Four Seasons Nursing & Rehabilitation Chha

“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 a review of the Home Health Agency (HHA) Error Summary Report for the period 08/06/2024 through 08/06/2025 and staff interviewed, the agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. This is evident for eleven hundred and seventy-eight (1178) clinical records documented in the HHA Error Summary by Agency Report. Failure to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days, has the potential for negative patient outcomes. The Findings Are: The HHA Error Summary by Agency Report for the period 08/06/2024 through 08/06/2025 documents: “Error # -3330 Record Submitted Late: The submission date is more than 30 days after M0090 (Start of Care) on this new record ... # of Assessments with error eleven hundred and seventy-eight (1178).” There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 8/13/2025 at 03:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the survey 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 interviews, the agency failed to ensure the patients received services as written in the plan of care. This was evident for 12 (twelve) of 17 (seventeen) clinical records reviewed (Patients #1, #2, #3, #4, #6, #10, #11, #12, #13, #15, #16, #17). Failure to ensure the patients received services as written in the plan of care has the potential risk for negative patient outcomes. The Findings are: 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The Home Health Certification and Plan of Care for the Certification Period 06/07/2025 to 08/05/2025 documents: SN (Skilled Nurse) 3 x week x 8 weeks (three times a week for eight weeks); PT (Physical Therapy) 06/09/25 2 x week x 1 week (twice a week for one week). The Supplemental Orders dated 07/07/2025 documents: 07/07/2025 PT (Physical Therapy) 2 x week x 3 week (twice a week for three weeks). The clinical care record lacks documented evidence of Skilled Nursing services for the week 07/06/2025 to 07/12/2025 – missed two visits; and Physical Therapy services for the week 06/09/2025 to 06/14/2025 – missed two visits and 07/13/2025 to 07/19/2025 – missed one visit. The Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024 documents: PT (Physical Therapy) 08/06/25 1 x week x 1 week (once a week for one week). The clinical care record lacks documented evidence of Physical Therapy services for the week 08/06/2025 to 08/09/2025 – missed one visit. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025 documents: SN (Skilled Nurse) 07/20/2025 3 x week x 8 weeks (three times a week for eight weeks). The clinical care record lacks documented evidence of Skilled Nurse services for the week 07/27/2025 to 08/02/2025 – missed one visit. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 06/19/2025 with the following diagnoses “Sepsis, Urinary Tract Infection, Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 06/19/2025 to 08/17/2025. The Home Health Certification and Plan of Care for the Certification Period 06/19/2025 to 08/17/2025 documents: PT (Physical Therapy) 06/30/2025 2 x week x 4 weeks (two times a week for four weeks). The clinical care record lacks documented evidence of Physical Therapy services for the week 07/13/2025 to 07/19/2025 – missed one visit. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient #17 has a Start of Care (SOC) date of 07/18/2025 with the following diagnoses “Aftercare following Joint Replacement Surgery, Bilateral Osteoarthritis of Knee” documented in the Home Health Certification and Plan of Care for the Certification Period 07/18/2025 to 09/15/2025. The Home Health Certification and Plan of Care for the Certification Period 07/18/2025 to 09/15/2025 documents: SN (Skilled Nurse) 07/18/2025 1 x week x 2 weeks (once a week for two weeks). The clinical care record lacks documented evidence of Skilled Nurse services for the week 07/20/2025 to 07/26/2025 – missed one visit. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #10 has a Start of Care (SOC) date of 04/22/2025 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 3, Essential (primary) hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 04/22/2025 to 06/20/2025. The Home Health Certification and Plan of Care for the Certification Period 04/22/2025 to 06/20/2025 documents: SN (Skilled Nurse) 04/22/2025 2 x week x 1 week (two times a week for one week), 04/27/2025 3 x week x 8 week (three times a week for eight weeks); PT (Physical Therapy) 04/22/2025 1 x week x 1 week (once a week for one week), 04/27/2025 2 x week x 1 week (two times a week one week). The clinical care record lacks documented evidence of the Physical Therapy services for the week 04/20/2025 to 04/26/2025 – missed one visit and 04/27/2025 to 05/03/2025 – missed two visits. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #15 has a Start of Care (SOC) date of 07/11/2025 with the following diagnoses “Chronic Obstructive Pulmonary Disease, COVID-19, Dysphagia oropharyngeal phase” documented in the Home Health Certification and Plan of Care for the Certification Period 07/11/2025 to 09/08/2025. The Home Health Certification and Plan of Care for the Certification Period 07/11/2025 to 09/08/2025 documents: SN (Skilled Nurse) 07/11/2025 1 x week x 1 week (one time a week for one week), 07/13/2025 2 x week x 1 week (two times a week for one week); PT (Physical Therapy) 07/14/2025 1 x week x 1 week (once a week for one week), 07/20/2025 2 x week x 4 week (two times a week four weeks); OT (Occupational Therapy) 07/15/2025 2 x week x 3 week (two times a week three weeks). The clinical care record lacks documented evidence of the Skilled Nursing services for the week 07/13/2025 to 07/19/2025 – missed one visit. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #16 has a Start of Care (SOC) date of 07/01/2025 with the following diagnoses “Pressure ulcer of sacral region, unstageable, Unspecified dementia” documented in the Home Health Certification and Plan of Care for the Certification Period 07/01/2025 to 08/29/2025. The Home Health Certification and Plan of Care for the Certification Period 07/01/2025 to 08/29/2025 documents: SN (Skilled Nurse) 07/01/2025 2 x week x 1 week (two times a week for one week), 07/06/2025 3 x week x 8 week (three times a week for eight weeks); PT (Physical Therapy) 07/01/2025 1 x week x 1 week (once a week for one week), 07/06/2025 2 x week x 4 week (two times a week four weeks). The clinical care record lacks documented evidence of the Skilled Nursing services for the week 06/29/2025 to 07/05/2025 – missed one visit, and for the week 07/13/2025 to 07/19/2025 – missed one visit. There is no documented evidence of patient receiving services as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient#2 has a Start of Care date of 07/09/2025 with diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Primary Hypertension, Polyarthritis, Other Reduced Mobility and Pain, Unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025 documents the following orders for Discipline: “PT (Physical Therapy) 07/13/2025: 1 x week x 1 week (once a week for one week), 07/28/2025: 2 x week x 3 weeks (two times a week for three weeks); Aide 07/29/2025: 4x week x 1 week, 4H duration (four times a week for one week, four hours a day).” The clinical record lacks documented evidence of the patient receiving Physical Therapy services as written in the plan of care for the week of 07/13/2025 to 07/19/2025 - missed one visit; week of 07/28/2025 to 08/02/2025 - missed two visits; week of 08/03/2025 to 08/09/2025 - missed two visits. The clinical record lacks documented evidence of the patient receiving Home Health Aide services as written in the plan of care for the week of 07/29/2025 to 08/02/2024 - missed one visit. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient#6 has a Start of Care date of 01/22/2024 with diagnoses of Parkinson’s Disease, Other Secondary Hypertension, Chronic Obstructive Pulmonary Disease, with (Acute) Exacerbation, Transient Cerebral Ischemic Attack, unspecified, Diverticulitis of the large intestine, and Colostomy status documented in the Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025. The Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025 documents: “PT (Physical Therapy) 07/15/2025: 1 x week x 9 weeks (once a week for nine weeks.” The Missed Therapy Visit Report dated 07/30/2025 and 08/05/2025 documents “Treatment not provided for the following reason: PT (Physical Therapy) unavailable. Patient informed and aware.” The clinical record lacks documented evidence of the patient receiving the Physical Therapy service as written in the individualized plan of care - missed two visits. