Luxe Home Health, LLC

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on policy review, record review, observation, and interview, the provider failed to meet the requirements for the Condition of Participation: Skilled Professional Services, when the provider failed to: - Provide ongoing interdisciplinary assessment of the patient (G0706); - Develop and evaluate the patient’s plan of care in partnership with the patient and/or caregiver (G0708); and - Provide services that are ordered by the physician as indicated in the plan of care (G0710). The cumulative effect of these deficient practices placed all patients at risk for unmet care needs and preventable decline.”

“Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This Standard is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: Skilled Professional Services, the home health provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. This restriction ends 12/04/2027.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure the registered nurse promptly notified the physician or allowed practitioner of changes in the patient’s condition requiring modification of the plan of care (POC) in, three of three clinical records reviewed (Records/Patients #1, #2, and #3). These failures resulted in missed opportunities to address clinical deterioration, modify interventions, and prevent further decline. This deficient practice has the potential to affect care and services for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Administration of Oxygen Therapy,” dated 2008, showed in part the following: - The home health nurse is responsible for ensuring that oxygen is administered as prescribed and evaluating response to therapy; and - Notify the physician when the patient’s health changes or deviates from baseline status. Review of the provider’s policy titled, “Wound Assessment and Documentation,” dated 2008, showed in part the following: - Purpose to identify parameters of wound assessment; and - Document the following on the visit reports: * The treatment and condition of the wound (each visit) * Appearance of the wound bed * Wound measurement (at least weekly), including the length, depth, and width of the wound in centimeters * Depth and location of undermining in centimeters * Color, odor, and estimated amount of drainage * Stage the wound weekly, compare the progress with the goals of therapy * Any patient/caregiver instructions on wound care and response to teaching, including ability to change dressings and manage the wound at home * Physician notification, if applicable. Review of the provider’s policy titled, “Waived Testing: Glucose and Prothromin Time,” dated 2023, showed in part, blood glucose monitoring is performed on patients, based upon discretion, and/or order, by the physician or allowed practitioner. Review of the provider’s policy titled, “Weight,” dated 2008, showed in part the following: - Purpose to measure weight gain or loss, to assess fluid or edema, and to evaluate compliance and medication regimen; - Notify the patient’s physician of a three-to-four-pound weight gain in one week; and - Document the patient’s weight and evaluate his/her fluid status on the visit report in relation to the disease process, diet, medication regimen, and intake and output. Document physician notification of inappropriate weight gain or signs of respiratory distress, as appropriate. Review of the provider’s policy titled, “Care Follows the Plan of Care,” dated 2023, showed in part the following: - Medications, services, and treatments are administered only as ordered by a physician or allowed practitioner; and - The agency (the provider) will ensure that there is evidence in the patient record that: * Care is delivered, in accordance with the POC, and is directed at the achievement of established goals * The POC conforms to physician or allowed practitioner orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 08/09/2025 with a primary diagnosis of pressure ulcer (skin injury caused by unrelieved pressure) to the sacrum stage 3 (three) (a full thickness loss of skin), other pertinent diagnoses included malignant neoplasm of the rectum (rectal cancer), and neoplasm related pain. The patient resided at home with a caregiver. Review of the POC dated 08/29/2025 through 10/07/2025, showed in part, the skilled nurse (SN) was to recognize and intervene to minimize complications and notify the physician immediately of any potential problems that impede completion of patient recovery and desired goals. Review of the SN visits on 08/11/2025, 08/13/2025 and 08/22/2025, showed: - Dizziness/lightheadedness and hypotension (low blood pressure); and - The SN failed to communicate the assessment findings to the physician. Review of SN visits dated 08/11/2025, 08/13/2025, 08/20/2025 resumption of care (ROC), 09/03/2025, and 09/05/2025, showed: - The patient had rectal pain consistently rated 4 (four)/10 to 8 (eight)/10 (a scale used to rate pain, 0 (zero) represents no pain and 10 represents the worst pain possible); and - The SN failed to communicate the persistent or escalating