Luxe Home Health LLC

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the Emergency Preparedness Plan had policies and procedures related to patient data management and information sharing for all patients and employees. Findings: A review of emergency preparedness records showed no Emergency Preparedness Plan policies and procedures related to patient data management and information sharing. On 03/13/26 at 8:52 a.m., Staff A stated the agency had no policies and procedures for patient information sharing.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Emergency Preparedness communication plan included current employee contact information for all patients and employees. Findings: A review of emergency preparedness records showed no communication plan which included current employee contact information for the agency. On 03/13/26 at 8:52 a.m., Staff A stated its emergency preparedness communication plan did not include contact information for current employees.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation, and maintenance of processes for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of emergency preparedness records showed no administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials. On 03/13/26 at 8:52 a.m., Staff A stated its emergency preparedness plan did not include processes and resource contact information for an integrated response.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2024 for all patients and employees. Findings: A review of emergency preparedness records showed no disaster table-top exercises, drills, community drills or plan activation events for calendar year 2024. On 03/13/26 at 8:52 a.m., Staff A stated the agency had no exercises, drills, or events in 2024.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure utilization and analysis of patient outcome data in its QAPI Program for all patients and employees. Findings: A review of QAPI records showed no patient outcome data was utilized for analysis and decision making in its QAPI program in calendar years 2024 and 2025. On 03/13/26 at 11:20 a.m., Staff A stated patient outcome data was not included in the QAPI program.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure baseline and goal measurements of the PIP through their QAPI Program for all patients and employees. Findings: A review of QAPI records showed no PIP baseline and goal measurements in calendar years 2024 and 2025. On 03/13/26 at 11:20 a.m., Staff A stated the PIP showed no measurable goals for 2024 and 2025.”

“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 record reviews and interviews, the agency failed to ensure individualized POCs included: 1.Pain management reporting parameters for eight (Patients #1, 2, 3, 4, 5, 6, 7 and #8) of nine patients. 2.Vital sign assessment reporting parameters for blood pressure, pulse, temperature and respiratory rate for eight (Patients #1, 2, 3, 4, 5, 6, 7 and #8) of nine patients. 3.Identification of wound care sites for five (Patients #1, 2, 5, 7 and #9) of nine patients. 4.Pulse Oximeter oxygen saturation reporting parameter for one (Patient #3) of nine patients. 5.Wound care intervention for two (Patients #4 and #6) of nine patients. 6.Physical therapy to evaluate and treat for one (Patient #4) of nine patients. Findings: Patient #1 A review of a POC dated 02/12/26 to 04/12/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 02/10/26 showed a pain level of 3 of 10 and documented no wound site location. 02/17/26 showed a pain level of 4 of 10 and documented no wound site location. 02/24/26 showed a pain level of 5 of 10 and documented no wound site location. 03/03/26 showed a pain level of 3 of 10 and documented no wound site location. On 03/13/26 at 9:12 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment from the prior POC because the wound site had healed. Patient #2 A review of a POC dated 01/13/26 to 03/13/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 01/14/26 showed a pain level of 4 of 10 and documented no wound site location. 01/21/26 showed a pain level of 4 of 10 and documented no wound site location. 01/28/26 showed a pain level of 4 of 10 and documented no wound site location. 02/04/26 showed a pain level of 4 of 10 and documented no wound site location. 02/11/26 showed a pain level of 6 of 10 and documented no wound site location. 02/18/26 showed a pain level of 4 of 10 and documented no wound site location. 02/25/26 showed a pain level of 4 of 10 and documented no wound site location. 03/02/26 showed a pain level of 4 of 10 and documented no wound site location. On 03/13/26 at 9:32 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment from the prior POC because the wound site had healed. Patient #3 A review of a POC dated 02/06/26 to 04/06/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess oximeter oxygen saturation level every visit. The POC showed no reporting parameters for pain management, vital sign readings and showed no oxygen saturation reporting parameters. SN visits dated: 02/09/26 showed a pain level of no pain and showed an oxygen saturation of 96 percent on 2 liters of oxygen. 02/11/26 showed a blood pressure of 98/70 with a pulse rate of 111 beats per minute. 02/16/26 showed a pain level of no pain and showed an oxygen saturation of 95 percent on 4 liters of oxygen. 02/23/26 showed a pain level of no pain and showed an oxygen saturation of 96 percent on 2 liters of oxygen. 