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient#11 has a Start of Care date of 01/11/2025 and Discharge date of 02/20/2025 with diagnoses of Aftercare following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Unilateral Primary Osteoarthritis, and Muscle Weakness documented in the Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025. The Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025 documents ““PT (Physical Therapy) 01/23/2025: 1 x week x 1 week (once a week for one week).” The Therapy Missed Appointment documents “The patient missed a visit on 01/23/2025 to 01/25/2025 due to PT (Physical Therapy) scheduling miscommunication.” The clinical record lacks documented evidence of the patient receiving the Physical Therapy service as written in the individualized plan of care - missed one visit. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient#12 has a Start of Care date of 04/18/2025 and Discharge date of 05/08/2025 with diagnoses Encounter for Surgical aftercare following Surgery of the Digestive System, Cholecystitis, Other Secondary Hypertension, Type 2 Diabetes Mellitus and Cerebral Infarction, unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 04/18/2025 to 06/16/2025. The Home Health Certification and Plan of Care for the Certification 04/18/2025 to 06/16/2025 documents “SN (Skilled Nursing) 04/20/2025: 2 x week x 2 weeks (two times a week for two weeks); Wound Care: RUQ (Right Upper Quadrant) Chole (cholecystostomy) tube: Cleanse around chole tube with soap and water, cover with dry gauze and secure with tape, change 2 X week (two times a week) The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Routine Visit on the following dates documents: 04/23/2025: RUQ Chole tube; Dressing change this visit: No 04/28/2025: RUQ Chole tube; Dressing change this visit: No There is no documented evidence of the patient receiving the Skilled Nursing service for dressing changes two times a week as ordered in the individualized plan of care. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 5. Patient #13 has a Start of Care date of 07/09/2025 with diagnoses of Parkinsonism, unspecified, Pressure Ulcer of Right Heel, Unstageable, Pressure Ulcer of Sacral Region, Stage 3, Essential Primary Hypertension, Polyarthritis, and Unspecified Dementia documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025 documents the following orders for Discipline: “SN ( Skilled Nursing) 07/13/2025: 3 x week x 8 weeks (three times a week for eight weeks); PT (Physical Therapy) 07/13/2025: 2 x week x 4 weeks (two times a week for four weeks); Aide 07/28/2025: 5x week x 3 weeks, 3H duration (five times a week for three weeks, three hours a day), 08/03/2025: 5 x week x 2 week, 3H duration (five times a week for two weeks, three hours a day).” The PT (Physical Therapy) Missed Visit Notes dated 08/04/2025 and 08/05/2025 documents “PT (“Name”) missed patient’s visit due to scheduling conflict, contacted MD’s office to notify them of the missed visits.” The clinical record lacks documented evidence of the of the patient receiving Physical Therapy as written in the individualized plan of care for the week of 08/04/2025 to 08/09/2025 - missed two visits. The clinical record lacks documented evidence of the of the patient receiving Skilled Nursing as written in the individualized plan of care for the week of 07/13/2025 to 07/19/2025 - missed one visit, the week of 07/27/2025 to 08/02/2025 - missed one visit. The clinical record lacks documented evidence of the patient receiving Aide service as written in the individualized plan of care for the week of 07/28/2025 to 08/02/2024 - missed two visits, and week of 08/03/2025 to 08/09/2025 - missed one visit. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the patient’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This was evident for 1 (one) of 17 (seventeen) clinical records reviewed (Patient #1). Failure to ensure that the patient or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The Verification of Receiving Bill of Rights and the Patient Rights and Responsibilities, Financial Liability, and Consents lacks documented evidence of the patient or legal representative’s signature. There is no documented evidence of the patient or legal representative’s signature confirming that he has received a copy of the notice of rights and responsibilities. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure the patient’s initial assessment was completed within 48 hours of the referral. This was evident for 6 (six) of 17 (seventeen) clinical records reviewed (Patients #1, #3, #4, #7, #10, #14). Failure to ensure the patient’s initial assessment is completed within 48 hours of the referral has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The hospital record for referral was received on 02/09/2024. The Start of Care Visit is dated 02/13/2024, 4 days after the referral. There is no documented evidence of the initial assessment being completed within 48 hours of the referral. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The In-Patient Referral is dated 07/11/2025. The Start of Care Visit is dated 07/14/2025, 3 days after the referral. There is no documented evidence of the initial assessment being completed within 48 hours of the referral. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 06/19/2025 with the following diagnoses “Sepsis, Urinary Tract Infection, Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 06/19/2025 to 08/17/2025. The Home Health Care Agency Referral Form with Date of Referral: 06/14/2025. The Start of Care Visit is dated 06/19/2025, 5 days after the referral. There is no documented evidence of the initial assessment being completed within 48 hours of the referral. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient #14 has a Start of Care (SOC) date of 07/24/2025 with the following diagnoses “Type 2 Diabetes Mellitus, Hyperglycemia, Pressure Ulcer of Sacral Region Stage 4” documented in the Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025. The referral date is 07/20/2025. The Start of Care Visit is dated 07/24/2025, 4 days after the referral. There is no documented evidence of the initial assessment being completed within 48 hours of the referral. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #7 has a Start of Care (SOC) date of 07/28/2025 with the following diagnoses “Unspecified fracture of vertebra, Unspecified atrial fibrillation, Type II diabetes mellitus” documented in the Home Health Certification and Plan of Care for the Certification Period 07/28/2025 to 09/25/2025. The referral date is 07/23/2025. The Start of Care Visit is dated 07/28/2025, 5 days after the referral. There is no documented evidence of the initial assessment being completed within 48 hours of the referral. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #10 has a Start of Care (SOC) date of 04/22/2025 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 3, Essential (primary) hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 04/22/2025 to 06/20/2025. The referral date is 04/10/2025. The Start of Care Visit is dated 04/22/2025, 12 days after the referral. There is no documented evidence of the initial assessment being completed within 48 hours of the referral. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the patient’s comprehensive assessment accurately reflect the patient’s status. This was evident for 7 (seven) of 17 (seventeen) clinical records reviewed (Patient #1, #3, #4, #8, #9, #12, #13). Failure to ensure the patient’s comprehensive assessment accurately reflect the patient’s current status has the potential risk for negative patient outcomes. The Findings Are: 1. Patient#12 has a Start of Care date of 04/18/2025 and Discharge date of 05/08/2025 with diagnoses of Encounter for Surgical aftercare following Surgery of the Digestive System, Cholecystitis, Other Secondary Hypertension, Type 2 Diabetes Mellitus and Cerebral Infarction, unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 04/18/2025 to 06/16/2025. The SN (Skilled Nursing) Routine Visit 05/01/2025 documents “RUQ (Right Upper Quadrant) Chole (cholecystostomy) tube; Type: Other: Chole Drain; Healing: Healed.” The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Discharge 05/08/2025 documents “RUQ (Right Upper Quadrant) Chole (cholecystostomy) tube; Type: Other: Chole Drain; Drainage: Serous; Drainage Amount: Moderate.” The comprehensive assessment(s) lacks documented evidence of an accurate and current status of the patient’s cholecystostomy tube incision - healed or serous moderate drainage. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #13 has a Start of Care date of 07/09/2025 with diagnoses of Parkinsonism, unspecified, Pressure Ulcer of Right Heel, Unstageable, Pressure Ulcer of Sacral Region, Stage 3, Essential Primary Hypertension, Polyarthritis, and Unspecified Dementia documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Start of Care on 07/09/2025 and SN Routine Visit (s) on 07/11/2025, 07/16/2025, 07/18/2025, 07/21/2025 and 07/23/2025 documents “General Systems Review/Skin/ Incision/ Wound: Left Outer Heel- Non Stageable Ulcer.” The SN Routine Visit (s) on 07/25/2025, 07/28/2025, 08/01/2025, 08/04/2025, 08/06/2025, 08/08/2025 and 08/11/2025 documents “General Systems Review/Skin/ Incision/ Wound: Right Heel Posterior Side Unstageable Pressure Ulcer.” The comprehensive assessment(s) lacks documented evidence of accurate location of the patient’s pressure ulcer - left or right heel. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The Recertification (follow-up) reassessment on 08/01/2025 documents: M1306. Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage or Higher or designated as Unstageable?: 0-No. General Systems Review/Skin/ Incision/Wound: Site Location: Left Groin; Type: Pressure Ulcer: Pressure Ulcer Stage: Stage 2. Site Location: Right Heel; Type: Pressure Ulcer: Pressure Ulcer Stage: Stage 2. The nursing comprehensive assessments lacks documented evidence of an accurate assessment of patient’s current status – no pressure ulcer but with two stage II ulcers. The Charts/Clinical Notes dated 08/04/2025 documents: New wound noted on lt (left) leg anterior shin - new verbal wound care was ordered. The Nursing Routine Visit (assessment) dated 08/06/2025, 08/08/2025, and 08/11/2025 lacks documented evidence of the accurate assessment of patient current status – no assessment of the new ulcer to left shin. The comprehensive assessment lacks documented evidence of an accurate reflection of patient’s wound status. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The Nursing Start of Care Visit dated 07/14/2025 documents: M1324. Stage of Most Problematic Unhealed Pressure Ulcer / Injury that is Stageable: NA – Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries. M1311 current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Stage 2: 1. General Systems Review/Skin/ Incision/Wound: Site Location: Sacral Area; Type: Pressure Ulcer, Pressure Ulcer Stage: Stage 2 The comprehensive assessment lacks documented evidence of an accurate assessment of patient’s current status – no pressure ulcer but with one stage II ulcers. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 06/19/2025 with the following diagnoses “Sepsis, Urinary Tract Infection, Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 06/19/2025 to 08/17/2025. The Nursing Start of Care dated 06/19/2025 documents: Does this patient have a surgical wound? No. The Charts/Clinical Notes documents: 06/19/2025 - Patient with Mid Abdomen wound intact. 06/24/2025 - Patient with Mid Abdominal surgical incision healing. The comprehensive assessments lacks documented evidence of an accurate assessment of patient’s current status – no wound / surgical assessment On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #8 (PAE/Potentially Avoidable Event) has a Start of Care date of 3/16/2025 and a discharge date of 3/25/2025 with the following diagnosis: Encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, initial encounter for closed fracture, fracture of unspecified carpal bone right wrist, Type 2 Diabetes without complications, Unspecified non-displaced fracture of surgical neck of right humerus, other cerebral infarct, Hyperlipidemia, history of falling documented on the Home Health Certification and Plan of Care for the Certification Period 3/16/2025-5/14/2025. The Clinical Notes dated 3/27/2025 documents “Communication received that patient returned to Korea on the 25th.” The OASIS (Outcome and Assessment Information Set) Discharge dated 3/24/2025, documents: M2410 To which inpatient facility has the patient been admitted? – 1. Hospital, M2420 Where is the patient after discharge from your agency– 2. Patient remained in the community … There is no documented evidence in the patient’s clinical records of the patient being hospitalized at discharge. The Discharge OASIS (Outcome and Assessment Information Set) data lacks documented evidence of accurately reflecting the patient’s discharge status at the time of assessment. On 08/14/2025 at 1:15 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient # 9 (PAE/Potentially Avoidable Event) has a Start of Care date of 10/15/2024 and discharge date of 12/11/2024 with the following diagnosis: Epilepsy, Unspecified, Intractable Without Status Epilepticus, Peripheral Vascular Disease, unspecified, Non Pressure chronic ulcer of other part of right foot with unspecified severity, Other cerebral infarction, Type 2 Diabetes Mellitus Without Complications, Essential (primary) Hypertension, Hyperlipidemia, Unspecified, Syncope and Collapse and Pain in Right Foot documented on the Home Health Certification and Plan of Care for the Certification Period 10/15/2024 to 12/13/2024. The Home Health Certification and Plan of Care for the Certification Period 10/15/2024 to 12/13/2024 documents a diagnosis of Non-pressure chronic ulcer with an order for wound care to right 2nd toe (second toe). The Start of Care OASIS (Outcome and Assessment Information Set) dated 10/15/2024, documents: M1306 - Does this patient have at least one Unhealed Pressure Ulcer/Injury …: 0 – No. M1330 documents: Does this patient have a stasis ulcer? 2 - Yes, patient has observable stasis ulcers only. M1332 Current number of stasis ulcer(s) that are observable:1 – One The OASIS (Outcome and Assessment Information Set) Discharge from Agency, on 12/11/2024, documents: General Systems Review\skin\incision\wound: Right 2nd (second) toe venous stasis ulcer healed. “M1306. Does this patient have at least one Unhealed Pressure Ulcer/Injury…:1 – Yes. M1307 The oldest stage 2 pressure ulcer that is present at discharge…:1 – Was present at the most recent SOC/ROC (start of care/resumption of care) assessment. M1311 - Current number of unhealed pressure ulcers/injuries…:1. The Clinical Notes dated12/11/2024 documents: “As per report wound healed. D/C (discharge) effective 12/11/2024, All goals met, MD (Medical Doctor) notified. There is no documented evidence in the clinical records of patient with pressure ulcer/injury at discharge. The Discharge OASIS (Outcome and Assessment Information Set) data lacks documented evidence of accurately reflecting the patient’s wound status at the time of assessment. The Start of Care, OASIS (Outcome and Assessment Information Set) dated 3/16/2025 documents: Pain Evaluation Current Pain Regimen: Pain is well controlled with current Plan of Care; Upper extremity pain Severity: Current rating with 0-10 Scale:7. There is no documented evidence the patient’s pain was adequately evaluated or addressed on admission. The Start of Care OASIS (Outcome and Assessment Information Set) data lacks documented evidence of accurately reflecting the patient’s pain control at the time of assessment. On 08/15/2025 at 3:30 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the survey findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that all medications were accurately reviewed and documented in the patient’s clinical record. This was evident for 3 (three) of 17 (seventeen) clinical records reviewed (Patient #2, #3, #6). Failure to ensure that all medications are accurately reviewed and documented in the patient’s clinical record has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The Medication Review Report from the nursing home (discharge) documents: Memantine HCl (Hydrochloride) Tablet 5 mg (milligram) two times daily. On 08/11/2025 at 3:37 PM a home visit was conducted and a copy was printed by the patient’s son of the list of medications patient is currently taking and it includes Memantine HCl (Hydrochloride) Tablet 5 mg (milligram) two times daily. The Medication List printed on 08/11/2025 lacks documented evidence of the Memantine. There is no documented evidence of the medication reconciliation. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #2 has a Start of Care date of 07/09/2025 with diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Primary Hypertension, Polyarthritis, Other Reduced Mobility and Pain, Unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. On 08/11/2025 at 12:40 PM during the observational home visit, the following medications were observed in the home and listed in the medication profile - dated 07/09/2025 - in the patient’s home admission packet “Tamsulosin 0.4mg (milligram) 1 (one) capsule by mouth every day at night; Tivicay 50 mg. 1(one) tablet by mouth every day in the morning; Emtricitabine 200-300mg 1(one) tablet by mouth in the morning.” There is no documented evidence the Plan of Care includes the following medications: Tamsulosin 0.4mg. capsule, Tivicay 50 mg. tablet, and Emtricitabine 200-300mg. tablet. The clinical record lacks documented evidence of all current medications being reviewed and reconciled. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient#6 has a Start of Care date of 01/22/2024 with diagnoses of Parkinson’s Disease, Other Secondary Hypertension, Chronic Obstructive Pulmonary Disease, with (Acute) Exacerbation, Transient Cerebral Ischemic Attack, unspecified, Diverticulitis of the large intestine, and Colostomy status documented in the Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025. On 08/12/2025 at 1:30 PM during the observational home visit, the following medications were observed “Prednisone 20 mg (milligram) 2 tablets daily by mouth; Thera Tears dry eye therapy lubricant.” There is no documented evidence the Plan of Care includes the following medications: Prednisone 20 mg. tablet, and Thera Tears dry eye therapy lubricant.” The clinical record lacks documented evidence of all medications being reviewed and reconciled. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure each patient’s individualized plan of care include all the required information. This was evident for eleven (11) of seventeen (17) clinical records reviewed (Patients #2, #3, #4, #5, #6, #9, #11, #12, #13, #14, #15). Failure to ensure individualized plan of care includes all the required information, has the potential risk for negative patient outcomes. The findings are: 1. Patient#5 has a Start of Care date of 08/05/2021 with the following diagnoses: “Myotonic muscular dystrophy muscle wasting and atrophy” documented in the Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025. The Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025 documents: DME (Durable Medical Equipment)/Supplies: Walker, Motorized Wheelchair. On 08/12/2025 at 12:30 PM during the observational home visit, the patient was observed using the rollator. During the interview, the PT (Physical Therapist) spoke with patient’s mother. The patient’s mother stated that her son does not have a motorized wheelchair. The clinical record lacks documented evidence of the correct types of necessary equipment and supplies required being included in the individualized plan of care. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #15 has a Start of Care (SOC) date of 07/11/2025 with the following diagnoses “Chronic Obstructive Pulmonary Disease, COVID-19, Dysphagia oropharyngeal phase” documented in the Home Health Certification and Plan of Care for the Certification Period 07/11/2025 to 09/08/2025. The Home Health Certification and Plan of Care for the Certification Period 07/11/2025 to 09/08/2025 documents: DME (Durable Medical Equipment)/Supplies: Walker, Cane. The Nursing Start of Care Visit dated 07/11/2025 documents: General System Review/Respiratory. Frequency of Oxygen Use: As needed. Method of Oxygen Delivery: Cannula. The Charts/Clinical Notes dated 07/14/2025 documents: Patient on oxygen via nasal cannula as needed. Oxygen safety was instructed to the patient and patient verbalized understanding. The clinical record lacks documented evidence of all types of necessary equipment and supplies required, being included in the individualized plan of care. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the 1. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025 documents: Wound Care Cleanse with NS (normal saline) apply Hydrogel Cover with Foam. The plan of care lacks documented evidence of the site for wound care. There is no documented evidence of a complete individualized plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #4 has a Start of Care (SOC) date of 06/19/2025 with the following diagnoses “Sepsis, Urinary Tract Infection, Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 06/19/2025 to 08/17/2025. The Patient Care Manual with revised date of 02/14/2025 documents: Foley Catheter/ Urostomy/ Nephrostomy Care: Physicians’ orders for foley catheter care must include the following – size of foley, frequency of change and flushing. Colostomy/ Ostomy Care: Physicians’ orders for Colostomy/ Ostomy care must include the following – frequency of changing the pouch, skin care around the stoma, including cleansing and addressing any irritation. The Nursing Start of Care visit dated 06/19/2025 documents: Patient has ostomy for bowel elimination; Patient requires a urinary catheter. The plan of care lacks documented evidence of the foley catheter size and frequency of change; and colostomy frequency of changing the pouch, skin care around the stoma. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #14 has a Start of Care (SOC) date of 07/24/2025 with the following diagnoses “Type 2 Diabetes Mellitus, Hyperglycemia, Pressure Ulcer of Sacral Region Stage 4” documented in the Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025. The Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025 documents: Wound Care R (right) arm AVF (arteriovenous fistula). Used for dialysis 3 X (three times) week. The plan of care lacks documented evidence of the hemodialysis safety measures – no blood pressure on right arm, monitoring for bruit and thrill, signs and symptoms of infection. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient#2 has a Start of Care date of 07/09/2025 with diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Primary Hypertension, Polyarthritis, Other Reduced Mobility and Pain, Unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025 documents “DME (Durable Medical Equipment)/Supplies: Walker.” On 08/11/2025 at 12:40 PM during the observational home visit, the following durable medical equipment were observed: rollator, quad cane (four point cane), stick cane (single point cane), and bathroom grab bars. The patient was interviewed and stated, “I’m using my rollator when I’m walking outside or if I have doctor’s appointment, I’m not using it inside, I have my quad cane and stick cane that I’m using around the house, the grab bars I’m using during shower.” The clinical record lacks documented evidence of the types of necessary equipment required being included in the individualized plan of care. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient#6 has a Start of Care date of 01/22/2024 with diagnoses of Parkinson’s Disease, Other Secondary Hypertension, Chronic Obstructive Pulmonary Disease, with (Acute) Exacerbation, Transient Cerebral Ischemic Attack, Diverticulitis of the large intestine unspecified, and Colostomy status documented in the Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025. The Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025 documents “DME (Durable Medical Equipment)/Supplies: Cane, Walker. and Nebulizer” The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Reassessment dated 07/14/2025 documents “Gastrointestinal Review: Colostomy Appliance Type: One Piece; Appliance Supplies used: Ostomy powder, Skin prep/sealant, adhesive remover, skin seals and deodorizer; Care Coordination: Physician Contact: To update on status of patient, For orders for POC (Plan of Care), Physician approves Plan of Care and/or changes, Spoke with: Physician office.” On 08/12/2025 at 1:30 PM during the observational home visit, the patient was observed using the following durable medical equipment: “rolling walker, stair chair lift, and right side bed rail.” Equipment and supplies observed included “bedside commode, quad cane (four point base), grab bars, wooden shower bench and colostomy supplies. The registered nurse was interviewed and stated, “These are the colostomy supplies as per doctor’s order for colostomy care and pouch change frequency is twice a week. I’m providing two visits a week.” The clinical record lacks documented evidence of the types of necessary durable medical equipment ,colostomy appliance, treatment supplies and the frequency of colostomy care including pouch changes as ordered by the physician required being included in the individualized plan of care. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient#11 has a Start of Care date of 01/11/2025 and Discharge date of 02/20/2025 with diagnoses of Aftercare following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Unilateral Primary Osteoarthritis, and Muscle Weakness documented in the Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025. The Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025 lacks documented evidence of the patient’s mental status, prognosis and activities permitted. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient#12 has a Start of Care date of 04/18/2025 and Discharge date of 05/08/2025 with diagnoses Encounter for Surgical aftercare following Surgery of the Digestive System, Cholecystitis, Other Secondary Hypertension, Type 2 Diabetes Mellitus and Cerebral Infarction, unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 04/18/2025 to 06/16/2025. The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Start of Care dated 04/18/2025 documents “Gastrointestinal Review: Colostomy Appliance Type: Two Piece; Appliance Supplies used: Ostomy powder, adhesive remover; Care Coordination: Physician Contact: To update on status of patient, For orders for POC (Plan of Care), Physician approves Plan of Care and/or changes, Spoke with: Physician office.” There is no documented evidence the Plan of Care includes the type of colostomy appliance, treatment supplies and the frequency of colostomy care including pouch changes as ordered by the physician. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 5. Patient #13 has a Start of Care date of 07/09/2025 with diagnoses of Parkinsonism, unspecified, Pressure Ulcer of Right Heel, Unstageable, Pressure Ulcer of Sacral Region, Stage 3, Essential Primary Hypertension, Polyarthritis, and Unspecified Dementia documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025 documents “Activities Permitted: B. Walker.” The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Start of Care 07/09/2025 documents “M1860. Ambulation/Locomotion: 5-Chairfast, unable to ambulate and unable to wheel self.” The Physical Therapy Initial Evaluation dated 07/12/2025 documents “Mobility: Non- Ambulatory” There is no documented evidence the Plan of Care includes the accurate activities permitted based on the patient’s current functional status being non-ambulatory. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. Patient # 9 (PAE/Potentially Avoidable Event) has a Start of Care date of 10/15/2024 and discharge date of 12/11/2024 with the following diagnosis: Epilepsy, Unspecified, Intractable Without Status Epilepticus, Peripheral Vascular Disease, unspecified, Non Pressure chronic ulcer of other part of right foot with unspecified severity, Other cerebral infarction, Type 2 Diabetes Mellitus Without Complications, Essential (primary) Hypertension, Hyperlipidemia, Unspecified, Syncope and Collapse and Pain in Right Foot documented on the Home Health Certification and Plan of Care for the Certification Period 10/15/2024 to 12/13/2024. The Home Health Certification and Plan of Care for the Certification Period 10/15/2024 to 12/13/2024 “Orders for Discipline and Treatment,” documents: Assess/Instruct patient/caregiver on blood glucose monitoring at frequency of ON SS (signs and symptoms) of hypo/hyperglycemia.” The clinical record lacks documented evidence of an accurate order for the required frequency of blood glucose monitoring being included in the individualized plan of care. On 08/14/2025 at 1:15 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that treatments are provided as ordered by a physician. This was evident for seven (7) of seventeen (17) clinical records reviewed (Patients #1, #3, #4, #6, #8, #11, #13). Failure to ensure that treatments are provided as ordered by the physician has the potential for negative patient outcomes. The findings are: 1. Patient#6 has a Start of Care date of 01/22/2024 with diagnoses of Parkinson’s Disease, Other Secondary Hypertension, Chronic Obstructive Pulmonary Disease, with (Acute) Exacerbation, Transient Cerebral Ischemic Attack, Diverticulitis of the large intestine unspecified, and Colostomy status documented in the Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025. The Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025 documents “Icy Hot Extra Strength External Cream 10-30% (percent) 1 Unit daily EX (external); Budesonide Inhaler Suspension 0.5mg(milligram) /2ml (milliliter) twice a day INH (inhalation).” On 08/12/2025 at 1:30 PM during the observational home visit, the patient was interviewed and stated, “I’m applying the ointment to my back (pointing to her lower back) and this Budesonide Inhaler Suspension 0.5mg /2ml using my nebulizer (pointing to the nebulizer machine).” The clinical record lacks documented evidence of an accurate order for Icy Hot Extra Strength External Cream 10-30% (percent) specifying to which affected area for external topical application and the use of Budesonide Inhaler Suspension 0.5mg /2ml specifying via nebulizer machine. There is no documented evidence of the treatment being administered as ordered by a physician. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient#11 has a Start of Care date of 01/11/2025 and Discharge date of 02/20/2025 with diagnoses of Aftercare following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Unilateral Primary Osteoarthritis, and Muscle Weakness documented in the Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025. The Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025 documents “Peri Guard External Ointment I Unit daily EX (External).” The clinical record lacks documented evidence of accurate order for Peri Guard External Ointment specifying to which affected area for topical application. There is no documented evidence of the treatment being administered as ordered by a physician. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #13 has a Start of Care date of 07/09/2025 with diagnoses of Parkinsonism, unspecified, Pressure Ulcer of Right Heel, Unstageable, Pressure Ulcer of Sacral Region, Stage 3, Essential Primary Hypertension, Polyarthritis, and Unspecified Dementia documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Charts/ Clinical Notes on 07/25/2025 documents “Skin tear on Left leg was cleansed with normal saline, patted dry treated with silver sulfadiazine, covered with Xeroform and secured with foam dressing.” The clinical care record lacks documented evidence of supplemental order for the treatment of skin tear on left leg. There is no documented evidence of the treatment being administered as ordered by a physician. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The Charts/Clinical Notes dated 08/04/2025 documents: New wound noted on lt (left) leg anterior shin new verbal wound care was ordered; SN (skilled nurse) cleansed wound with NSS (normal saline solution), pat dry, Calcium Alginate DSD (dry sterile dressing) and Klink, secured with Ace Bandage. The clinical care record lacks documented evidence of supplemental order for the treatment for the left shin and physical therapy visit on 07/27/2025 and 07/28/2025. There is no documented evidence of the services and treatment being administered as ordered by a physician. