Palm Valley Health Care II 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 interview the agency failed to ensure staff consistently followed infection control policies and procedures including the prevention of the spread of infectious and communicable disease related to hand hygiene, glove use, and use of barriers during home visits for 2 of 5 active Patients (Patient #2 and 3) reviewed for infection control in that: LVN A and LVN B failed to follow proper infection control procedures and policies while conducting home visits with patients #2 and #3. 1.) Missed opportunities for glove changes/proper use of PPE (gloves), performing hand hygiene, and proper use of barriers. a) LVN A failed to change gloves during wound care after removing soiled gauze bandage to left and right foot, moving from one wound site to another, after cleansing a wound, before applying ointment. b) LVN A failed to place a barrier between her nursing bag flap and used contaminated supplies thus contaminating the nursing bag. c) LVN A failed to place a barrier for her clean wound care supplies. d) LVN B failed to change gloves and perform proper hand hygiene during wound care. This deficient practice could place Patients #2 and #3, as well as other active patients, at risk for cross-contamination, increased infections, and potential worsening of their conditions and comorbidities (medical conditions that coexist along with primary diagnosis). The findings included: Record review of the Agency’s policy manual contained a policy titled, “Infection Prevention and Control Plan 2025”, with a revision date of 01/12/25, quoted in part, “The Infection Control and Prevention Program is established to reduce the possibility of acquiring and spreading an infection…The agency maintains an infection control program for the surveillance, identification, prevention control, and investigation of infectious and communicable diseases. Infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection…The agency uses evidence-based national guidelines or, in the absence of such guidelines…review of healthcare literature…Elderly patient population, by nature of their age, diagnosis, or treatments ordered is a increased risk to develop…infections…Patients with diabetes (affects how the body uses sugar) have an increased risk of skin and soft tissue infections due to neuropathy (damage to the nerves outside the brain and spinal cord)…hyperglycemia (high blood sugar)…Statement of goals of the IC program…limiting the spread of infections associated with procedures…Limiting the spread of infection associated with the use of medical equipment, device, supplies, 100% compliance with cleaning supplies, devices, and equipment. Limiting unprotected exposure to pathogens/100% compliance with use of PPE…improving compliance with CDC hand hygiene…compliance with local, state, and federal laws and regulation governing infection prevention and control…staff will follow hand hygiene procedures/standard precaution…staff will utilize PPE appropriately to decrease risk of acquisition and transmission of HAIs. Staff will be educated on proper use including donning and removing PPE and expectations of PPE…all staff including clinical and non-clinical will have responsibilities for preventing and controlling infections…” Record review of the Agency’s policy manual contained a policy titled, “Infection control, prevention, and infection tracking”, with a no date, quoted in part, “Agency name will maintain and document and infection control program and follow accepted standards of practice, including the use of standard precaution to prevent the transmission of infection and communicable diseases…The program will coordinate among staff to ensure surveillance, identification, prevention, control, and investigation of all infections...” Record review of the Agency’s policy manual contained a policy titled, “Personal Protective Equipment (PPE)”, with no date, quoted in part, “The appropriate use and disposal of PPE is essential for the health and safety of agency name, staff, and patients. PPE will ensure the wearer will not spread infection or illness if the wearer comes into contact with potentially infectious…fluids…PPE is also used to help prevent the wearer from transferring microorganisms that could harm vulnerable patients, such as those with co-morbidities and/or weakened immune system. PPE is the most important overall infection control strategies…Procedure…Gloves will be worn by staff when contamination might occur and should and should never be worn for more than one patient/procedure/and/or area….Prior to putting on gloves hands should be preferably washed with antibacterial soap and/or equal to, or hand sanitizer…gloves are to be removed promptly after use, before touching non contaminated/clean areas/items/environmental surface, or other