pain to the physician. Review of the SN visits on 08/13/2025 and 08/22/2025, showed: - Patient refusal of wound assessment or care; and -The SN failed to communicate the patient’s refusals to the physician. Review of the SN visit dated 08/18/2025, showed the patient was hospitalized for a urinary tract infection (UTI). Review of the SN visits dated 08/22/2025 and 08/27/2025, showed: - Intermittent urinary incontinence; - No catheter (a sterile tube placed in the bladder to drain urine) assessment; and - The SN failed to communicate assessment findings to the physician. Review of the SN visit dated 08/27/2025, showed: - Unstageable pressure ulcer with serosanguinous drainage (blood-tinged fluid), the patient had a stage 3 pressure ulcer on admission; and - The SN failed to communicate the deterioration of the patient’s wound to the physician. Review of the SN visits on 09/03/2025 and 09/05/2025, showed: - Increased weakness and inability to bear weight; and - The SN failed to communicate the assessment findings to the physician. Review of the SN visits on 09/03/2025 and 09/05/2025, showed: - Poor appetite; and - The SN failed to communicate the assessment findings to the physician. Review of the SN visits dated 09/03/202, 09/05/2025, 09/10/2025, and 09/12/25, showed: - Confusion and cognitive decline; and - The SN failed to communicate the assessment findings to the physician. Review of the SN note dated 09/03/2025, 09/05/2025, 09/10/2025 and 09/12/2025, showed: - The SN failed to document an assessment of the wound and failed to document wound measurements; and - The SN failed to notify the physician of their inability to assess. Review of the SN visit dated 09/12/2025, showed the patient was hospitalized for dehydration, malnutrition, and wound infection/deterioration. During an interview on 12/04/2025 at 9:51 AM, the administrator (who also serves as the clinical manager/director of nursing) stated that: - There had been no measurements of the wounds since admission; - On 08/27/2025, the nurse documented the patient had an unstageable pressure ulcer (full thickness tissue loss) and the wound was assessed but not measured; - There was no physician notification; and - The physician should should have been notified the patient was refusing dressing changes and had increasing/intolerable pain. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2024 with a primary diagnosis of type 2 (two) diabetes mellitus (a group of diseases that results in too much sugar in the blood) with foot ulcer (an open wound or sore on the foot that fails to heal) and , chronic systolic (congestive) heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided at home. Review of the POC dated 11/01/2025 through 12/30/2025, showed in part: - Notify physician of vital sign parameters out of range; - (Notify physician of) Fasting blood sugar (measure the glucose (sugar) in the blood): greater than 180 mg (milligram)dl (deciliter) less than 70 mg/dl; - (Notify physician of) Random blood sugar: greater that 200 mg/dl less than 70 mg/dl; - SN to assess integumentary status, identify any signs and symptoms of impaired skin integrity, report significant changes to physician; - SN indicated for wound care management based on physician orders due to inherent complexity of the wound, and SN to instruct patient/caregiver on wound care performance and assess wound progression or decline; - SN to assess diabetic status, identify any signs and symptoms of impaired diabetic function, report significant changes to the physician; - SN may obtain blood sugar level via fingerstick as needed for signs/symptoms of hyperglycemia (high blood sugar/hypoglycemia (low blood sugar); and - SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy, coordinate care with physician for need to change plan of care. Review of the SN notes, dated 11/10/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/21/2025, 11/24/2025, 11/26/2025, 11/28/2025, and 12/01/205, showed: - The SN failed to assess or check the patient’s blood sugar; - The SN failed to obtain weights (due to the patient’s diagnosis of CHF); and - The SN failed to obtain weekly wound measurements. During an interview on 12/04/2025 at 10:47 AM, registered nurse (RN) B stated that he/she did not check blood sugars due to a non-functioning glucometer, did not weigh the patient, and did not measure wounds weekly. During an interview on 12/04/2025 at 9:51 AM, the administrator stated that the omissions required physician notification. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/29/2025 with a primary diagnosis of venous insufficiency (a condition where leg veins struggle to send blood back to the heart, causing blood and fluid to pool in the legs due to damaged one-way valves). Other pertinent diagnosis included type 2 diabetes mellitus with chronic kidney disease, non-pressure chronic ulcer (a skin breakdown or injury not caused by sustained external pressure) to the right and lower legs, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and heart failure. Review of the POC dated 09/27/2025 through 11/25/2025, showed in part: - Oxygen 2 liters per minute (2L/min) continuous flow as needed for shortness of breath; - Notify physician of vital sign parameters out of range; - (Notify physician of) Pain level: greater than 6 (six) out of 10 (6/10); - (Notify physician of) Fasting blood sugar: greater than 180 mg/dl or less than 70 mg/dl; - (Notify physician of) Random blood sugar: greater that 200 mg/dl or less than 70 mg/dl; - SN to instruct patient/caregiver regarding self-management of oxygen therapy, perform risk assessment and administer oxygen at 2 L/min; - Clinician to instruct patient/caregiver regarding heart failure status and self-management program including weight monitoring; - Skilled nurse to instruct patient on daily self-monitoring program and report to SN weight gain /loss of 2 pounds a day or 5 (five) pounds a week; and - SN to assess diabetic status, identify any signs and symptoms of impaired diabetic function, report significant changes to physician. Review of the SN notes showed: - On 09/15/2025, oxygen increased from 2 L/min to 3 L/min; pain 8/10; increased edema (swelling of the tissues) and erythema (redness) and no physician notification. - On 09/29/2025, oxygen increased to 6 L/min, pain 7 (seven)/10, and no physician notification. - On 10/01/2025, Oxygen remained at 6 L/min and no physician notification. Across all visits, weights, blood sugars, and wound measurements were missing. During an interview on 12/04/2025 at 9:15 AM, the administrator stated that: - No weights were documented; - There were no blood sugar checks; - There was no documentation to show why the oxygen was increased to 6 liters and why there was no physician notification; and - There were no wound assessments/wound measurements documented.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure coordination of services in, two out of three records reviewed (Records/Patients #1 and #3). The provider failed to ensure timely communication of significant changes in condition, failed to coordinate physician notification, and failed to ensure the plan of care (POC) was updated or implemented when clinical changes occurred. These failures placed patients at risk for delayed intervention, unmanaged symptoms, and further decline in health status. This deficient practice has the potential to affect care and services for all the patients served by the provider. Findings Included: Review of the provider’s policy titled, “Coordination of Care,” dated 2023, showed in part the following: - The clinical manager provides oversight of all patient care services, including: * Coordinating patient care * Ensuring the patient needs are continually assessed * Ensuring the development, implementation, and updates of the individualized POC; - The organization communicates, and coordinates care, with the patient, to share information needed to implement the care/service plan; and - Any revision to the POC due to a change in patient health status is communicated with the patient, representative, caregiver, and all physicians involved. Review of the provider’s policy titled, “Coordination of Services,” dated 2023, showed in part, the organization coordinates care by: - Ensuring communication with all physicians involved in the POC - Integrating orders, from all physicians involved in the POC, to ensure the coordination of all services, and interventions, provided to the patient, to ensure continuity of care - Ensuring patients and caregivers receive ongoing education and training; and - Ensuring nurses provide on-going evaluation and assessment of patient needs. Review of the provider’s policy titled, “Care Follows the Plan of Care,” dated 2023, showed in part the following: - Medications, services, and treatments are administered only as ordered by a physician or allowed practitioner; - The agency (the provider) will ensure that there is evidence in the patient record that: * Care is delivered, in accordance with the POC, and is directed at established goals, and the POC conforms to physician orders; and - Supervisory clinicians will review the record to determine if the POC is being followed. Review of the provider’s policy titled, “Patient/Client Notification of Changes,” dated 2023, showed in part the following: - Any revision to the POC, due to a change in the patient’s health status, will be communicated in writing, to the patient, patient’s caregiver, and all physicians issuing orders; and - Physician orders may be verbally communicated and must be signed, timed, and dated. Review of the provider’s policy titled, “Review of Plan of Care,” dated 2023, showed in part the following: - The individualized POC is reviewed and revised, by the physician who is responsible for the home health POC and the home health organization, as frequently as the patient’s condition or needs require, but no less that once every 60 days, beginning with the start of care date; - The home health organization promptly alerts the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the POC should be altered; and - The organization must promptly alert the relevant physician(s) to any changes in the patient’s condition, or needs, that suggest outcomes are not being achieved, and/or that the POC should be altered. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 08/09/2025 with a primary diagnosis of pressure ulcer (skin injury caused by unrelieved pressure) to the sacrum stage 3 (three) (a full thickness loss of skin), other pertinent diagnoses included malignant neoplasm of the rectum (rectal cancer), and neoplasm related pain. The patient resided at home with a caregiver. Review of the skilled nurse (SN) notes dated 08/11/2025, 08/13/2025, 08/22/2025, 08/27/2025, 09/03/2025, 09/05/2025m 09/10/2025, and 09/12/2025, showed nursing documentation showed significant changes in condition, that included: - Increased pain severity; - Dizziness, hypotension (low blood pressure); - Worsened pressure injury; - Poor intake and refusals of care; - Confusion, increased weakness, and inability to bear weight, and - New bowel incontinence. The clinical record failed to show any physician notification, communication to the administrator (who also serves as the clinical manager/director of nursing), or revision of the POC in response to these changes. Review of a transfer summary dated 09/15/2025, showed the patient was hospitalized due to dehydration, malnutrition, and wound infection/deterioration. Care coordination occurred only at the point of hospital transfer. During an interview on 12/04/2025 at 9:51 AM and 11:07 AM, the administrator stated that: - Nurses should have notified the physician of worsening wounds, refusals of care, or uncontrolled pain; - The registered nurse (RN) was responsible for evaluating the POC each visit; - He/she would not know if nurses recognized or responded to changes unless staff reported them; and - There was no active QAPI (Quality Assurance and Program Improvement). RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/29/2025 with a primary diagnosis of venous insufficiency (a condition where leg veins struggle to send blood back to the heart, causing blood and fluid to pool in the legs due to damaged one-way valves). Other pertinent diagnosis included type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood) with chronic kidney disease, non-pressure chronic ulcer (a skin breakdown or injury not caused by sustained external pressure) to the right and lower legs, cellulitis (a common bacterial skin infection affecting the skin’s deeper layers), chronic obstructive pulmonary disease ((COPD; a group of lung diseases that block airflow and make it difficult to breathe) and heart failure. Review of the POC dated 09/27/2025 through 11/25/2025, showed the following: - Oxygen 2 (two) liters per minute (2L/min) as needed for shortness of breath; - SN to provide wound care to bilateral extremities; - Notify physician of vital sign parameters out of range; - (Notify physician of) Pain level: greater than 6 out of 10 (6/10) (a pain scale used to rate pain, 0 represents no pain and 10 represents the worst pain possible); - (Notify physician of) Fasting blood sugar (measure the glucose (sugar) in the blood): greater than 180 mg (milligram)dl (deciliter) or less than 70 mg/dl; - (Notify physician of) Random blood sugar: greater that 200 mg/dl or less than 70 mg/dl; and - Skilled nurse to instruct patient on daily self-monitoring program and report to SN weight gain /loss of 2 pounds a day or 5 (five) pounds a week. Review of a SN note dated 09/29/2025 at 12:00 PM, showed: - 2 plus (+) pitting edema (swelling of the tissues) to bilateral extremities; - Shortness of breath and oxygen continuous at 6 L/min (the POC showed 2 liters); - Current pain 5/10; - The past week worst pain was 7(seven)/10; and - Pain during wound care. The assessment failed to include weight assessment, blood sugar assessment, edema interventions, and complete wound assessment. The SN failed to notify the physician regarding pain up to 7/10 and oxygen increased to 6 L/min. Review of a SN note dated 10/01/2025 at 11:00 AM, showed: - 2 + pitting edema to bilateral extremities; and - Shortness of breath and oxygen at 6 L/min. The assessment failed to include weight assessment, blood sugar assessment, edema interventions, complete wound assessment, and physician orders for wound treatment. The SN failed to notify the physician of the oxygen at 6 liters. During an interview on 12/04/2025 at 9:15 AM, the administrator stated that: - No weights were documented; - There were no blood sugar checks documented; - There was no documentation explaining why oxygen was increased to 6 L/min and there was no physician notification; - There were no wound measurements or wound descriptions; - Pain was documented, but there were no interventions shown; - The POC goals were not carried over on recertification; and - The patient had ace wraps for edema.