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025 documents: Wound Care Cleanse with NS (normal saline) apply Hydrogel cover with Foam. The Charts/Clinical Notes dated 08/08/2025 documents: New wound care orders/recommendations by Dr (doctor) as follow: Cleanse wounds with NSS (normal saline solution), pat dry, apply Calcium Alginate and Foam dressing. The clinical care record lacks documented evidence of supplemental order for the treatment for the new wound orders. There is no documented evidence of the treatment being administered as ordered by a physician. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care (SOC) date of 06/19/2025 with the following diagnoses “Sepsis, Urinary Tract Infection, Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 06/19/2025 to 08/17/2025. The clinical care record lacks documented evidence of supplemental order for the physical therapy visit on 07/29/2025. There is no documented evidence of services being administered as ordered by a physician. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. Patient #8 (PAE/Potentially Avoidable Event) has a Start of Care date of 3/16/2025 and a discharge date of 3/25/2025 with the following diagnosis: Encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, initial encounter for closed fracture, fracture of unspecified carpal bone right wrist, Type 2 Diabetes without complications, Unspecified non-displaced fracture of surgical neck of right humerus, other cerebral infarct, Hyperlipidemia, history of falling documented on the Home Health Certification and Plan of Care for the Certification Period 3/16/2025-5/14/2025. The Home Health Certification and Plan of Care for the Certification Period 3/16/2025-5/14/2025 documents: Right arm: Covered with Cast, Right hip: Covered with dressing …Unable to perform wound care due to: will be removed by MD. The Start of Care, OASIS (Outcome and Assessment Information Set) dated 3/16/2025 documents:M1340 Does this patient have a surgical wound? 2 – Surgical wound known but not observable due to non removeable dressing/device. Right arm: Cast – Dressing changed this visit: Yes, per orders see Care Plan. Right hip: Covered with dressing - Dressing changed this visit: Yes, per orders see Care Plan. There clinical record lacks documented evidence of the SN (Skilled Nurse) following the medical orders in the plan of care. There is no documented evidence of the treatments being administered in accordance with the physician orders. On 08/14/2025 at 1:15 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to promptly alert the relevant physician to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This was evident for 1 (one) of 17 (seventeen) clinical records reviewed (Patient #14). Failure to ensure the agency promptly alert the relevant physician to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care (SOC) date of 07/24/2025 with the following diagnoses “Type 2 Diabetes Mellitus, Hyperglycemia, Pressure Ulcer of Sacral Region Stage 4” documented in the Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025. The Charts / Clinical Notes dated 07/25/2025 and 7/31/2025 documents: Sacral wound, pink wound bed with moderate drainage. The Charts / Clinical Notes dated 08/04/2025 documents: Sacral decubitus with some maceration. The clinical care record lacks documented evidence of the physician notification with the change in wound status. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that there is a revised plan of care to reflect the patients updated current information. This was evident in 1 (one) of 17 (seventeen) patient clinical records reviewed (Patient #1). Failure to ensure that there is a revised plan of care to reflect the patient’s updated current information has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The Charts/Clinical Notes dated 08/04/2025 documents: New wound noted on lt (left) leg anterior shin new verbal wound care was ordered; SN (skilled nurse) cleansed wound with NSS (normal saline solution), pat dry, Calcium Alginate DSD (dry sterile dressing) and Klink, secured with Ace Bandage. The plan of care lacks documented evidence of being revised to reflect the new ulcer to left shin. There is no documented evidence of the revised plan of care to reflect the patients updated current information. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the patient or his or her representative was notified of changes to the patient’s discharge. This was evident for 3 (three) of 17 (seventeen) clinical records reviewed (Patients #9, #11, #12). Failure to ensure the patient or his or her representative was notified of the changes in the patient’s discharge has the potential risk for negative patient outcomes. The findings are: 1. Patient#11 has a Start of Care date of 01/11/2025 and Discharge date of 02/20/2025 with diagnoses of Aftercare following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Unilateral Primary Osteoarthritis, and Muscle Weakness documented in the Home Health Certification and Plan of Care for the Certification Period 01/11/2025 to 03/11/2025. The PT (Physical Therapy) Daily Note Visit /Billing Sheet dated 02/20/2025 documents “Plan: Progressing Patient Next Visit, Progressing pt(patient) as per POC (Plan of Care).” The Therapy Discharge Note 02/21/2025 documents “Patient(‘Name”) has been discharged from our care for the following reasons: Per MD patient was instructed to remain off of L (left) knee until MD appointment on 02/21/2025- Unable to complete D/C (discharge) visit d/t (due to) end of POC (Plan of Care). Patient achieved all goals set forth at IE (Initial Evaluation), between RA and DC (Readmission and Discharge).” There is no documented evidence of the revision related to plans for the patient’s discharge on 02/20/2025 being communicated to the patient or family and other health care professional who will be responsible for providing care and services to the patient after discharge from the agency. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient#12 has a Start of Care date of 04/18/2025 and Discharge date of 05/08/2025 with diagnoses of Encounter for Surgical aftercare following Surgery of the Digestive System, Cholecystitis, Other Secondary Hypertension, Type 2 Diabetes Mellitus and Cerebral Infarction, unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 04/18/2025 to 06/16/2025. The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Routine Visit 05/01/2025 documents “Next Home Visit: Next visit per visit frequency, Plan for Next Visit: As per established goals, POC (plan of care) Reviewed: Patient satisfied with POC.” The Charts/ Clinical Notes documents the following “05/02/2025: Skilled Nursing: 4 (four) SN (Skilled Nursing) approved from 05/02/2025 to 05/17/2025.” There is no documented evidence of the revision related to plans for the patient’s discharge on 05/08/2025 being communicated to the patient or family and other health care professional who will be responsible for providing care and services to the patient after discharge from the agency. On 08/15/2025 at 11:30 AM, the Director of Patient Services was interviewed and stated, “If it’s not documented in the chart/ clinical notes, I don’t have it.” 1. Patient # 9 (PAE/Potentially Avoidable Event) has a Start of Care date of 10/15/2024 and discharge date of 12/11/2024 with the following diagnosis: Epilepsy, Unspecified, Intractable Without Status Epilepticus, Peripheral Vascular Disease, unspecified, Non Pressure chronic ulcer of other part of right foot with unspecified severity, Other cerebral infarction, Type 2 Diabetes Mellitus Without Complications, Essential (primary) Hypertension, Hyperlipidemia, Unspecified, Syncope and Collapse and Pain in Right Foot documented on the Home Health Certification and Plan of Care for the Certification Period 10/15/2024 to 12/13/2024. The Physical Therapy Treatment Note dated 11/4/2024 documents: Plan/Goal for next visit: Patient will be able to do transfers independently. The Physical Therapy Missed Visit Note dated 11/7/2024 documents “11/4/2024 D/C (discharge); goals met. There is no documented evidence the Physical Therapist notified the patient/his or her representative of the changes in the discharge date. The Clinical notes SN (Skilled Nurse) dated 12/11/2024 documents: D/C Visit Patient’s R (right) 2nd toe healed. VN instructed … There is no documented evidence the