persons (including yourself). Gloves should not be worn to handle or write on charts, tablets, or to touch any other communal, clean surfaces…NOTE: GLOVES ARE NOT A SUBSTITUTE FOR EMPLYING GOOD HAND HYGEINE…wash hand or use alcohol-based hand sanitizer immediately after removing gloves and PPE…” Record review of the Agency’s policy manual contained a policy titled, “bloodborne pathogens”, with a no date, quoted in part, “Agency name will minimize the occupational exposure to bloodborne pathogens…It is standard operating procedure for all employees…to adhere to the following precautions…Gloves should be worn when handling blood-soiled items…as well as surfaces, material and objects exposed to them…hands should be washed after removing…gloves… Record review of the Agency’s policy manual contained a policy titled, “Skilled Nursing Services” with no date, quoted in part, “Agency name has adopted, Clinical Nursing Skills and Techniques (11th edition), Perry Potter-Ostendorf-LaPlante: Prentice Hall addition as well as Home Health Agency Clinical Manual by Elsevier products on Evolve…” Record review of the Agency’s policy manual contained a policy titled, “Clinical Nursing Skills and Techniques (11th edition),” published in 2025, quoted in part, “Infection Control…Basic infection control techniques, called standard precautions, are the evidence-based approaches that apply in the care of all patients…These techniques reduce the spread of infection….Hand hygiene and clean gloving are two of the most common medically aseptic skills you will perform…This is done by breaking the links in the chain of infection…Medical Asepsis…Practice standards…CDC…WHO…Hand hygiene is the most important and basic technique in preventing and controlling transmission of infection…Skills Hand hygiene…before and after having direct contact with patients, before and after direct contact with a patient’s intact skin (e.g., when taking pulse or blood pressures)…before clean/aseptic procedure…after contact with…wounds…when moving from a contaminated body site to a clean body site during patient care…after removing gloves…” Record review of the Agency’s policy manual contained a policy titled, “Clinical Nursing Skills and Techniques (11th edition),” published in 2025, quoted in part, “Dressing…applying dressings…perform hand hygiene and apply clean gloves. Assess condition of skin around wound and existing dressing…remove and dispose of gloves and perform hand hygiene…organize and set up any equipment needed…place biohazard bag within reach…Perform hand hygiene and apply clean gloves…with gloved hand remove dressing…dispose of gloves and soiled dressing…perform hand hygiene…apply clean gloves…cleanse from least to most contaminated area…use sterile gauze to blot wound bed…apply antiseptic ointment…dispose of gloves…perform hand hygiene…apply dressing (see agency policy)…” 1. Review of Patient #2 “Home Health certification and plan of care” documented a 82-year-old geriatric (older adult population aged 65 or older) male with primary diagnosis of Unspecified open wound, left foot, Hypertensive heart and chronic kidney disease (heart conditions that arise due to chronic high blood pressures & gradual decline in kidney function), heart failure (occurs when the heart muscle is unable to pump blood effectively), Type 2 Diabetes Mellitus with diabetic chronic kidney disease (condition that affects how the body used insulin and sugar), Chronic kidney disease (gradual decline in kidney function and its ability to filter waste from your blood), anemia (not having enough health red blood cells to carry oxygen to the bodies tissues), bradycardia (slow heart rate), atrial fibrillation (irregular and often rapid heart rhythm), hyperlipidemia (abnormally high levels of fat in the blood), Benign prostatic hyperplasia (enlargement of the prostate gland), dementia (decline in cognitive function that affects memory, thinking, and social abilities), and dependence on other enabling machines and devices (use of wheelchair, walker). The form also documented a start of care as 06/14/25 and a “current episode” or certification period as 08/08/25-10/06/25 with skilled nurse visits once daily for sixty days and three as needed visits. Safety: Prone to skin breakdown, Proper handling of biohazard waste, Standard Precautions/Infection control. Form titled “Wound Care XX” dated 09/18/25 documented wound care orders as follows: Left foot medial (toward midline of the body), left 2nd toe distal (away from the center of the body or point of attachment), left great toe medial, and right 2nd toe cleanse with Vashe (wound cleanser to fight bacteria and infection), pat dry, apply Santyl (helps clean wound by breaking down damaged collagen in dead tissue) and Gentamycin (used to treat skin infections susceptible to bacteria) to the wound base, and cover