St Anthonys Home Healthcare Services Inc.

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on record review, observation, and interviews the agency failed to enforce its written policy addressing infection control including the prevention of the spread of infectious and communicable disease for 2 of 6 active Patients (Patient #2 and #3) reviewed for infection control in that: LVN A failed to follow proper infection control procedures while conducting a home visit with Patient #2 and #3: 1) LVN A was observed entering the nursing bag with contaminated gloves on during visits for Patient #2 and #3, resulting in cross-contamination. 2) LVN A was observed placing the nursing bag directly on the floor in the homes of Patient #2 and #3’s, increasing the potential for contamination. 3) LVN A was observed placing used equipment into the nursing bag without proper cleaning and disinfection following the care for Patient #3. 4) LVN A failed to utilize a protective barrier for supplies during care of Patient #3. 5) LVN A did not perform appropriate glove changes when transitioning from dirty to clean wound care tasks for Patient #3. 6) LVN A failed to perform proper hand hygiene (handwashing with soap or with sanitizing hand gel) at appropriate times during care of Patient #3. 7) LVN A touched her face and glasses with contaminated gloves and continued wound care without changing gloves, resulting in cross-contamination risk for Patient #3. 8) LVN A placed a biohazard sharps container on patient’s bed during care of Patient #3, creating a contamination risk. This deficient practice placed Patient #1, Patient #3, and LVN A at risk for transmission of infectious organisms, increased infection risks, and further deterioration of the patient’s wounds and overall health status. The findings included: Record review of [Agency Name] Policy and Procedure Manual titled “Infection Control Program” with a revision date of 07/01/20, quoted in part, Purpose: To outline the policies and procedures for an infection control program which applies to patients/clients, staff, and care provided. The program improves patient/client health outcomes through risk reduction, prevention, identification, and control of infections and communicable disease in patients/clients and staff. Policy: The Agency’s Infection Control Program will be based on the following criteria…current scientific methods of surveillance and prevention or control of adverse outcomes related to infections…CDC guidelines…State guidelines…OSHA…Current federal, state, and local laws and regulations…Prevention and Control Activities…The agency will follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infection and communicable diseases…Other policies to be followed by staff to prevent, control, an improve infections include: Hand Hygiene, Cleaning and Management of Supplies and Equipment, Hazardous Material and Waste, Disposal of Dressings…Aseptic Procedure Policy…” Record review of [Agency Name] Policy and Procedure Manual titled “Hand Hygiene IC.15” with a revision date of 08/15/22, quoted in part, Purpose: To ensure patient/client care staff practice proper hand hygiene techniques and nail care to aid in the prevention and spread of infection per CDC guidelines…Policy: All Agency staff providing patient/client care will perform proper hand hygiene in accordance with CDC recommendations…Procedure:…hand hygiene…prior to initial entry into the supply bag, Immediately before touching a patient/client, before performing an aseptic task…After contact with body fluids or excretions…wound dressings…before moving from a contaminated body site to a clean body site during patient/client care, After touching a patient/client or the patient’s/client’s immediate environment…After removing gloves…” Record review of [Agency Name] Policy and Procedure Manual titled “Bag Technique IC.60” with a revision date of 11/01/20, quoted in part, “Purpose: To describe the procedure for maintaining a contaminate free home health bag and preventing cross contamination. Policy: The principles in a bag technique are developed and used to maximize the efficient use of the bag and to assure asepsis and the control of infection…Bag technique…In the patient/client home, a barrier is to be placed under the bag. Bags should never be placed on the floor…After cleansing hands, the supplies and/or equipment needed for the visit are removed from the bag…When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe, and placed on a clean surface, hands are cleansed per CDC guidelines and clean equipment is returned to the bag. Record review of [Agency Name] Policy and Procedure Manual titled “Cleaning and Management of Supplies and Equipment” with a revision date of 12/01/22, quoted in part, “Purpose: To ensure the proper cleaning and management of supplies and equipment is maintained by staff. Policy: Agency staff providing patient/client care will follow Agency procedure for the cleaning and management of supplies…and equipment according to CDC guidelines, federal/state regulations…” Record review of [Agency Name] Policy and Procedure Manual titled “Personal Protective Equipment (PPE) IC.70” with a revision date of 08/15/22, quoted in part, “Purpose: To provide guidance on protecting patient/clients and staff utilizing Personnel Protective Equipment (PPE)…Policy…Guidance for PPE use in the home…Staff will use alcohol-based hand sanitizer…before putting on and after removing PPE…” Record review of [Agency Name] Policy and Procedure Manual titled “Standards of Practice PC.10” with a revision date of 01/13/18, quoted in part, “Purpose: To provide patient/client within acceptable standards of practice by agency staff. Policy: All agency services must be provided in accordance with agency policies and procedures, current clinical practice guidelines, and accepted professional standards of practice…Procedure…Patient/Client care staff will adhere to the respective state professional practice acts, and to agency policies and procedures during patient/client visits.” Review of Patient #2 “Home Health certification and plan of care” dated 02/27/26 documented a 64-year-old female with primary diagnosis of Aftercare following joint replacement surgery. Other diagnosis include unilateral primary osteoarthritis (occurs when protective cartilage that cushions the ends of the bones wears down over time), right knee, presence of right artificial knee joint, morbid obesity (overweight), hypertension (high blood pressure), personal history of other venous thrombosis and embolism (formation of blood clots), long-term use of anticoagulants/antithrombotics/antiplatelet (medications that reduce the formation of blood clots), and history of falling. The form also documented a start of care as 02/26/26 and a “current episode” or certification period as 02/27/26 through 04/27/26 with skilled nurse visits for two times a week for two weeks and once a week for five weeks. Further review of the plan of care included Safety Measures: Standard Precautions/Infection Control. An