03/02/26 showed a pain level of no pain and showed an oxygen saturation of 96 percent on 2 liters of oxygen. On 03/13/26 at 9:32 a.m., Staff A stated the POC did not include pain, vital sign or oxygen saturation reporting parameters. Patient #4 A review of a POC dated 01/31/26 to 03/31/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and perform wound care interventions to the Sacrum of cleanse with normal saline, apply calcium alginate and Medi-honey and cover with bordered foam dressing two times a week and physical therapy to evaluate and establish treatment plan. The POC showed no reporting parameters for pain management or vital sign readings and showed no PT referral or evaluation. SN visits dated: 02/04/26 showed a pain level of no pain and documented no wound site interventions. 02/11/26 showed a pain level of no pain and documented no wound site interventions. 02/18/26 showed a pain level of 2 of 10 and documented no wound site interventions. 02/25/26 showed a pain level of 2 of 10 and documented no wound site interventions. 03/02/26 showed a pain level of 4 of 10 and documented no wound site interventions. On 03/13/26 at 9:32 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site interventions from the prior POC because the wound interventions and SN visit frequency had changed. 3.The POC should not have included PT evaluation that was conducted in the prior certification period. Patient #5 A review of a POC dated 01/06/26 to 03/06/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess and measure the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 01/12/26 showed a pain level of 3 of 10 and documented no wound site location or measurements. 01/19/26 showed a pain level of 6 of 10 and documented no wound site location or measurements. 01/26/26 showed a pain level of 5 of 10 and documented no wound site location or measurements. 02/02/26 showed a pain level of 6 of 10 and documented no wound site location or measurements. 02/09/26 showed a pain level of 6 of 10 and documented no wound site location or measurements. 02/16/26 showed a pain level of 5 of 10 and documented no wound site location or measurements. 02/23/26 showed a pain level of 7 of 10 and documented no wound site location or measurements. 03/02/26 showed a pain level of 7 of 10 and documented no wound site location or measurements. On 03/13/26 at 10:15 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment and measurement interventions from the prior POC because the wound site had healed. Patient #6 A review of a POC dated 02/21/26 to 04/21/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and perform wound care interventions to the left posterior leg of cleanse with normal saline, apply lactic acid 15%, Gentamycin and Acticoat cover with absorbent pad dressing two times a week. The POC showed no reporting parameters for pain management or vital sign readings. SN visits dated: 02/25/26 showed a pain level of 4 of 10 and documented wound site interventions at a one time a week frequency. 03/02/26 showed a pain level of 3 of 10 and documented wound site interventions at a one time a week frequency. On 03/13/26 at 10:25 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site interventions from the prior POC at frequency two times a week after they were changed to one time a week. Patient #7 A review of a POC dated 02/08/26 to 04/08/26 showed orders for SN to observe, assess and teach pain management, perform assessment of vital signs and assess the wound site every visit. The POC showed no reporting parameters for pain management or vital sign readings and did not identify a wound site location. SN visits dated: 02/12/26 showed a pain level of no pain and documented no wound site location. 02/19/26 showed a pain level of 3 of 10 and documented no wound site location. 02/26/26 showed a pain level of 3 of 10 and documented no wound site location. 03/05/26 showed a pain level of 3 of 10 and documented no wound site location. On 03/13/26 at 10:50 a.m., Staff A stated: 1.The POC did not include pain or vital sign reporting parameters. 2.The POC should not have included wound site assessment from the prior POC because the wound site had healed. Patient #8 A review of a POC dated 02/02/26 to 04/02/26 showed orders for SN to observe, assess and teach pain management and perform assessment of vital signs every visit. The POC showed no reporting parameters for pain management or vital sign readings. SN visits dated: 02/06/26 showed a pain level of 4 of 10. 02/09/26 showed a pain level of 3 of 10. On 03/13/26 at 11:00 a.m., Staff A stated the POC did not include pain or vital sign reporting parameters. Patient #9 A review of a POC dated 01/01/26 to 03/01/26 showed orders for SN to assess and measure the wound site every visit. The POC did not identify a wound site location. SN visits dated: 01/06/26 showed no wound site location or measurements. 01/13/26 showed no wound site location or measurements. 01/21/26 showed no wound site location or measurements. On 03/13/26 at 11:10 a.m., Staff A stated the POC should not have included wound site assessment and measurement from the prior POC because the wound site had healed.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were documented for wound care interventions for one (Patient #4) of nine patients. Findings: Patient #4 A review of the clinical record showed agency receipt of a faxed order dated 01/28/26 for a SN visit frequency of one-time a week to perform wound site treatment interventions to the Sacrum of wound cleanser, apply skin prep and collagen and cover with gauze dressing. The clinical record showed no entry of the order. On 03/13/26 at 10:00 a.m., Staff A stated the order dated 01/28/26 was not entered into the patient’s record.”

