Elara Caring IV

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that Emergency Preparedness documents were updated every two years for all patients and all employees. Findings: A review of administrative records showed a document dated 11/28/19 titled, “MERC Response Team Names and Phone Numbers.” The surveyor compared information contained in “MERC Response Team Names and Phone Numbers” with current RMRS map including names of RMRS staff, titles, and telephone numbers. The contact information for agency staff to use was not updated. On 12/03/25 at 1:45 pm, Staff A stated the information in the document titled, “MERC Response Team Names and Phone Numbers” had not been updated in the last two years.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure assessments were completed and uploaded in a timely manner for one (Pt #2) of twelve patients. Findings: A review of a POC dated 11/19/25 to 01/17/26 showed orders for PT effective 11/23/25 once a week for one week. The record did not contain a PT assessment for the week of 11/23/25. On 12/03/25 at 2:20 pm Staff A stated the PT assessment should have been turned in within 48 hours of the evaluation.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to include orders in the POC for one (Pt #2) of twelve patients. Findings: A review of the SOC assessment dated 11/19/25 documented in part, “She has trouble arranging her medications and will need a weekly med planner fill...” The review showed a POC dated 11/19/25 to 01/17/26 that did not show orders for a medication planner or a weekly med planner fill. On 12/03/25 at 2:20 pm, Staff A stated the orders for a weekly medication planner being filled should have been included in the POC orders.”

“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 record review and interview, the agency failed to provided the ordered wound care for one (Pt #9) of twelve patients. Findings: Pt #9 A review of the record showed a certification period dated 09/20/25 - 11/18/25 with a ROC dated 09/26/25. The orders for wound care from the ROC read as follows: “Incisional wound vac dressing is in place. Keep this in place for seven days and do not get the dressing wet. Reinforce with adhesive sheets as needed. After seven days, remove the wound vac dressing and replace with silver island dressing.” The nurses’ notes documented the followings. 10/02/25 - Wound care provided; Incisional wound vac dressing is in place. Keep this in place for seven days and do not get the dressing wet, reinforce with adhesive sheets, as needed after seven days remove the wound vac dressing replace with silver island dressing. 10/08/25 - Wound care not provided; covered by non-removable dressing or device. 10/15/25 - Wound care not provided; covered by non-removable dressing or device. 10/22/25 - Wound care provided; Incisional wound vac dressing is in place. Keep this in place for seven days and do not get the dressing wet, reinforce with adhesive sheets, as needed after seven days remove the wound vac dressing replace with silver island dressing. 10/29/25 - Wound care provided; Incisional wound vac dressing is in place. Keep this in place for seven days and do not get the dressing wet, reinforce with adhesive sheets, as needed after seven days remove the wound vac dressing replace with silver island dressing. On 12/03/25 at 2:50 pm, Staff A stated wrong wound dressings had been documented.”

“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 record review and interview, the agency failed to ensure: 1) A current POC was provided to the Assisted Living Facility for one (Pt #5) of one patients residing in an Assisted Living Facility; 2) A physician was notified of an oxygen saturation below parameters for one (Pt #6) of twelve patients. Findings: Pt #5 A review of the home health agency record at the assisted living showed no current plan of care for the certification period of 11/14/25 - 01/12/25. Pt #6 A review of the record showed a POC dated 10/26/25 - 12/2/24/25 with orders to report an oxygen saturation of less than 90%. A nursing assessment dated 10/27/25 did not show physician notification of an oxygen saturation of 84% with the patient receiving oxygen at 5 L/min per minute via nasal cannula on the day the patient assessment was conducted. On 12/03/25 at 10:25 am Assisted Living Staff #1 stated there was no current plan of care for Pt #5. On 12/03/2 at 2:50 pm Staff B stated the POC should be provided to a facility within 5 days of the SOC or recertification assessment. On 12/03/25 at 2:45 pm Staff B stated the nurse should have notified the physician of the oxygen saturation of 84% at the time of assessment for Pt #6.”