observation was conducted of LVN A during a home visit with Patient #2 on 03/26/26 at 11:00 am. Brief introductions were made and consent signed by Patient #2. The surveyor observed the home to be clean and have safe pathways. The surveyor and LVN A entered the living room for Patient #2. Patient #2 sat in the recliner. LVN A placed protective barrier on the floor and then placed her nursing bag on the top of barrier. LVN A used hand sanitizer to cleanse her hands. LVN A and surveyor conducted a medication reconciliation with medication profile…LVN A put on gloves. LVN A proceeded to check patient #2’s temperature with the thermometer and assess her oxygen levels with the pulse oximetry (used to measure oxygen levels in the blood. LVN A reached into her nurse’s bag with contaminated gloves on and removed her stethoscope (used to listen to internal body sounds) and blood pressure cuff (used to measure blood pressure). LVN A assessed blood pressure, heart, lungs, and abdomen. LVN A further assessed bilateral (both) lower legs and post-surgical scar to right knee. LVN A removed gloves and discarded the gloves in trash can and sanitized hands. Review of personnel record for LVN A documented a date of hire as 09/28/18. Personnel record revealed an active and unencumbered license with an expiration date of 11/30/27. A job description for a Licensed Vocational Nurse described essential functions…Under the direction of the RN, participate in planning and implementing specialize procedures and duties that assist in meeting the nursing care needs of the patient in accordance with agency policies…Provide care utilizing infection control measures that protect both staff and patient. LVN A was oriented to Agency policies upon hire on 09/21/18 and on 09/26/25. LVN A was trained on infection control, standard precautions, hand hygiene, bag technique, and PPE upon hire and on 09/21/18 and 03/18/26. Further review included a “Nursing Competency Checklist” conducted upon hire and on 09/21/18 which included the following: Hand washing, wound care, wound care techniques, dressing changes, aseptic/sterile technique, bag technique, work area preparation, and standard precautions. Review of Patient #3 “Home Health certification and plan of care” dated 02/21/26 documented a 93-year-old female with primary diagnosis of Pressure ulcer of sacral region, stage 3. Other diagnosis include Alzheimer’s disease, Dementia, Diabetes Mellitus Type II, Chronic obstructive pulmonary disease, Personal history of urinary tract infections, long-term use of anticoagulants (medications that reduce the formation of blood clots), and Dependence on wheelchair. The form also documented a start of care as 04/29/25 and a “current episode” or certification period as 02/23/26 through 04/23/26 with skilled nurse visits for two times a week for nine weeks and three as needed visits. Further review of the plan of care included Safety Measures: Standard Precautions/Infection Control. An observation was conducted of LVN A during a home visit with Patient #3 on 03/27/26 at 11:00 am. Brief introductions were made and consent signed by FM AA. The surveyor observed the home to be clean and have safe pathways. The surveyor and LVN A entered the room for Patient #3 where he was observed to be lying in a supine (back) position in a hospital bed noted to be clean and awake at this time. LVN A placed his nursing bag on the floor with no protective barrier. LVN A then proceeded to place the biohazard container on top of the bed next to Patient #3 with no protective barrier. LVN A used hand sanitizer to cleanse her hands and removed stethoscope, thermometer, and blood pressure cuff. LVN A assessed Patient #3’s temperature, blood pressure and auscultated her lungs, heart and abdomen. LVN A further removed the glucometer machine from her nursing bag with her contaminated gloves donned and then places the glucometer machine on top of the bed with no protective barrier for her supplies. Furthermore, supplies were not disinfected prior to using on Patient #3. LVN A again removes lancet device from her nursing bag with contaminate gloves on. LVN A assesses blood glucose of Patient #3. LVN A removes discards lancet into biohazard sharps container. LVN A places glucometer machine and lancet device into her nursing bag without cleansing supplies. LVN A out on gloves and discarded in trash can. LVN A sanitized hands and put on gloves. LVN A removed pulse oximetry from nursing bag and assessed oxygen. LVN A and surveyor conducted a medication reconciliation with medication profile…LVN A removed gloves and discarded in trash can. LVN A sanitized hands. LVN A donned new gloves and gathered wound care supplies from Patient #3’s box. LVN A removed a biohazard bag and protective barrier from the nursing bag. LVN A proceeded to place protective barrier on the bed and set up supplies on the protective barrier. LVN A removed gloves and put on new gloves. No use of hand hygiene. LVN A cut silver alginate, opened gauze, and placed hydrogel and collagen on the inside of gauze. LVN A touched her glasses with gloves on. LVN A and FM A positioned Patient #3 into a side lying position and opened brief. LVN A opened gauze and poured Vashe onto gauze then cleansed sacral wound. LVN A discarded gauze in biohazard bag. Repeated two more times. LVN A proceeded to open cotton tip applicator and poured Vashe onto tip of applicator. LVN A cleansed inside of sacral wound with cotton tip applicator and discarded in biohazard bag. LVN A applied hydrogel/collagen mix to sacral wound. LVN A further applied Calmoseptine around periwound then placed silver alginate on top of sacral wound and further covered with border form. LVN A reapplied brief and repositioned Patient #3. LVN A discarded protective barrier into biohazard bag and removed gloves then applied hand sanitizer. Exited home with biohazard bag and discarded into outside garbage can. In an interview on 03/27/26 at 3:00 pm with LVN A, the surveyor presented the following findings during home visits for Patient #2 and #3. 1) LVN A was observed entering the nursing bag with contaminated gloves on during visits for Patient #2 and #3. 2) LVN A was observed placing the nursing bag directly on the floor in the homes of Patient #2 and #3. 3) LVN A was observed placing used equipment into the nursing bag without proper cleaning and disinfection following the care for Patient #3. 4) LVN A failed to utilize a protective barrier for supplies during care of Patient #3. 5) LVN A did not perform appropriate glove changes when transitioning from dirty to clean wound care tasks for Patient #3. 6) LVN A failed to perform proper hand hygiene at appropriate times during care of Patient #3. 7) LVN A touched her face and glasses with contaminated gloves and continued wound care without changing gloves for Patient #3. 