Skilled Nurse notified the patient/his or her representative of the changes in the discharge date. On 08/14/2025 at 1:15 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure the patient received training and education according to the plan of care objectives. This was evident for 3 (three) of 17 (seventeen) clinical records reviewed (Patient #10, #14, #16). Failure to ensure the patient received training and education according to the plan of care objectives has the potential risk for negative patient outcomes. The findings are: 1. Patient #14 has a Start of Care (SOC) date of 07/24/2025 with the following diagnoses “Type 2 Diabetes Mellitus, Hyperglycemia, Pressure Ulcer of Sacral Region Stage 4” documented in the Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025. The Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025 documents: Assess/Instruct patient/caregiver on proper wound care. Patient’s son is to do wound care on the days VN (visiting nurse) does not visit. The Nursing Start of Care Visit dated 07/24/2025 documents: Type of Assistance: supervision and safety: Non-agency caregivers need training/supportive services to provide assistance. The Charts / Clinical Notes dated 08/04/2025 documents: Sacral decubitus with some maceration. The clinical care record lacks documented evidence of the wound care training, demonstration, return demonstration, and evaluate the caregiver’s capability. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 1. Patient #10 has a Start of Care (SOC) date of 04/22/2025 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 3, Essential (primary) hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 04/22/2025 to 06/20/2025. The Home Health Certification and Plan of Care for the Certification Period 04/22/2025 to 06/20/2025 documents: Instruct patient/caregiver on pressure relief/shearing reduction measures. Instruct patient/caregiver on use of pressure relieving devices. The Nursing Start of Care Visit dated 04/22/2025 documents: Type of Assistance: supervision and safety: Non-agency caregiver(s) currently provide assistance. The Charts/Clinical Notes dated 04/25/2025, 04/28/2025, 04/30/2025, 05/02/2025, 05/05/2025, and 05/07/2025 documents: Skilled Nurse instructed patient and caregiver on signs and symptoms of infection as follows: high fever, pain in wound sides, redness, swelling, pain with touch wounds, foul odor, purulent discharge, instructed immediately report these symptoms to MD (Medical Doctor)/RN (Registered Nurse). The clinical care record lacks documented evidence of the pressure relief/shearing reduction measures and use of pressure relieving devices training, demonstration, return demonstration, and evaluate the caregiver’s capability. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #16 has a Start of Care (SOC) date of 07/01/2025 with the following diagnoses “Pressure ulcer of sacral region, unstageable, Unspecified dementia” documented in the Home Health Certification and Plan of Care for the Certification Period 07/01/2025 to 08/29/2025. The Home Health Certification and Plan of Care for the Certification Period 07/01/2025 to 08/29/2025 documents: Instruct patient/caregiver on pressure relief/shearing reduction measures. Instruct patient/caregiver on use of pressure relieving devices. The Nursing Start of Care Visit dated 07/01/2025 documents: Type of Assistance: supervision and safety: Non-agency caregiver(s) currently provide assistance. General System Review/Skin: Friction and Shear. Frequently slides down in bed or chair requiring frequent repositioning with maximum assistance. Skilled Nursing Visit dated 07/07/2025, 07/28/2025, and 08/04/2025, documents: Skin/Wound Education instructed on: Wound care as per order. Skilled Nursing Visit dated 07/09/2025 and 07/23/2025 documents: Skin/Wound Education instructed on: Wound care as per order, Clean technique, Dressing change (type, frequency, procedure). Skilled Nursing Visit dated 07/18/2025, 07/21/2025, 07/30/2025, 08/01/2025, 08/06/2025, and 08/11/2025 lacks documented evidence of the Skin/Wound Education instructions provided to patient/caregiver. The clinical care record lacks documented evidence of the pressure relief/shearing reduction measures and use of pressure relieving devices training, demonstration, return demonstration, and evaluate the caregiver’s capability. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure the the written visit schedule provided to the patient is consistent with the patient’s most current plan of care.. This was evident for 1 (one) of 17 (seventeen) clinical records reviewed (Patient #2). Failure to ensure the written visit schedule provided to the patient is consistent with the patient’s most current plan of care has the potential risk for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 07/09/2025 with diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Primary Hypertension, Polyarthritis, Other Reduced Mobility and Pain, Unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. On 08/11/2025 at 12:40PM during the observational home visit, there is no written visit schedule of Skilled Nursing, Physical Therapy and Home Health Aide included in the admission packet. The patient was interviewed and stated “For my Physical Therapy, our schedule never clicked. It will be nice if he can put in the calendar the specific days and the time, so I know that he is coming here at home.” There is no documented evidence of a written visit schedule of services being provided to the patient and/or family. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interviews, the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for three (3) of seventeen (17) clinical records reviewed (Patients #1, #3, #14). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care (SOC) date of 02/13/2024 with the following diagnoses “Venous Insufficiency, Chronic Venous Hypertension with Ulcer and Inflammation of Right Lower Extremity” documented in the Home Health Certification and Plan of Care for the Certification Period 08/06/2025 to 10/04/2024. The Home Health Certification and Plan of Care for the Certification Period 06/07/2025 to 08/05/2025 documents: Assess wound location, size, stage, drainage, wound bed and periwound care. The Nursing Start of Care assessment dated 07/14/2025 and nursing routine visits dated 06/09/2025, 06/11/2025, 06/16/2025, 06/18/2025, 06/20/2025, 06/23/2025 documents: General Systems Review/Skin/ Incision/Wound: Site Location: Right Heel; Type: Pressure Ulcer, Pressure Ulcer Stage: Stage 2; Wound Measurement: Measure Weekly; Wound tissue Observed: Pink. Site Location: Left Groin; Type: Pressure Ulcer, Pressure Ulcer Stage: Stage 2; Wound Measurement: Measure Weekly; Wound tissue Observed: Pink. The clinical care record lacks documented evidence of the measurement and wound bed description of a stage II pressure ulcers on 06/04/2025 for comprehensive assessment, and from 06/09/2025 to 06/23/2025 visits. There is no documented evidence of a complete Skilled Nursing services - complete assessment for the ulcers as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 07/14/2025 with the following diagnoses “Heart Failure, Pressure Ulcer of Sacral Region Stage 2” documented in the Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025. The Home Health Certification and Plan of Care for the Certification Period 07/14/2025 to 09/11/2025 documents: Assess wound location, size, stage, drainage, wound bed and periwound care. The Nursing Start of Care assessment dated 07/14/2025 documents: General Systems Review/Skin/ Incision/Wound: Site Location: Sacral Area; Type: Pressure Ulcer, Pressure Ulcer Stage: Stage 2; Wound Measurement: Measure Weekly; Wound tissue Observed: Pink. The clinical care record lacks documented evidence of the measurement and wound bed description of a stage II pressure ulcer on 07/14/2025 for comprehensive assessment, and from 07/21/2025 to 07/28/2025 and 08/04/2025 to 08/11/2025 visits. There is no documented evidence of a complete Skilled Nursing services - complete assessment for the ulcers as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #14 has a Start of Care (SOC) date of 07/24/2025 with the following diagnoses “Type 2 Diabetes Mellitus, Hyperglycemia, Pressure Ulcer of Sacral Region Stage 4” documented in the Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025. The Home Health Certification and Plan of Care for the Certification Period 07/24/2025 to 09/21/2025 documents: Assess wound location, size, stage, drainage, wound bed and periwound care. The Nursing Start of Care dated 07/24/2025 documents: General Systems Review / Skin / Incision/ Wound Site Location: Sacrum; Pressure Ulcer Stage: Stage 4; Wound Tissue Observed: Pink. The clinical care record lacks documented evidence of the wound bed description of a stage 4 pressure ulcer on 07/24/2025 for comprehensive assessment, and measurement and wound bed description from 07/31/2025 to 08/12/2025 visits. There is no documented evidence of a complete Skilled Nursing services - complete assessment for the ulcers as written in the plan of care. On 08/14/2025 at 11:30 AM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record reviews, policy review, and staff interviews, the agency failed to ensure clinical notes are submitted in a timely manner. This was evident for three (3) of seventeen (17) clinical records reviewed (Patients #2, #6, #13). Failure to ensure clinical notes are submitted in a timely manner, has the potential for negative patient outcomes. The findings are: The Policy Skilled Nursing Notes documents “Documentation will occur on the same day as the service is rendered.” 1. Patient #2 has a Start of Care date of 07/09/2025 with diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Primary Hypertension, Polyarthritis, Other Reduced Mobility and Pain, Unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The SN (Skilled Nursing) Routine Visit on 07/16/2025 documents “Electronically signed by (“SN Name”) on 08/12/2025.” The clinical record lacks documented evidence of Skilled Nursing timely submission and electronically signing of clinical notes. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 01/22/2024 with diagnoses of Parkinson’s Disease, Other Secondary Hypertension, Chronic Obstructive Pulmonary Disease, with (Acute) Exacerbation, Transient Cerebral Ischemic Attack, unspecified, Diverticulitis of the large intestine, and Colostomy status documented in the Home Health Certification and Plan of Care for the Certification Period 07/15/2025 to 09/12/2025. The SN (Skilled Nursing) OASIS (Outcome and Assessment Information Set) Recertification (Follow-up) Reassessment on 07/14/2025 and SN (Skilled Nursing) Routine Visit(s) 07/17/2025, 07/22/2025,07/24/2025, 07/29/2025, 07/31/2025, 08/05/2025, and 08/08/2025 documents “Electronically signed by (“SN Name”) on 08/13/2025.” The clinical record lacks documented evidence of Skilled Nursing timely submission and electronically signing of clinical notes. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #13 has a Start of Care date of 07/09/2025 with diagnoses of Parkinsonism, unspecified, Pressure Ulcer of Right Heel, Unstageable, Pressure Ulcer of Sacral Region, Stage 3, Essential Primary Hypertension, Polyarthritis, and Unspecified Dementia documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The SN (Skilled Nursing) Routine Visit on 07/28/2025, 08/04/2025, 08/06/2025, 08/08/2025 and 08/11/2025 documents “Electronically signed by (“SN Name”) on 08/13/2025.” The clinical record lacks documented evidence of Skilled Nursing timely submission and electronically signing of clinical notes. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that Home Health Aides follow the paraprofessional plan of care for completion of the assigned tasks. This was evident for two (2) of seventeen (17) clinical records reviewed (Patients #2 & #13). Failure to ensure that Home Health Aides follow the paraprofessional plan of care for completion of the assigned tasks has the potential for negative patient outcomes. The findings are: 1.Patient #2 has a Start of Care date of 07/09/2025 with diagnoses of Bilateral Primary Osteoarthritis of Knee, Essential Primary Hypertension, Polyarthritis, Other Reduced Mobility and Pain, Unspecified documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Home Care Aide Care Plan documents the following assigned tasks to be provided Every Visit: “Shower, Personal Care, Assist with Dressing, Hair Care, Shampoo, Skin Care, Foot Care, Medication Reminder Assist with Ambulation and Meal Preparation.” The clinical record lacks documented evidence of the Home Health Aide following the paraprofessional plan of care for completion of the assigned tasks “Shower, Personal Care, Assist with Dressing, Hair Care, Shampoo, Skin Care, Foot Care, Medication Reminder Assist with Ambulation and Meal Preparation” on 07/30/2025 and 08/01/2025. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #13 has a Start of Care date of 07/09/2025 with diagnoses of Parkinsonism, unspecified, Pressure Ulcer of Right Heel, Unstageable, Pressure Ulcer of Sacral Region, Stage 3, Essential Primary Hypertension, Polyarthritis, and Unspecified Dementia documented in the Home Health Certification and Plan of Care for the Certification Period 07/09/2025 to 09/06/2025. The Home Care Aide Care Plan documents the following tasks to be provided Every Visit: “Positioning: Encourage Assist every 2 (two) hours.” The clinical record lacks documented evidence of the Home Health Aide following the paraprofessional plan of care for completion of the assigned task “Positioning: Encourage Assist every 2 (two) hours” on 07/30/2025 to 08/01/2025 and 08/04/2025 to 08/06/2025, and 08/08/2025. On 08/14/2025 at 12:20 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to coordinate care delivery to the patient or caregivers. This was evident for one (1) of five (5) patient care records reviewed (Patient #1). Failure to coordinate care delivery to the patient or caregivers has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/12/2023 and a discharge date of 09/26/2023 with the following diagnoses “Bilateral Primary Osteoarthritis of Knee, Hypertension, Dementia” documented in the Home Health Certification and Plan of Care for the Certification Period 07/12/2023 to 09/09/2023. The Home Health Certification and Plan of Care for the Certification Period 07/12/2023 to 09/09/2023 documents: “Aid 07-16-23 2 x week x 4 weeks, 3h (twice a week for four weeks, three hours) duration; 08-12-23 5 x week x 4 weeks, 4h (five times a week for four weeks, four hour) duration.” The Duty Sheet documents aide services being provided with time in of 07:45am from 08/01/2023 to 08/11/2023, 8:00am on 08/14/2023, 12:15pm on 08/15/2023, and 1:45pm on 08/16/2023. The clinical record lacks documented evidence of the coordination of the delivery of care (aide services late time in) to the family on 08/15/2023 and 08/16/2023. On 02/06/2025 at 4:30PM, the Administrator, the Director of Patient Services, the Director of Intake, and the Operations Manager were interviewed and stated, “No notes were found on these dates”, and no further explanation for the findings.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to ensure that services must be provided in accordance with HHA own policies and procedure. This was evident for one (1) of five (5) patient care records reviewed (Patient #4). Failure to ensure that services must be provided in accordance with HHA own policies and procedure has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a referral date 12/19/2023. The Email Print-out documents: 12/20/2023 “Pt (patient) with uncontrolled DM (Diabetes Mellitus), diabetic foot ulcer, with recent hospitalization for infected wound/ OM (Osteomyelitis). NTUC (not taken under care) d/t (due to) poor wound healing potential.” The Administrative Policy and Procedure Manual for Intake/Referral documents: “All NTUC’ed (not taken under care) referrals after discussion with the DPS/Designee must be communicated via email, phone call, facsimile machine or the referral source reasons why agency could not take case under their care (NTUC) and document such communication in the intake tracking log and patient medical record. The clinical record lacks documented evidence of the communication in the intake tracking log and patient medical record of not accepting/admitting patient with the referral agency. On 02/06/2025 at 4:30PM, the Director of Patient Services was interviewed and stated, “I don’t see no notes, and I asked the staff, they could not answer my question too.””