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on policy review, record review, observation, and interview, the provider failed to ensure services ordered on the plan of care (POC) were provided as ordered in, two of three clinical records reviewed (Records/Patients #2 and #3). The provider failed to follow physician ordered wound care, provide required monitoring, and failed to ensure the POC updates reflected all active treatment orders. These failures created risk for wound deterioration, infection, uncontrolled blood sugars, and cardiopulmonary decompensation. This deficient practice has the potential to affect care and services for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Follows the Plan of Care,” dated 2023, showed in part the following: - Medications, services, and treatments are administered only as ordered by a physician or allowed practitioner; - The agency (the provider) will ensure that there is evidence in the patient record that: * Care is delivered, in accordance with the POC, and is directed at the achievement of established goals * The POC conforms to physician or allowed practitioner orders; and - The clinician completing a supervisory visit will review the client record to determine if the POC is being followed. Review of the provider’s policy titled, “Coordination of Services,” dated 2023, showed in part, the organization coordinates care by: - Being responsible for the professional coordination of these services, under the direction of the patient/client’s physician; - Integrating orders, from all physicians involved in the POC, to ensure the coordination of all services, and interventions, provided to the patient, to ensure continuity of care; and - The staff professional nurse is responsible for the professional coordination of all home care services, the established POC is carried out, on-going evaluation, and assessment, of the patient/client’s home care needs. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2024 with a primary diagnosis of type 2 (two) diabetes mellitus (a group of diseases that results in too much sugar in the blood) and foot complications. The patient resided at home. Review of the POC dated 11/01/2025 through 12/30/2025, showed in part: - Notify physician of vital sign parameters out of range; - (Notify physician of) Fasting blood sugar (measure the glucose (sugar) in the blood): greater than 180 mg (milligram)dl (deciliter) or less than 70 mg/dl; - (Notify physician of) Random blood sugar: greater that 200 mg/dl or less than 70 mg/dl; - Skilled nurse (SN) may obtain blood sugar level via fingerstick as needed for signs/symptoms of hyperglycemia (high blood sugar/hypoglycemia (low blood sugar); - SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy, coordinate care with physician; - SN to assess integumentary status, identify any signs and symptoms of impaired skin integrity, report significant changes; and - Ordered wound care: clean with soap and water, pat dry, apply BIOPAD (Brand; a primary dressing that can accelerate the closure of hard-to-heal wound) to wound bed, cover with foam dressing, place compression sock over dressing, and wrap low leg with ReadyWrap (Brand; compression wrap). Review of the SN notes dated 11/10/2025, 11/12/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/21/2025, 11/24/2025, 11/26/2025, 11/28/2025, and 12/03/2025, showed: - The nurse applied Hydrofera Blue (Brand; an antibacterial foam dressing) to the left heel wound; however, Hydrofera Blue was not listed on the POC; - The nurse failed to apply the compression sock and ReadyWrap as ordered; - The nurse failed to document the patient’s blood sugar readings; - The nurse failed to document skin assessments; and - The nurse failed to follow the physician orders as indicated in the POC. Observation on 12/03/2025 at 2:07 PM showed registered nurse (RN) A: - Applied Hydorfera Blue to the wound, which was not ordered on the POC; and - Applied compression socks and wrapped the left leg with ReadyWrap (adjustable compression wrap) correctly per the POC. During an interview on 12/03/2025 at 2:07 PM, the patient stated that his/her glucometer (a device for measuring the concentration of glucose in the blood) had been broken and he/she was waiting for a replacement. During an interview on 12/03/2025 at 2:07 PM, the patient’s caregiver stated that: - RN B had not been wrapping the patient’s leg with compression sock and ReadyWRap as RN A did; - RN B had been using 4x4 gauze instead of the ordered wrapping method; - RN B had been putting ammonium lactate 12% cream (used to moisturize and soften rough, dry skin) on the patient’s foot (without physician orders); - The patient’s A1C had been within normal limits; and - The patient’s blood sugars were not being monitored due to lack of glucometer supplies. During an interview on 12/04/2025 at 10:47 AM, registered nurse (RN) B stated that:: - The glucometer was not working so blood sugars were not checked; - The wound was not measured; and - The wound should have been measured weekly; During an interview on 12/04/2025 at 9:15 AM, the administrator (who also serves as the clinical manager/director of nursing (DON)) stated that: - The only wound measurement was on 10/31/2025 and 12/01/2025 and there were no other measurements; - The patient does not monitor his/her blood sugar and staff had not documented any blood sugars since the start of