8) LVN A placed a biohazard sharps container on patients bed during care of Patient #3. LVN A agreed with the above findings. LVN A further confirmed awareness that: infection control precautions must be used every home, hand hygiene must be performed between glove changes and before re-entering a nursing bag, use of proper PPE (gloves), protective barriers were to be used for bag and supplies, equipment should be disinfected, and bags should not be placed on the floor. LVN A further confirmed she was trained upon hire and yearly for infection control precautions by the agency. LVN A additionally confirmed that Infection Control and Standard precautions were a part of the plan of care for Patient #2 and #3. Surveyor further asked why LVN A did not follow proper infection control precautions during their home visit. LVN A stated, “I don’t know…Maybe I was nervous.” The surveyor additionally asked considering your patient’s age, diagnosis, and comorbidities how cannot using infection control precautions during a home visit affect patient care. LVN A stated, “The patients have a low immunity, and it can cause a lot of different things such as respiratory, skin, or oral infections. Also, the wound for Patient #3 can get more infected without proper infection control precautions.” In subsequent interview with DON on 03/30/26 at 12:15 pm, the surveyor presented the findings of infection control for the home visits with Patients #2 and #3. The DON confirmed the agency provided trainings to their nurses for infection control upon hire and annually. DON confirmed the agency’s infection control precautions were to be used at all times during a home visit, barriers were to be used for bag and supplies, hand hygiene should be performed when necessary, use of proper PPE, proper disinfection of equipment. DON agreed that these findings were an infection control issue. The surveyor asked why proper infection control precautions were not used for Patient #2 and #3. DON stated, “I don’t see a reason or excuse, she knows better.” The surveyor further asked considering the patient’s age, diagnosis, and comorbidities how cannot using infection control precautions during a home visit affect patient care. DON stated, “They could end up with more infections, and the wound would not heal as quickly as it could. It can definitely effect patient healing and affect the other patients diagnosis. They could cause more bacteria or infections.” Further interview with Adm conducted on 03/30/26 at 1:30 pm, the surveyor presented the findings of infection control for home visit with Patient #2 and #3. The Adm confirmed the agency provided trainings for their staff for infection control upon hire and annually. The Adm further confirmed that infection control precautions should be used in every home. Adm agreed to these infection control findings. The surveyor asked why proper infection control precautions were not used for Patient #2 and #3. Adm stated, “It could cause further infection to the patients. “The surveyor additionally asked considering your patient’s age, diagnosis, and comorbidities how by not using infection control precautions during a home visit affect patient care. Adm stated, “It could have impacted on them with a bigger problem for increased infection and the nurses need to protect our patients.” Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Hand Hygiene, home care” revision date 02/19/23 contains the following in part: “Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids…Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands aren’t visibly soiled); after removing gloves; and after contact with inanimate objects in the patient’s environment. WHO simplifies points of hand hygiene into five key moments. 1. Before touching a patient 2. Before clean/aseptic procedure 3. After body fluid exposure 4. After touching a patient 5. After touching patient surrounding…Handwashing, arms angled downward under the faucet…wet your hands and wrist with warm water, apply enough soap to cover all surfaces of your hands…work up generous lather by rubbing your hands together vigorously for at least 20 seconds…” Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Standard precautions, home care” revised date 08/18/22 contains the following in part: “The Centers for Disease Control and Prevention (CDC) developed standard precautions to protect against the transmission of infection… Standard precautions include hand hygiene, appropriate use of personal protective equipment (PPE), and proper handling of potentially contaminated items, including patient equipment, items in the environment, sharps, and specimens…. Wear gloves if you may or will come into contact with blood…body fluids… contaminated surfaces or objects…. Change your gloves and perform hand hygiene if your gloves become…soiled and when moving from a contaminated to a clean site during patient care to avoid cross-contamination. Avoid touching your face, body, and other surfaces and items not needed for direct patient care with your gloved hands to reduce the risk of transmitting infectious organisms”. Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Wound dressing application, home care” revised date 02/19/24 contains the following in part: “Organize equipment and supplies on a clean surface. Place a fluid-impermeable pad between environment and the equipment and supplies…perform hand hygiene. Put on gloves…remove old dressing…discard…remove and discard soiled gloves…perform hand hygiene…new gloves…clean wound…remove and discard soiled gloves…perform hand hygiene…put on new gloves…apply prescribed medications and cover…remove gloves…perform hand hygiene…” Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Bag technique, home care” revised date 05/19/22 contains the following in part: “Bag technique is a process used by home health workers to prevent transmission of microorganisms that may be present on the outside or the inside of the bag. Bag technique involves proper hand hygiene, placement, cleaning, maintenance, and management of equipment and supplies…Perform hand hygiene before entering the bag…never remove items from the bag wearing gloves. If supplies are needed, remove gloves, perform hand hygiene, and remove additional supplies… Using a fluid-impermeable pad as a barrier between the bag and the patient’s home demonstrates respect for the patient’s property and health by reducing the risk of contamination…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to the surveyor upon exit on 03/30/26.”

