physician. 17-12-2(g)”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure that ongoing education and training was provided and documented based on the skilled needs assessed and goals identified in the comprehensive assessment for 4 of 7 skilled patient records reviewed. (Patients #1, #2, #6, and #8) Findings included: 1. The agency’s policy “PATIENT EDUCATION” states that all patients receive appropriate, timely, and individualized education to promote safe and effective care, improve health outcomes, and support patient independence while in the home setting. Ongoing education should be based on assessed needs, orders, and the POC and the clinicians should implement this education with verbal instruction, demonstration and return demonstration, written materials, visual aids or videos, and teach-back method to verify comprehension and all elements should be documented clearly in the patient’s record. 2. A review of clinical record for Patient #1 (SOC 09/26/2024, certification period of 05/24/2025 to 07/22/2025) included a Home Health Care Certification and Plan of Care signed by the Alternate Clinical Manager on 05/19/2025. Patient #1 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 3. The clinical record for Patient #2 (SOC 02/05/2020, certification period of 09/11/2024 to 11/09/2024) included a Home Health Care Certification and Plan of Care signed by RN 3 on 09/09/2024. Patient #2 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 4. The clinical record for Patient #6 (SOC 08/19/2024, certification period 10/13/2025 to 12/11/2025) included a Home Health Care Certification and Plan of Care signed by RN 2 on 12/10/2025. Patient #6 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 5. The clinical record for Patient #8 (SOC 06/27/2023, certification period 10/14/2025 to 12/12/2025) included a Home Health Care Certification and Plan of Care signed by the Alternate Clinical Manager on 10/13/2025. Patient #8 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 6. During an interview on 12/15/2025 at 10:56 AM, the Administrator and Director of Nursing indicated the EMR system uses charting by exception which prevents thorough explanation of education completed by the nurse and response of the patient. They indicated nurses should be putting this into the narrative. 17-14-1(a)(1)(G)”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure medication was reviewed and reconciled, or reflected the orders given by the physician or the way the patient was taking the medication with documentation of communication with the physician for 2 of 4 patient home visit observations. (Patients #5 and #6) Findings include: 1. The agency’s policy titled “On-Going Assessments” requires clinicians to assess patients at each visit to evaluate their response to care and identify any changes. If changes are identified including medications or treatments requiring physician approval the clinician must notify the physician and ensure updates are documented and signed accordingly. 2. The clinical record for Patient #5 for certification period 11/11/2025 through 01/09/2026 evidenced the Medication Profile was reviewed with the caregiver and documented as having no changes.During a home visit observation on 12/15/2025 at 8:53 PM, LPN 1 administered medications that were not listed on the current Medication Profile and were not reflected on the POC. LPN 1 also reported that primidone had been discontinued approximately one week earlier per the physician, but the Director of Nursing had not been notified so the medication list could be updated. LPN 1 further stated that the long‑acting insulin, ordered for bedtime administration, had been changed by the physician to morning administration due to hypoglycemia concerns, but this change was also never communicated to the Director of Nursing for reconciliation. 3. The clinical record for Patient #6 for certification period 12/12/2025 through 02/09/2026 evidenced the Medication Profile was reviewed by LPN 1 and evidenced one change, an antibiotic started for an ear infection.During a home visit observation on 12/15/2025 at 12:37 PM, the patient reported taking gabapentin differently than prescribed, taking only one capsule daily unless symptoms required more. The patient also stated that the aspirin taken daily was not an extended‑release formulation as listed, and that cyanocobalamin had always been administered intramuscularly, not subcutaneously as documented. When interviewed, RN 2 could not explain why the medication list contained incorrect formulation, route, and administration details. RN 2 acknowledged not recognizing the discrepancies during review and was unaware the patient was not taking gabapentin as prescribed. RN 2 failed to ensure the Medication Profile and POC accurately reflected the correct type, route, and administration of all medications. 4. During an interview on 12/16/2025 at 1:39 PM, the Director of Nursing indicated LPN 1 should update him/her immediately upon any change with an ordered medication or if the physician allows a medication to be taken differently than ordered so that a new order can be written, sent to the physician, signed and then put into the clinical record for it to updated on the POC. The Director of Nursing indicated that RN 2 has to ensure that each medication is checked thoroughly each time a review is done to ensure all listed medications are accurate and conform to physician’s orders or updates can be sent to the physician for approval. 17-14-1(a)(2)(E)-RN 17-14-1(a)(2)(B)-LPN”