VNA Health System

“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 a review of policies, clinical records (CR), observation, and staff interview the agency failed to ensure that treatments were provided as ordered by a physician for one (1) of two (2) CR’s reviewed requiring wound care (CR#5) Review of policy and procedure for verbal and telephone orders on 1/8/25 at 9:00 AM states, “17. The medical record should reflect a clear picture of the care/services provided...the medical record is composed of...physical assessments/reassessments, observations and responses to care...physicians orders. The progress notes should reflect the problem(s) or symptom(s) being treated, procedures performed, other interventions, patient outcomes in response to treatment...plan for next visit (including follow-up and monitoring), physician communication and content...when changes in plan of care occur, reason for change in plan of care. All documentation should correlate to the patient’s care plan.” Review of medical records on 1/7/26 PM at approximately 10:00 AM revealed the following: CR5: Start of Care 12/10/25, certification period 12/10/25-2/7/25. Primary diagnosis: Venous Insufficiency (poor blood flow). The physician ordered plan of care dated 12/10/25 required skilled nursing (SN) to be provided one (1) to two (2) times a week for 9 weeks. Skilled nursing was to assess, teach, manage, and perform wound care to (wound 1) the right posterior leg stasis ulcer (Wound 1, a slow-healing leg sore caused by venous insufficiency where blood pools in the legs, increasing pressure, leaking fluid, and damaging skin tissue), cleanse with antibacterial soap and water, apply ammonium acitate peri wound, place calcium alginate with silver onto wound bed, cover with a DSD (dry sterile dressing) secure with gauze wrap, apply tubi grip, and top with two (2) ace wraps daily. CR5’s caregiver to complete the days SN not in. On 12/15/25, CR5’s physician reviewed orders from the 12/12/25 wound visit, ordered that the SN continue the same wound care, and increased the SN visits to one (1) to three (3) times a week until the end of the current certification period as CR5 no longer requires weekly wound clinic appointments. On 12/26/25, M\CR5’s physician discontinued the prior wound care and ordered SN to cleanse the right lower extremity (RLE) wound with antibacterial soap and water, apply ammonium lactate or Vaseline to the entire foot and leg (excluding the wound), apply oil of emulsion gauze to the open wound, cover with a DSD, and secure with gauze wrap three (3) times per week. CR5 was to apply a single layer of tubi grip and ace wrap in the morning to both legs (bilateral lower extremities, BLLE) and remove at night (HS) from the base of the toes to below the knee. Review of CR5’s SN visits and treatment documentation revealed the following: On 12/15/25, 12/17/25, and 12/19/25, SN applied ammonium lactate to CR5’s RLE posterior wound (Wound 1), not ammonium acetate as ordered. On 12/22/25, SN identified that CR5 had the following new BLLE wounds: Wound 2: On the anterior (front) proximal (upper) shin of the RLE, a stasis ulcer measuring 2 centimeters (cm) long (L) by 2 cm wide (W) by 0.1 cm deep (D). Wound 3: On the anterior mid-shin of the RLE, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 cm D. Wound 4: On the lateral (outside) aspect of the L ankle, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 D. Wound 5: On the lateral aspect of the L ankle, a stasis ulcer measuring 2 cm L by 22 cm W by 0.1 cm D. On 12/22/25, the SN indicated “new popped blisters noted on the BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wound covered with calcium alginate and DSD, gauze wrap, tubi (grip) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s newly identified additional BLLE wounds or documentation that the SN received new orders regarding the four (4) new wounds identified on 12/22/25. The SN completed wound treatments on the four (4) newly identified wounds without a physician’s order and utilized ammonium lactate on Wound 1, `not ammonium acetate as ordered. On 12/24/25, the SN identified that CR5 had a new, additional wound (Wound 6) located on the L anterior, proximal shin measuring 2 cm L by 2 cm W x 0.1 D. The SN documented “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and dry skin, wounds covered with calcium alginate and DSD, gauze wrap, tubi (grips) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s Wound 6 and not documentation that the SN received new orders regarding Wound 6. The SN completed wound treatments on Wounds 2, 3, 4, and, and the newly identified wound (Wound 6) without a physician’s order and utilized ammonium lactate on Wound 1, not ammonium acetate as ordered. On 12/29/25, the SN documented that Wounds 3 and 4 were resolved, however Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on the BL shin, all wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and abd (abdominal pad), gauze wrap, tubi, and ace x2.” The SN completed wound treatments on the LLE (Wounds 5 and 6) without a physician’s order. On 12/31/25, the SN documented that Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 5 and 6 without a physician’s order. On 1/2/26, the SN documented that Wound 2 was resolved, however Wounds 1, 5, and 6 continued. The SN documented that Wound 4 had re-opened, but no measurements were provided. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 4, 5 and 6 without a physician’s order. On 1/4/26, the SN documented that Wounds 2, 3, 4, and 5 were resolved, however Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order. On 1/7/26, the SN documented that Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order. Observation of CR5’s wound care during a home visit on 1/7/26 at approximately 10:15 AM confirmed continuance of both Wounds 1 and 6, with dressings noted on CR5’s BLLE upon entry to the home. Employee 7, Registered Nurse, completed BLLE dressing changes for CR5. Prior to exiting the home at approximately 10:40 AM, Employee 7 reviewed CR5’s physician orders regarding the dressing changes with the surveyor and could not located physician’s orders for CR5’s LLE dressings that were completed during the home visit. Employee 7 confirmed the BLLE wounds observed and that there were no physician orders documented for the LLE dressing(s). Interview with the Agency Director on 1/7/26 at approximately 11:30 AM confirmed the above 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 a review of policies, clinical records (CR) and staff interview the agency failed to promptly alert the physician of changes in the patient’s condition requiring the plan of care to be altered for one (1) of two (2) CR’s reviewed requiring wound care (CR#5) Review of policy and procedure for verbal and telephone orders on 1/8/25 at 9:00 AM states, “17. The medical record should reflect a clear picture of the care/services provided...the medical record is composed of...physical assessments/reassessments, observations and responses to care...physicians orders. The progress notes should reflect the problem(s) or symptom(s) being treated, procedures performed, other interventions, patient outcomes in response to treatment...plan for next visit (including follow-up and monitoring), physician communication and content...when changes in plan of care occur, reason for change in plan of care. All documentation should correlate to the patient’s care plan.” Review of clinical records on 1/7/26 at 1000 AM revealed the following: CR#5 Start of care 12/10/15 for the certification period 12/10/25-2/7/26. Primary diagnosis: Venous Insufficiency (poor blood flow). The physician ordered plan of care dated 12/10/25 required skilled nursing (SN) skilled nursing to assess, teach, manage, and perform wound care to (wound 1) the right posterior leg stasis ulcer (a slow-healing leg sore caused by venous insufficiency where blood pools in the legs, increasing pressure, leaking fluid, and damaging skin tissue), cleanse with antibacterial soap and water, apply ammonium acitate peri wound, place calcium alginate with silver onto wound bed, cover with a DSD (dry sterile dressing) secure with gauze wrap, apply tubi grip, and top with two (2) ace wraps daily. CR5’s caregiver to complete the days SN not in. On 12/22/25, SN identified that CR5 had the following new BLLE (bilateral lower extremity) wounds: Wound 2: On the anterior (front) proximal (upper) shin of the RLE, a stasis ulcer measuring 2 centimeters (cm) long (L) by 2 cm wide (W) by 0.1 cm deep (D). Wound 3: On the anterior mid-shin of the RLE, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 cm D. Wound 4: On the lateral (outside) aspect of the L ankle, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 D. Wound 5: On the lateral aspect of the L ankle, a stasis ulcer measuring 2 cm L by 22 cm W by 0.1 cm D. On 12/22/25, the SN indicated “new popped blisters noted on the BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wound covered with calcium alginate and DSD, gauze wrap, tubi (grip) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s newly identified additional BLLE wounds or documentation that the SN received new orders regarding the four (4) new wounds identified on 12/22/25. On 12/24/25, the SN identified that CR5 had a new, additional wound (Wound 6) located on the L anterior, proximal shin measuring 2 cm L by 2 cm W x 0.1 D. The SN documented “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and dry skin, wounds covered with calcium alginate and DSD, gauze wrap, tubi (grips) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s Wound 6 and no documentation that the SN received new orders regarding Wound 6. Interview with the director on 1/9/26 at approximately 11:00 AM confirmed the above 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 a review of policies, clinical records (CR) and staff interview the agency failed to provide services ordered by the physician as indicated in the plan of care for one (1) of two (2) CR’s reviewed requiring wound care (CR#5) Review of policy and procedure for verbal and telephone orders on 1/8/25 at 9:00 AM states, “17. The medical record should reflect a clear picture of the care/services provided...the medical record is composed of...physical assessments/reassessments, observations and responses to care...physicians orders. The progress notes should reflect the problem(s) or symptom(s) being treated, procedures performed, other interventions, patient outcomes in response to treatment...plan for next visit (including follow-up and monitoring), physician communication and content...when changes in plan of care occur, reason for change in plan of care. All documentation should correlate to the patient’s care plan.” Review of clinical records on 1/7/26 at 1000 AM revealed the following: CR5: Start of Care 12/10/25, certification period 12/10/25-2/7/25. Primary diagnosis: Venous Insufficiency (poor blood flow). The physician ordered plan of care (POC) dated 12/10/25 required skilled nursing (SN) to be provided one (1) to two (2) times a week for 9 weeks. Skilled nursing was to assess, teach, manage, and perform wound care to (wound 1) the right posterior leg stasis ulcer (Wound 1, a