“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 observation, record review and interview, the agency failed to ensure the patient’s medication list were updated to assure that all the drugs were indicated to identify ineffective drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy for 3 of 6 active Patients (#1, #2, and #3) whose records were reviewed. This failure placed the agency’s patients at risk for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Findings: Review of Patient #1 “Home Health certification and plan of care” dated 11/29/24 documented an 88-year-old female with primary diagnosis of hypertension heart and kidney disease (blood pressure remains elevated over time impacting the heart and kidneys). Other diagnosis include Congestive heart failure (heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts), Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), Depression (persistent feeling of sadness and loss of interest), Hyperlipidemia (high levels of fats in the blood), Felty’s syndrome (triad of arthritis, enlarged spleen, and low neutrophil, leading to increased infection risk), Gastro-esophageal reflux disease (stomach acid flows back into esophagus), Peripheral vascular disease (plaque build-up inside artery walls, reducing blood flow), Iron deficiency anemia (body lacks sufficient iron), restless leg syndrome, pain in left shoulder, Glaucoma (eye disease that damage the optic nerve), Acute pharyngitis (inflammation of the pharynx), history of falls/Urinary Tract Infections, and Long term use of antithrombotics/antiplatelets (medications that reduce the formation of blood clots ). The clinical record documented a start of care date as 11/29/24 and a “current episode” or certification period as 03/24/26 through 05/22/26 with skilled nurse visits for once-a-week times nine weeks. The plan of care included orders for skilled nursing to assess medication compliance at each visit. Review of Patient #1’s medication profile for 03/24/26 through 05/22/26 further revealed medications listed as the following: • Azithromycin (medication that fights bacteria and infections) 250mg by mouth 2 tablets for one day then 1 tablet daily x4 days. (completed) • Omeprazole (medication used to treat excess stomach acid) 20 mg 1 tablet two times a day. • Metoprolol Succinate ER (medication used to treat high blood pressure) 25mg 1 tablet by mouth two times a day. • Pramipexole Dihydrochloride (medication used for Parkinson’s disease to reduce tremors, stiffness, muscle spasms, and poor motor control) 0.125 mg 1 tablet by mouth two times a day. • Losartan Potassium (medication used to treat high blood pressure) 50mg 1 tablet by mouth daily. • Donepezil (medications used to improve memory, attention, and daily functioning) 5mg 2 tablets to equal 10mg by mouth daily. • Xalatan Ophthalmic (medication used to lower pressure in the eyes) 0.005% one drop to each eye every evening. • Memantine (medication used to improve memory, attention, reasoning, and ability to perform daily activities) 10mg 1 tablet by mouth twice a day. • Clopidogrel Bisulfate (medication used to reduce blood clots) 75mg 1 tablet by mouth daily. • Furosemide (medication used to treat fluid retention and high blood pressure) 40mg 1 tablet by mouth daily. • Ferrous Sulfate (medication is an iron supplement) 325mg 1 tablet by mouth daily. • Loratadine (medication used to treat allergies) 10mg 1 tablet by mouth daily. • Levothyroxine (medication that replaces or provides thyroid hormone support) 25mcg 1 tablet by mouth daily x90 days. • Leflunomide (medication used to treat arthritis and reduce inflammation) 10mg 1 tablet by mouth daily. • Atorvastatin (medication used to lower cholesterol and fat levels in the blood) 40mg 1 tablet by mouth daily. • Sertraline (medication used for depression) 50mg 1 tablet by mouth daily. • Pregabalin (medication used to calm overactive nerves in the nervous system) 50mg 1 capsule by mouth in the evening. An observation was conducted of LVN B during a home visit with Patient #1 on 03/27/26 at 10:00 am. FM BB provided LVN B and the surveyor with Patient #1 medication bag. The surveyor conducted a medication reconciliation with LVN B. Medication bag included Pantoprazole 40mg 1 tablet by mouth before meals, Pramipexole Dihydrochloride 0.5mg with a dispensed date of 09/17/25, Furosemide 20mg 1 tablet by mouth daily as needed with a dispensed date of 06/06/25, Cyproheptadine (medication used to stimulate appetite) 4mg 1 tablet by mouth twice a day with a dispensed date of 03/19/26, and Tacrolimus ointment (medication used to treat moderate to severe eczema) 0.1% apply to affected area once a day with a dispense date of 02/18/26. Further documentation revealed a progress note dated 02/03/26 from MD CC and faxed to agency on 02/17/26 with listed current medications as the following: Atorvastatin 40mg 1 tablet by mouth daily, Clopidogrel Bisulfate 75mg 1 tablet by mouth daily for 90 days, Donepezil 10mg by mouth daily, Fluticasone Propionate (nasal spray used to treat allergies and reduce inflammation) 50mcg 1 spray in each nostril once daily, Furosemide 20mg 1 tablet by mouth daily, Ferrous Sulfate 325mg 1 tablet by mouth daily, Latanoprost 0.005% one drop to each eye every evening, Leflunomide 10mg 1 tablet by mouth daily, Levothyroxine 25mcg 1 tablet by mouth daily x90 days, Loratadine10mg 1 tablet by mouth daily, Losartan Potassium 50mg 1 tablet by mouth daily, Memantine 10mg 1 tablet by mouth twice a day, Mupirocin 2% ointment 1 application twice a day, Omeprazole20 mg 1 tablet before morning meal once daily, Pramipexole Dihydrochloride 0.5 mg 1 tablet by mouth two times a day, Pregabalin 50mg 1 capsule by mouth in the evening, and Sertraline 50mg 1 tablet by mouth daily. Discontinued medications: Azithromycin (medication for bacterial infections), Cyproheptadine 4mg, Dextromethorphan (medication is a cough suppressant), Oseltamivir (medication used to treat and prevent the flu), and Tessalon Perles (medication used to relieve coughs). Review of Patient #1’s medication profile revealed discrepancies between the documented medication list, medications observed in the home, MD progress notes, and medications listed in the plan of care. Patient #1’s clinical record did not include documented evidence that LVN A, RN I, and DON updated the Patient Medication Profile for certification period 03/24/26 through 05/22/26. Observation revealed additional medications present in the home that were not reflected in the medication profile which included: Pantoprazole 40mg 1 tablet by mouth before meals, Pramipexole Dihydrochloride 0.5mg with a dispensed date of 09/17/25, Furosemide 20mg 1 tablet by mouth as needed with a dispensed date of 06/06/25, Cyproheptadine 4mg 1 tablet by mouth twice a day with a dispensed date of 03/19/26, and Tacrolimus ointment 0.1% apply to affected area once a day with a dispense date of 02/18/26. In an interview with LVN B on 03/30/26 at 12:00 pm, the surveyor presented the above findings. LVN B confirmed he was is the primary nurse for Patient #1. LVN B further confirmed that a medication review must be conducted at every home visit and agreed that there were medication discrepancies based on the medication reconciliation conducted with the surveyor. LVN B further confirmed that the medication profile had not been updated, was incomplete and inaccurate. The surveyor asked when the last medication reconciliation for Patient #1 was conducted. LVN B stated, “Oh, my goodness, I can’t remember off the top of my head, and it’s been a few weeks to be honest with you, and I can’t pinpoint a date.” The surveyor asked why the medication profile wasn’t updated. LVN B stated, “The other family does not always provide medications if the other sibling