Carter Healthcare of Oklahoma, LLC

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, PT staff failed to conduct initial evaluations timely as part of the comprehensive assessment for four (#2, #3, #4 and #7) of seven (#1-#7) records reviewed. Patient #2 Review of Patient #2 record for SOC certification period 10/30/25 to 12/283/25 revealed a primary diagnosis of Pneumonia and referral for SN and PT services. Further review revealed a SOC OASIS was completed by the SN on 10/30/25 and a PT initial evaluation was completed on 11/8/25 (9 days later). A communication note titled “Provider Notification” dated 10/31/25 documented, “PT eval will not be performed within 48 hrs. of referral. PT eval has been scheduled for the week of 11/03/25”. The record failed to provide the reason the initial PT evaluation was not completed within 5 days of the SOC as part of the comprehensive assessment. Patient #3 Review of Patient #3 record for SOC certification period 10/08/25 to 12/06/25 revealed a primary diagnosis of Type II Diabetes Mellitus with Foot Ulcer and referral for SN and PT services. Further review revealed a SOC OASIS was completed by the SN on 10/08/25 and a PT initial evaluation was completed on 10/20/25 (12 days later). A Provider Notification dated 10/14/25 documented, “PT eval will not be performed within 48 hrs. of referral. PT eval has been scheduled for the week of 10/20/25”. The record failed to provide the reason the initial PT evaluation was not completed within 5 days of the SOC as part of the comprehensive assessment. Patient #4 Review of Patient #4 record for SOC certification period 11/14/25 to 01/12/26 revealed a primary diagnosis of Malignant Neoplasm of Rectum and referral for SN and PT services. Further review revealed a SOC OASIS was completed by the SN on 11/14/25 and a PT initial evaluation was completed on 11/20/25 (6 days later). A Provider Notification dated 11/17/25 documented, “PT eval will not be performed within 48 hrs. of referral. PT eval has been scheduled for the week of 11/17/25”. The record failed to provide the reason the initial PT evaluation was not completed within 5 days of the SOC as part of the comprehensive assessment. Patient #7 Review of Patient #7 record for SOC certification period 09/30/25 to 11/28/25 revealed a primary diagnosis of Acute Respiratory Failure and referral for SN and PT services. Further review revealed a SOC OASIS was completed by the SN on 09/30/25 and a PT initial evaluation was completed on 10/17/25 (17 days later). The SOC assessment indicated multiple falls and that Pt #7 would benefit from PT. The record failed to provide the reason the initial PT evaluation was not completed within 5 days of the SOC as part of the comprehensive assessment. During an interview on 12/10/25 at 2:15 PM, RN1 stated the PT initial evaluations were not completed timely as part of the comprehensive assessment for Patient #2, #3, #4 and #7.”

“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 record review and interview, SN staff failed to promptly notify the physician of a patient fall with injuries and increased pain for one (#5) of seven (#1-#7) records reviewed. Patient #5 Review of Patient #5 record for certification period 10/18/25 to 12/16/252 revealed a primary diagnosis of Type II Diabetes Mellitus with Chronic Kidney Disease with orders for SN visits 1 time a week for 9 weeks. Further review revealed a SN Visit Note on 12/02/25 documented Patient #5 had a fall and skin tear on right forearm, bruising on ribs and complained of shoulder, hip and back pain of “10”. A picture of the right forearm skin tear was identified but no documentation provided evidence the physician was notified of the fall with injuries or the pain level of “10”. During an interview on 12/10/25 at 2:15 PM, RN1 stated there was no evidence the SN notified the physician of the patients fall, injuries or reported pain level of “10” as required.”

“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 record review, observations and interview, SN staff failed to provide services and interventions as ordered in the POC for three (#2, #3 and #6) of seven (#1-#7) records reviewed. Patient #2 Review of Patient #2 record for SOC certification period 10/30/25 to 12/28/25 revealed a primary diagnosis of Pneumonia, Chronic Obstructive Pulmonary Disease and Dependance on Supplemental Oxygen. The POC contained orders for SN visits 1 time a week for 7 weeks and for the “SN to educate on use of oxygen sign to help first responders and provide sign and secure to exterior door as needed”. During a home visit conducted on 12/10/25 at 10:00 AM, a portable oxygen tank and concentrator were visible in the living room but no “Oxygen Sign” was observed on the exterior or interior of the home. When this Surveyor asked the CG if an Oxygen Sign was posted in the home, the CG stated, “No”. The SN retrieved an Oxygen Sign from the patient’s Admission packet and provided to the CG to post in the home. Patient #3 Review of Patient #3 record for SOC certification period 10/08/25 to 12/06/25 revealed a primary diagnosis of Type II Diabetes Mellitus with Foot Ulcer. The POC contained orders for SN visits 2 times a week for 9 weeks and PT visits 2 times a week for 4 weeks and 1 time a week for 3 weeks. Further record review failed to provide evidence a SN visit or PT visit was conducted the week of 10/12/25. There was no documentation the physician was notified of a Missed Visit, or the reason visits were not conducted as ordered. Patient #6 Review of Patient #6 record for SOC certification period 08/13/25 to 10/11/25 revealed a primary diagnosis of Hypertensive Heart Failure and Type II Diabetes Mellitus. The POC contained orders for SN visits 1 time a week for 9 weeks, orders for the “SN to assess patient’s weight log every visit” and parameters to notify the physician for “Fasting Blood Sugar >300 or 350 or <60”. Further record review failed to provide evidence the SN assessed weights for visits conducted from 09/09/25,09/19/25 or 10/06/25 and no blood sugar results were documented for SN visits 08/13/25 or 10/06/25. During an interview on 12/10/25 at 2:15 PM, RN1 stated the SN failed to provide interventions as ordered on the POC for Patient #2, #3 and #6.”