slow-healing leg sore caused by venous insufficiency where blood pools in the legs, increasing pressure, leaking fluid, and damaging skin tissue), cleanse with antibacterial soap and water, apply ammonium acitate peri wound, place calcium alginate with silver onto wound bed, cover with a DSD (dry sterile dressing) secure with gauze wrap, apply tubi grip, and top with two (2) ace wraps daily. CR5’s caregiver to complete the days SN not in. On 12/15/25, CR5’s physician reviewed orders from the 12/12/25 wound visit, ordered that the SN continue the same wound care, and increased the SN visits to one (1) to three (3) times a week until the end of the current certification period as CR5 no longer requires weekly wound clinic appointments. On 12/26/25, CR5’s physician discontinued the prior wound care and ordered SN to cleanse the right lower extremity (RLE) wound with antibacterial soap and water, apply ammonium lactate or Vaseline to the entire foot and leg (excluding the wound), apply oil of emulsion gauze to the open wound, cover with a DSD, and secure with gauze wrap three (3) times per week. CR5 was to apply a single layer of tubi grip and ace wrap in the morning to both legs (bilateral lower extremities, BLLE) and remove at night (HS) from the base of the toes to below the knee. Review of CR5’s SN visits and treatment documentation revealed the following: On 12/15/25, 12/17/25, and 12/19/25, SN applied ammonium lactate to CR5’s RLE posterior wound (Wound 1), not ammonium acetate as ordered/indicated in CR5’s POC. On 12/22/25, SN identified that CR5 had the following new BLLE wounds: Wound 2: On the anterior (front) proximal (upper) shin of the RLE, a stasis ulcer measuring 2 centimeters (cm) long (L) by 2 cm wide (W) by 0.1 cm deep (D). Wound 3: On the anterior mid-shin of the RLE, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 cm D. Wound 4: On the lateral (outside) aspect of the L ankle, a stasis ulcer measuring 2 cm L by 2 cm W by 0.1 D. Wound 5: On the lateral aspect of the L ankle, a stasis ulcer measuring 2 cm L by 22 cm W by 0.1 cm D. On 12/22/25, the SN indicated “new popped blisters noted on the BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wound covered with calcium alginate and DSD, gauze wrap, tubi (grip) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s newly identified additional BLLE wounds or documentation that the SN received new orders and/or updated CR5’s POC regarding the four (4) new wounds identified on 12/22/25. The SN completed wound treatments on the four (4) newly identified wounds without a physician’s order or what was identified in CR5’s POC and utilized ammonium lactate on Wound 1, `not ammonium acetate as ordered/indicated in CR5’s POC. On 12/24/25, the SN identified that CR5 had a new, additional wound (Wound 6) located on the L anterior, proximal shin measuring 2 cm L by 2 cm W x 0.1 D. The SN documented “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and dry skin, wounds covered with calcium alginate and DSD, gauze wrap, tubi (grips) and ace x2.” There was no documentation that the SN notified the physician and/or wound clinic of CR5’s Wound 6, update CR5’s POC, and no documentation that the SN received new orders regarding Wound 6. The SN completed wound treatments on Wounds 2, 3, 4, and, and the newly identified wound (Wound 6) without a physician’s order and utilized ammonium lactate on Wound 1, not ammonium acetate as ordered/indicated in CR5’s POC. On 12/29/25, the SN documented that Wounds 3 and 4 were resolved, however Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on the BL shin, all wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and abd (abdominal pad), gauze wrap, tubi, and ace x2.” The SN completed wound treatments on the LLE (Wounds 5 and 6) without a physician’s order or as indicated in CR5’s POC. On 12/31/25, the SN documented that Wounds 1, 2, 5, and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 5 and 6 without a physician’s order or as indicated in CR5’s POC. On 1/2/26, the SN documented that Wound 2 was resolved, however Wounds 1, 5, and 6 continued. The SN documented that Wound 4 had re-opened, but no measurements were provided. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wounds 4, 5 and 6 without a physician’s order or as indicated in CR5’s POC. On 1/4/26, the SN documented that Wounds 2, 3, 4, and 5 were resolved, however Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order or as indicated in CR5’s POC. On 1/7/26, the SN documented that Wounds 1 and 6 continued. The SN indicated “new popped blisters noted on BL shins. All wounds cleansed with antibacterial soap and water, ammonium lactate applied peri wound and on dry skin, wounds covered with oil of emulsion and ABD, gauze wrap, tubi (grips) and ace x2. The SN completed wound treatments on Wound 6 without a physician’s order or as indicated in CR5’s POC. Observation of CR5’s wound care during a home visit on 1/7/26 at approximately 10:15 AM confirmed continuance of both Wounds 1 and 6, with dressings noted on CR5’s BLLE upon entry to the home. Employee 7, Registered Nurse, completed BLLE dressing changes for CR5. Prior to exiting the home at approximately 10:40 AM, Employee 7 reviewed CR5’s physician orders and POC regarding the dressing changes with the surveyor and could not located physician’s orders for CR5’s LLE dressings that were completed during the home visit. Employee 7 confirmed the BLLE wounds observed and that there were no physician orders documented for the LLE dressing(s). Interview with the director on 1/9/26 at approximately 11:30 AM confirmed the above findings.”