is not available. They are not up to par with her medications and appointments. It’s no excuse though, I should review the medications at every visit.” The surveyor further asked how not updating the medication profile can affect the quality of care for patients. LVN B confirmed that it could affect their diagnosis and they could have a decline in health. Review of Patient #2 “Home Health certification and plan of care” dated 02/27/26 documented a 64-year-old female with primary diagnosis of Aftercare following joint replacement surgery. Other diagnosis include unilateral primary osteoarthritis (occurs when protective cartilage that cushions the ends of the bones wears down over time), right knee, presence of right artificial knee joint, morbid obesity (overweight), hypertension (high blood pressure), personal history of other venous thrombosis and embolism (formation of blood clots), long-term use of anticoagulants/antithrombotics/antiplatelet (medications that reduce the formation of blood clots), and history of falling. The form also documented a start of care as 02/26/26 and a “current episode” or certification period as 02/27/26 through 04/27/26 with skilled nurse visits for two times a week for two weeks and once a week for five weeks. The plan of care further included orders and treatments: SN to instruct pt/cg on new diagnoses and on new or changed medications. Review of Patient #2’s plan of care and medication profile for 02/27/26 through 04/27/26 further revealed medications listed as the following: • Prednisone 4mg (medication used to reduced inflammation). • Xarelto (medication used to help prevent or treat blood clots) 10mg 1 tablet by mouth daily. • Acetaminophen-Codeine (medication used to relief pain) 300-15mg 1 tablet by mouth every 4 hours as needed. • Amlodipine Besylate (medication used to treat high blood pressure) 5mg 1 tablet by mouth daily. An observation was conducted of LVN A during a home visit with Patient #2 on 03/26/26 at 11:00 am. Patient #2 provided LVN A and the surveyor with a Ziploc bag with medications. The surveyor conducted a medication reconciliation with LVN A. Medication bag included Turmeric (supplement medication used to reduce inflammation) 860mg once daily, Zinc (supplement medication used to increase immunity) 50mg once daily, Losartan (medication used for high blood pressure) 100mg 1 tablet once daily, Spironolactone (reduce fluid retention) 25mg 1 tablet once daily, Amlodipine Besylate (medication used to treat high blood pressure) 5mg 1 tablet once daily, Atorvastatin (medication used to lower cholesterol and fat levels) 20mg 1 tablet once daily, Vitamin C (supplement medication used to increase immunity) 500mg 1 tablet once daily, and Duloxetine (medication used for depression) 30mg 1 capsule once daily. Further documentation revealed a discharge summary dated 02/26/26 from MD CC and faxed to agency on 02/27/26 with listed unchanged medications as the following: Amlodipine Besylate 5mg 1 tablet by mouth daily, Vitamin C once daily, Aspirin 81mg once daily, Atorvastatin 20mg once daily, Duloxetine 30mg 1 capsule twice daily, Losartan 100mg 1 tablet once daily, Oxybutynin (reduces muscle spasms of the bladder and urinary tract) 5mg 1 tablet once daily as needed, Spironolactone 25mg 1 tablet twice daily, and Zinc. Review of Patient #2’s medication profile revealed discrepancies between the documented medication list, medications observed in the home, discharge summary, and medications listed in the plan of care. Patient #2’s clinical record did not include documented evidence that LVN A, RN I, and DON updated the Patient Medication Profile for certification period 02/27/26 through 04/27/26. Observation revealed additional medications present in the home that were not reflected in the medication profile which included: Turmeric 860mg once daily, Zinc 50mg once daily, Losartan 100mg 1 tablet once daily, Spironolactone 25mg 1 tablet once daily, Atorvastatin 20mg 1 tablet once daily, Vitamin C 500mg 1 tablet once daily, and Duloxetine 30mg 1 capsule once daily. Review of Patient #3 “Home Health certification and plan of care” dated 02/21/26 documented a 93-year-old female with primary diagnosis of Pressure ulcer of sacral region, stage 3 (full-thickness skin injury that extend into the subcutaneous fat but do not expose muscle, tendon, or bone). Other diagnosis include Alzheimer’s disease (disorder that affects memory, thinking, and behavior), Dementia (decline in cognitive function, affecting memory, thinking and behavior, and the ability to perform everyday activities), Diabetes Mellitus Type II (condition that affects how the body uses insulin and sugar), Chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), Personal history of urinary tract infections, long-term use of anticoagulants (medications that reduce the formation of blood clots), and Dependence on wheelchair. The form also documented a start of care as 04/29/25 and a “current episode” or certification period as 02/23/26 through 04/23/26 with skilled nurse visits for two times a week for nine weeks and three as needed visits. The plan of care further included orders and treatments: SN to instruct pt/cg on new/changed medications throughout certification period. Review of Patient #3’s plan of care and medication profile for 02/23/26 through 04/23/26 further revealed medications listed as the following: • Acetaminophen ER (medication used for pain relief) 650mg 1tablet by mouth every 6 hours as needed. • Ketoconazole external (medication used for skin infections) 2% twice a day to affected area. • Triamcinolone Acetonide External (medication used for skin infections) 0.1% twice a day. • Flagyl (medication used to treat bacterial and parasitic infections) 500mg by mouth three times a day with meals. • Calmoseptine External (medication used to protect, treat, or heal skin from wetness) 0.44-20.6% apply to each wound care. • Mupirocin External (medication used for skin infections) 2% apply to each wound care. • Vashe (medication to cleanse, irrigate, and debride wounds) Cleansing External apply to each wound care. • Hydralazine (medication used for hypertension) 10mg 1 tablet by mouth as needed if systolic >160. • Albuterol Sulfate Inhalation (medication used to relax the muscles of the airways) (2.5mg/3ml) 0.083% every 8 as needed for dyspnea (shortness of breath). • Atorvastatin Calcium (medication used to lower cholesterol and fat levels in the blood) 20mg 1 tablet by mouth every night. • Quetiapine Fumarate (medication used to regulate mood, behavior, and thought processes) 50mg 1tablet by mouth every night. • Xarelto (medication used to treat and prevent blood clots) 2.5mg 1 tablet by mouth twice a day. • Tramadol (medication used for pain relief) 50mg 1 tablet by mouth as needed. • Atorvastatin Calcium 20mg ½ tablet by mouth every night. • Nystatin (antifungal medication used to treat yeast infections) 100000 unit/gm apply to affected area twice a day. • Miralax (medication used for constipation) 17 gm/scoop in 8 ounces of liquid by mouth