“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 and interviews, the agency failed to ensure: 1.SN visit frequency was conducted as ordered for two (Patients #4 and #6) of nine patients. 2.Aide visit frequency was conducted as ordered for one (Patient #8) of nine patients. Findings: Patient #4 A review of a POC dated 01/31/26 to 03/31/26 showed orders for SN visit frequency of two times a week for nine weeks. The clinical record showed SN visit during the weeks of: 02/01/26 to 02/07/26 SN visit was conducted on 02/04/26 (two visits ordered, one visit conducted). 02/08/26 to 02/14/26 SN visit was conducted on 02/11/26 (two visits ordered, one visit conducted). 02/15/26 to 02/21/26 SN visit was conducted on 02/18/26 (two visits ordered, one visit conducted). 02/22/26 to 02/28/26 SN visit was conducted on 02/25/26 (two visits ordered, one visit conducted). 03/01/26 to 03/07/26 SN visit was conducted on 03/03/26 (two visits ordered, one visit conducted). The clinical record showed no patient refusal of visit, physician notification or change in orders. On 03/13/26 at 10:00 a.m., Staff A stated the SN visits were not conducted as ordered. Patient #6 A review of a POC dated 02/21/26 to 04/21/26 showed orders for SN visit frequency of two times a week for nine weeks. The clinical record showed SN visit during the weeks of: 02/22/26 to 02/28/26 SN visit was conducted on 02/23/26 (two visits ordered, one visit conducted). 03/01/26 to 03/07/26 SN visit was conducted on 03/02/26 (two visits ordered, one visit conducted). The clinical record showed no patient refusal of visit, physician notification or change in orders. On 03/13/26 at 10:25 a.m., Staff A stated the SN visits were not conducted as ordered. Patient #8 A review of a POC dated 02/02/26 to 04/02/26 showed orders for aide visits frequency of two times a week. The clinical record showed no aide visits during the weeks of: 02/02/26 to 02/07/26 no aide visits were conducted (two visits ordered, no visit conducted). 02/08/26 to 02/12/26 no aide visits were conducted (two visits ordered, no visit conducted). The clinical record showed no patient refusal of visit, physician notification or change in orders. On 03/13/26 at 11:00 a.m., Staff A stated: 1.Aide visits should not have been included on the POC. 2.No aide visits were conducted.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of QAPI records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2024 and 2025. On 03/13/26 at 11:20 a.m., Staff A stated: 1.The agency provided PT and OT services to patients in 2024 and 2025. 2.The QAPI meetings in 2024 and 2025 had no PT or OT participation.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure SN visit notes showed interventions and patient response to wound care for one (Patient #4) of nine patients. Findings: Patient #4 A review of a POC dated 01/31/26 to 03/31/26 showed orders for a SN visit frequency of two times a week for nine weeks for SN to perform wound care to the sacrum of cleanse with normal saline, apply calcium alginate and Medi-honey and cover with bordered foam dressing two times a week. A review of the clinical record of SN visits conducted on 02/04/26, 02/11/26, 02/18/26, 02/25/26 and on 03/03/26 showed no documentation of interventions that were performed by the nurse during the visits and showed no patient response to the interventions. On 03/13/26 at 10:10 a.m., Staff A stated the SN visit notes did not document what the nurse did and how the patient tolerated the treatments.”