care; - The administrator (who serves as the DON) reviews SN documentation before submission and acknowledged he/she “must have missed” the lack of blood sugar and integumentary assessments; - The wound clinic was not listed on the POC, but documentation dated 11/04/2025 included compression socks and ReadyWrap that matched POC expectations; - Hydrofera Blue was ordered by the wound clinic; and - The clinic orders were not from the primary care physician, and the provider failed to incorporate these orders into the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/29/2025 with a primary diagnosis of venous insufficiency (a condition where leg veins struggle to send blood back to the heart, causing blood and fluid to pool in the legs due to damaged one-way valves). Other pertinent diagnosis included type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood) with chronic kidney disease, chronic obstructive pulmonary disease ((COPD; a group of lung diseases that block airflow and make it difficult to breathe), heart failure and chronic lower-extremity ulcers. Review of the POC dated 09/27/2025 through 11/25/2025, showed the following: - Oxygen 2 liters as needed for shortness of breath; - Notify physician of vital sign parameters out of range; - (Notify physician of) Fasting blood sugar (measure the glucose (sugar) in the blood): greater than 180 mg (milligram)dl (deciliter) or less than 70 mg/dl; - (Notify physician of) Random blood sugar: greater that 200 mg/dl or less than 70 mg/dl; - SN to assess diabetic status, edema (swelling of the tissues), venous ulcers (slow healing open sores caused by poor circulation), and complete physical assessment each visit; - Skilled nurse to instruct patient on daily self-monitoring program and report to SN weight gain /loss of 2 pounds a day or 5 (five) pounds a week; - SN to instruct patient/caregiver regarding self-management of oxygen therapy, perform risk assessment and administer oxygen at 2 liters/minute (2L/min); and - The POC failed to show any current goals. Review of a SN note dated 09/15/2025 at 12:10 PM, showed: - 3 (three) plus (+) pitting edema to bilateral extremities; - Shortness of breath and oxygen continuous at 3 L/min (2 L/min was ordered); - Current pain rating 6 (six)/10, worst patient 8 (eight)/10 (pain scale used to rate pain, 0 (zero) represents no pain and 10 represents the worst pain possible) in past week; - Worsening bilateral extremity pain, increased swelling, erythema (redness); - Plan to go to the emergency room later that day; and - Popped blisters and wounds. The assessment failed to include weight, blood sugar information, edema interventions, and complete wound assessment including popped blisters. The nurse failed to notify the physician of the increased swelling and erythema, pain rated 6-8/10, and oxygen increased to 3 L/min (the POC showed 2 L/min). Review of a SN note dated 09/29/2025 at 12:00 PM, showed: - 2 plus pitting edema to bilateral extremities; - Shortness of breath and oxygen at 6 L/min (the POC showed 2 L/min); and - Current pain rating 5 (five)/10, worst pain 7(seven)/10 in past week; The assessment failed to include weight, blood sugar information, edema interventions, and complete wound assessment. The clinical record failed to show physician ordered interventions for pain rated at a 7/10 or shortness of breath with oxygen at 6 L/min. Review of a SN note dated 10/01/2025, showed: - 2 plus bilateral extremity edema; and - Shortness of breath with oxygen continuous at 6 L/min; The assessment failed to include weight, blood sugar information, edema interventions, complete wound assessment, and physician notification of oxygen at 6 liters/minute. During an interview on 12/04/2025 at 9:15 AM, the administrator stated that: - No weights were documented; - There were no blood sugar checks; - There was no documentation supporting why oxygen was at 6 liters/minute, and no documentation of physician notification; - There were no wound measurements or descriptions; - Nurses did not document interventions for pain; - POC goals had not been carried over onto the recertification; and - The patient had ace wraps for edema. During an interview on 12/04/2025 at 10:47 AM, registered nurse (RN) B stated that he/she: - Asked about blood sugars but did not check them; - Did not weigh the patient, due to not having a scale; - Did not measure wounds because they “had not changed,” though measurements were required weekly; and - Noted the physician was difficult to reach and they relied on the caregiver for orders. During an interview on 12/04/2025 at 11:07 AM, the administrator confirmed and stated that: - The RN must evaluate and revise the POC with condition changes; - If weights and blood sugars were unobtainable, physician notification was expected, but this was not occurring; - Wounds were to be measured weekly; - QAPI (Quality Assurance Improvement Plan) had not identified incomplete documentation or failures to follow the POC; and - There was no active QAPI program in place to ensure nursing staff recognized and responded to changes in condition.”