day. • Pantoprazole (medication used to treat excess stomach acid) 40mg 1 tablet by mouth daily. • Cetirizine (medication used to treat allergies) 10mg 1 tablet by mouth daily. • Melatonin (medication used to sleep) 10mg 1 tablet by mouth daily. • Fluticasone Propionate Nasal (medication used to treat allergy symptoms, nasal congestion reducing inflammation) 50 mcg 1 spray in each nostril daily. • Nitrostat Sublingual (medication that dilates blood vessels) 0.4 mg 1 tablet every 5 minutes-may repeat up to 3 doses. • Montelukast (medication used to treat allergies) 10mg 1 tablet daily, Aspirin 81mg 1 tablet daily. • Symbicort Inhalation (medication used to reduce inflammation in the airways) 160-4.5mcg 2 puffs two times a day. • Lexapro (medication used for depression) 5mg 1 tablet by mouth daily. • Voltaren Transdermal (medication used for pain relief) 1% apply to affected area three times a day as needed for pain. An observation was conducted of LVN A during a home visit with Patient #3 on 03/27/26 at 11:00 am. FM AA provided LVN A and the surveyor with a Ziploc bag with medications. The surveyor conducted a medication reconciliation with LVN A. This medication bag contained discrepancies of the following medications Famotidine (medication used to decrease stomach acid) 40mg twice a day dated 03/23/26, Levocetirizine (medication used to treat allergies) 5mg 1 tablet in the evening dated 03/19/26, Escitalopram (Lexapro) 10mg 1 tablet daily dated 01/292/6, Acetaminophen 500mg over the counter medication with no date, Melatonin 12mg over the counter medication with no date. Review of Patient #3’s medication profile revealed discrepancies between the documented medication list, medications observed in the home, and medications listed in the plan of care. Patient #3’s clinical record did not include documented evidence that LVN A, RN I, and DON updated the Patient Medication Profile for certification period 02/23/26 through 04/23/26. Observation revealed additional medications present in the home that were not reflected in the medication profile which included: Famotidine 40mg twice a day dated 03/23/26, Levocetirizine 5mg 1 tablet in the evening dated 03/19/26, Escitalopram (Lexapro) 10mg 1 tablet daily dated 01/29/26, Acetaminophen 500mg over the counter with no date, Melatonin 12mg over the counter with no date. In an interview with LVN A on 03/27/26 at 3:00 pm, the surveyor presented the above findings for Patient #2 and Patient #3. LVN A confirmed that LVN C is the primary nurse for Patient #2 and #3. LVN A further confirmed that a medication review must be conducted at every home visit and agreed that there were medication discrepancies that were not in the medication profile, dosages had changed, medications had been completed and discontinued based on the medication reconciliation conducted with the surveyor. LVN A further confirmed that the medication profile had not been updated, was incomplete and inaccurate. The surveyor asked when the last medication reconciliation for Patient #2 and #3 was conducted. LVN A stated, “It should have been at the last visit but I’m not sure since I’m not a regular nurse for these patients.” The surveyor asked why the medication profile wasn’t updated. LVN A stated, “I feel like some family members don’t give all the medications for the patient, I really can’t say why since I’m not the primary nurse for these patients. I’m just filling in for the nurse because she is out on leave.” The surveyor further asked how not updating the medication profile can affect the quality of care for patients. LVN A stated, “It could affect the patient having a decline in health. Patients may not know that a medication was discontinued and may still be taking it, or uneducated about the medication and its side effects.” Further interview with LVN C on 03/30/26 at 1:05 pm, the surveyor presented the above findings for Patient #2 and Patient #3. LVN C confirmed that she was the primary nurse for Patient #2 and #3. LVN C further confirmed that a medication review must be conducted at every home visit. LVN C was unable to confirm if the medication profile had not been updated, was complete and accurate. The surveyor asked when the last medication reconciliation for Patient #2 and Patient #3 was conducted. LVN C confirmed a medication reconciliation was conducted on 03/18/2026 for Patient #2 and for Patient #3 it was her last visit, she was unable to determine a date. The surveyor asked why the medication profile wasn’t updated. LVN C stated, “Patient #2 did not tell me about these medications. Patient #3’s (FM AA), the provider is always there, and I cannot review medications if FM AA is not there.” The surveyor further asked how not updating the medication profile can affect the quality of care for patients. LVN C stated, “It can have a negative effect on the quality of care for the patient, but they do not always show us all their medications. I was not aware of the other medications these patients were taking.” In an interview with the DON on 03/30/26 at 12:15 pm, the surveyor presented the above findings for Patients #1, #2, and #3. DON confirmed that LVN B is the primary nurse for Patient #1 and LVN C was the primary nurse for Patients #2 and #3. DON further confirmed that employees are trained upon hire and annually on agency policies and procedures and the policy for medication review is to be conducted at every home visit. The DON further confirmed that the medication profiles for Patients #1, #2, and #3 had not been updated, were incomplete, and inaccurate. The surveyor asked why the medication profile wasn’t updated. DON stated, “It just didn’t get done. I’m not sure.” The surveyor further asked how not updating the medication profile affects the quality of care for patients. DON stated, “It’s not following the plan of care, and the patient may not get healed and improve their health. If it was ordered by the doctor, then there’s a reason so they can get better.” Further interview with the Adm on 03/30/26 at 1:30 pm, the surveyor presented the above findings for Patients #1, #2, and #3. Adm further confirmed that employees are trained upon hire and annually on agency policies and procedures and the policy for medication should be reviewed every home visit, and on the start of care, recertification, discharge, and when there are medication changes. The Adm further confirmed that the medication profiles for Patients #1, #2, and #3 had not been updated, were incomplete, and inaccurate. The surveyor asked why the medication profile wasn’t updated. Adm stated, “I’m not sure to be honest, oversight on their part.” The surveyor further asked how not updating the medication profile affects the quality of care for patients. Adm confirmed that the Patients could have negative effects if medications are not reviewed. Record review of the Agency’s policy manual a policy titled, “TX.16 Medication List and Monitoring”, with date of 08/01/20, quoted in part, “Purpose: To outline a process for ongoing medication monitoring…Policy: Medication monitoring will include appropriate data/information to develop an accurate patient/client medication history and a current and complete medication profile…Procedure: The agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient/client…Professional clinical staff will update the medication list with any changes in the medication regimen. The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 03/30/26.”

“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, observation , and interview, the agency failed to ensure that skilled nursing (SN) services ordered by the physician in the plan of care were provided for 2 of 6 active patients (#1 and #3) whose records were reviewed. 1. Licensed Vocational Nurse (LVN) B failed to conduct weights at every visit per the plan of care for Patient #1. 2. Licensed Vocational Nurse (LVN) C failed to conduct wound care ordered by physician on the following dates: 01/08/26, 01/12/26, 01/15/26, 01/19/26, 01/22/26 for Patient #3. The failure to provide skilled nursing services as ordered by the physician and outlined in the plan of care placed the patient at risk for undetected adverse reactions to medications, delayed identification of changes in condition, potential hospitalization, and other adverse health outcomes. The findings included: Review of Patient #1 “Home Health certification and plan of care” dated 01/22/26 documented an 88-year-old female with primary diagnosis of hypertension heart and kidney disease (blood pressure remains elevated over time impacting the heart and kidneys). Other diagnosis include Congestive heart failure (heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts), Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), Depression (persistent feeling of sadness and loss of interest), Hyperlipidemia (high levels of fats in the blood), Felty’s syndrome (triad of arthritis, enlarged spleen, and low neutrophil, leading to increased infection risk), Gastro-esophageal reflux disease (stomach acid flows back into esophagus), Peripheral vascular disease (plaque build-up inside artery walls, reducing blood flow), Iron deficiency anemia (body lacks sufficient iron), restless leg syndrome, pain in left shoulder, Glaucoma (eye disease that damage the optic nerve), Acute pharyngitis (inflammation of the pharynx), history of falls/Urinary Tract Infections, and Long term use of antithrombotics/antiplatelets (medications that reduce the formation of blood clots). The form also documented a start of care as 11/29/24 and certification period as 01/23/26 through 03/23/26 with skilled nurse visits for two times a week for one week, once weekly for seven weeks and three as needed. The plan of care further included orders and treatments: • SN is to weigh patient on each visit and report to MD any weight gain of greater than 2 lbs in 24 hours or 5 lbs in one week. Additionally review of Patient #1 SN notes documented the following: • On 01/26/26 SN note signed by LVN B failed to reveal a documented weight. • On 01/29/26 SN note signed by LVN B failed to reveal a documented weight. • On 02/02/26 SN note signed by LVN B failed to reveal a documented weight. • On 02/10/26 SN note signed by LVN B failed to reveal a documented weight. • On 02/19/26 SN note signed by LVN B failed to reveal a documented weight. • On 02/23/26 SN note signed by LVN B failed to reveal a documented weight. • On 03/05/26 SN note signed by LVN B failed to reveal a documented weight. • On 03/12/26 SN note signed by LVN B failed to reveal a documented weight. Review of personnel record for LVN B documented a date of hire as 09/17/19. Personnel record revealed an active and unencumbered license with an expiration date of 10/31/26. A job description for a Licensed Vocational Nurse described essential functions…Under the direction of the RN, participate in planning and implementing specialize procedures and duties that assist in meeting the nursing care needs of the patient in accordance with agency policies…Assist the RN with carrying out the plan of care. LVN B was oriented to Agency policies upon hire on 07/29/19 and on 03/11/26. In an interview on 03/30/26 at 12:00 pm with LVN B, the surveyor presented the following findings during home visit for patient #1. 1) Failed to weigh Patient #1 on the following dates: 01/26/26, 01/29/26, 02/02/26, 02/10/26, 02/19/26, 02/23/26, 03/05/26, and 03/12/26. LVN B agreed to these findings. LVN B confirmed that he was responsible for Patient #1, and the plan of care was to be followed as outlined. LVN B further confirmed he was unaware that weights were to be conducted at every home visit. The surveyor asked why there were no weights conducted for Patient #1 as indicated in the plan of care for certification period 01/23/26 through 03/23/26. LVN B stated, “I overlooked it. That’s something that I had not noticed, and she is stable enough with the walker to do the weights but unfortunately, I did not see that in the plan of care.” The surveyor further asked how cannot conducting weights at each visit according to the plan of care affect the quality of care for Patient #1 who has a diagnosis of Congestive Heart Failure. LVN B stated, “It can have a negative effect and if she has developed more than 5 lbs she can develop complications, such as strain on her heart, develop abnormal breathing, cyanosis, and increased fluid in the lungs or in general.” Review of Patient #3 “Home Health certification and plan of care” dated 12/24/25 documented a 93-year-old female with primary diagnosis of Pressure ulcer of sacral region, stage 3 (full-thickness skin injury that extend into the subcutaneous fat but do not expose muscle, tendon, or bone). Other diagnosis include Alzheimer’s disease (disorder that affects memory, thinking, and behavior), Dementia (decline in cognitive function, affecting memory, thinking and behavior, and the ability to perform everyday activities), Diabetes Mellitus Type II (condition that affects how the body uses insulin and sugar), Chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), Personal history of urinary tract infections, long-term use of anticoagulants (medications that reduce the formation of blood clots), and Dependence on wheelchair. The form also documented a start of care as 04/29/25 and a certification period as 12/25/25 through 02/22/26 with skilled nurse visits for once a week for one week, two times a week for eight weeks, and three as needed visits. The plan of care further included orders and treatments: • Wound #1--stage 3 pressure ulcer to sacral region- using aseptic technique and sterile (procedures used to prevent the spread of harmful microorganisms and maintain an environment free from infection) supplies, SN to perform wound care as follows: cleanse wound with vashe (wound solution used to cleanse, irrigate, moisten, and debride wounds) using gauze, apply collagen powder (accelerates wound healing) only with hydrogel collagen (promotes healing for wounds), protect periwound (refers to the skin and tissue surrounding a wound) with calmoseptine (protects and heals skin irritations), apply collagen, cover with bordered foam. This is to be done every other day. Upon further review, Patient #3 record documented orders for wound care that included the following: • 12/31/25- New wound care orders changes, SN to perform wound care as follows: cleanse wound with vashe using gauze, apply collagen powder only with hydrogel collagen; protect periwound with calmoseptine, apply silver alginate, cover with bordered foam. This order was faxed and received by the agency on 01/05/26 at 6:20 pm. Furthermore, was signed by an agency employee on 01/06/26. • 01/14/26-Patient to continue with current wound care orders. This order was faxed from wound care center on 01/15/26 and received by agency on this date. Additionally, upon review SN notes documented the following: • SN notes signed and dated by LVN C: 01/08/26, 01/12/26, 01/15/26, 01/19/26, 01/22/26 documented wound care…SN performed wound care as follows: cleansed wound with Vashe method, applied collagen powder with hydrogel, protected periwound area with calmoseptine, primary dressing of collagen, secondary dressing applied bordered foam. Review of personnel record for LVN C documented a date of hire as 06/17/16. Personnel record revealed an active and unencumbered license with an expiration date of 03/31/26. A job description for a Licensed Vocational Nurse described essential functions…Under the direction of the RN, participate in planning and implementing specialize procedures and duties that assist in meeting the nursing care needs of the patient in accordance with agency policies…Assist the RN with carrying out the plan of care. LVN C was oriented to Agency policies upon hire on 06/17/16 and on 06/16/25. In an interview on 03/30/26 at 1:05 pm with LVN C, the surveyor presented the following findings during home visit for patient #3. 1) LVN C failed to conduct wound care ordered by physician on the following dates: 01/08/26, 01/12/26, 01/15/26, 01/19/26, 01/22/26 for Patient #3. LVN C confirmed that she was responsible for Patient #3, and the plan of care was to be followed as outlined. LVN C further confirmed she is unable to look at her notes, so she can’t say she agrees to these findings. The surveyor asked if she was aware of the wound care changes received by the agency on 01/06/26. LVN C stated, “Yes. The wound care specialist sees her every Wednesday, and they send the orders to the agency and then I review the notes and I go by the latest order that they have and sometimes they change the order and it was hard to keep up with the orders. So, I would do whatever orders were there. If I did document the wrong order and I can correct. They kept changing the orders and it was hard to keep up with the wound care orders.” The surveyor asked why LVN C was doing wound care for previous orders when the plan of care and updated progress notes indicated wound care had changed. LVN C stated, “The wound care center would leave the supplies, and the FM AA would tell me what the new wound care orders were. So, I know I was doing the correct wound care orders.” The surveyor stated however the nursing documentation does not reflect the correct wound care orders, why. LVN C confirmed she does not know why, and she currently doesn’t have access to her notes. The surveyor asked considering Patient #3’s age, diagnosis, and comorbidities how cannot following a plan of care for wound care affect the quality of care for this patient. LVN C states, “If you don’t follow the plan of care, the patient takes longer to heal and may get worse and not have a good outcome.” Further interview with DON on 03/30/26 at 12:15 pm. The surveyor presented the above findings for Patients #1, and #3. DON confirmed that LVN B was responsible for Patient #1 and LVN C was responsible for Patient #3. Furthermore, the DON agreed to these findings for Patient #1 and #3. The DON confirmed that the plan of care and orders should be followed at every visit. The surveyor asked why there are no weighs conducted for visit for the certification period 01/23/26 through 03/23/26. DON stated, I don’t know why he wouldn’t have done that. We also have scales available at the agency for them to take and use at the home visits.” The surveyor asked considering Patient #1’s age, diagnosis, and comorbidities how cannot following the plan of care and physician orders affect the quality of care for this patient. DON stated, “The patient could have fluid retention, and it may not be treated, and we weigh the patient so the doctor could adjust their medications to relieve the fluid retention. They may have shortness of breath due to fluid retention.” The surveyor asked why the plan of care and new wound care orders not followed for Patient #3. DON confirmed she does not know. The surveyor further asked considering Patient #3’s age, diagnosis, and comorbidities how cannot following wound care orders affect the quality of care for this patient. DON stated, “It could affect the patients healing and that’s why the patient is having weekly wound care changes, and it can hinder the healing process.” Additional interview with the Adm on 03/30/26 at 1:30 pm 02/23/26 at 11:00 am. The surveyor presented the above findings for Patients #1, and #3. Adm confirmed that LVN B was responsible for Patient #1 and LVN C was responsible for Patient #3. Furthermore, the Adm agreed to these findings. Adm confirmed that staff was to follow the plan of care and orders. The surveyor asked why there are no weighs conducted for visit for the certification period 01/23/26 through 03/23/26. Adm stated, “I don’t know why this happened. We have quality assurance to audit, and we have a 100% on all our nursing notes.” The surveyor asked considering Patient #1’s age, diagnosis, and comorbidities how cannot following the plan of care and physician orders affect the quality of care for this patient. Adm stated, “It could exacerbate their condition.” The surveyor asked why the plan of care and new wound care orders not followed for Patient #3. The Adm confirmed she did not know why. The surveyor further asked considering Patient #3’s age, diagnosis, and comorbidities how cannot following wound care orders affect the quality of care for this patient. Adm stated, “It would impede the wound care healing process.” Record review of [Agency Name] Policy and Procedure Manual titled “Implementing care and treatment” with a revision date of 08/01/20, quoted in part, “Purpose: To ensure patient care and treatment are provided as identified in the care planning process.” Record review of [Agency Name] Policy and Procedure Manual titled “TX.5 Orders for care” with a revision date of 11/01/20, quoted in part, “Purpose: to ensure patient care is provided in accordance with a physician and/or non-physician practitioner order and federal and state laws and regulations…Policy: Agency will obtain orders and provide care in accordance with physician and/or non-physician practitioner orders…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to the surveyor upon exit on 03/30/26.”