with dry gauze and secure with tape. An observation was made of LVN A performing wound care during a home visit with patient #2 on 09/18/25 at 8:30 am. Brief introductions were made, and consent was signed by patient #2. LVN A entered home and washed hands according to CDC guidelines. LVN A placed barrier on the kitchen table and her bag on top of barrier. LVN A removed trash bag out of bag and placed into the right side of bag. LVN A donned (put on) gloves and opened a flap extending from the right side of her bag. LVN A asked patient about any urinary, pain, and sleep issues. Patient denied any issues. LVN A grabbed the freestyle system (a continuous glucose monitoring system) from bag and placed it against patient’s left arm and received a digital reading of 116 mg/dl (milligrams per deciliter) (measures sugar levels in the blood), checked oxygen via pulse oximetry (measures oxygen saturation in the blood) with a reading of 98% room air and a 67 pulse, checked temperature on forehead at 97.7. LVN A Placed pulse oximetry, and thermometer on right flap of bag. There was No barrier placed between bag flap and used supplies, contaminated bag. LVN A Checked blood pressure (pressure of circulating blood against the walls of blood vessels) manually to right arm, blood pressure at 112/62. Assessed lungs and heart with a stethoscope (used to listen to the sounds made by the heart, lungs or intestines, as well as blood flow in arteries and veins). Placed stethoscope and blood pressure cuff on right flap with the other used supplies. Doffed (took off) gloves and placed gloves in trash bag. Hand sanitizer. Donned gloves. Grabbed scissors and cuts used/soiled gauze bandage (woven gauze dressing) off the left foot. Gauze bandage placed in trash bag. Pulled out a new gauze and placed it on top of agency folder. No barrier between clean supplies and table/agency folder. No change of gloves or use of hand sanitizer post removing used/soiled gauze bandage. LVN A opened gauze package and sprayed gauze with vashe (wound cleanser to fight bacteria and infection) cleanser. LVN A cleansed wound 2nd toe on left foot. Trashed gauze. No change of gloves or use of hand sanitizer prior to moving to next wound. LVN A cleansed outer great left toe medial (refers to being toward the midline of the body) with vashe cleanser and gauze. Placed used gauze in trash bag. Opened topical ointment (helps clean wound by breaking down damaged collagen in dead tissue) and gentamicin (used to treat skin infections susceptible to bacteria) and mixed medication with cotton tip applicator on the inside opened gauze package. LVN A placed Santyl and gentamicin on 1st cotton tip applicator and applied to 2nd left toe and then puts more mix on 2nd cotton tip applicator and placed on outer great left toe medial and left foot medial. LVN A cuts gauze and wraps 2nd left toe and secures with tape. No change of gloves or hand sanitizer while moving to next wound. Wounds should have been done separately from start to finish to prevent cross-contamination. LVN A cuts gauze and wrapped great left toe and secured with tape. Doffed gloves. Hand sanitizer. Donned gloves. Removed used/soiled gauze bandage and gauze from 2nd toe right foot, placed gauze in trash. No gloves change or use of hand sanitizer. Cleanses 2nd toe right foot with vashe cleanser, pat dried. Trash. Applied topical ointment/gentamicin mix to right toe with cotton tip applicator. Wrapped 2nd toe right foot with gauze and secured with tape. Doffed gloves. Hand sanitizer. Disinfected scissors, BP cuff. Thermometer, pulse oximetry, and stethoscope. Picked up bag and then barrier. Discarded trash and barriers. Hand sanitized. In an interview with LVN A on 09/24/25 at 10:30 am, surveyor presented the above infection control findings during home visit for patient #2 which included the following: Missed opportunities for glove changes/ Proper use of PPE (gloves), proper use of barriers, and missed opportunities for hand hygiene. LVN A agreed to these infection control findings and confirmed she is the primary nurse for patient #2 and revealed that standard precautions/infection control precautions are included in the plan of care for patient #2. LVN A was trained on infection control policies upon hire, annually, and had refreshers every few months with the agency. LVN A further confirmed her last infection control training was on 02/21/25. LVN A also confirmed that infection control precautions are to be used at every home visit and is aware of infection control policies. Surveyor asked LVN A why she did not follow infection control policies regarding, proper use of personal protective equipment, proper procedures for handwashing/hand sanitizer, and proper procedures for barriers. LVN A confirmed that she may have forgotten some steps due to her nervousness. LVN A further confirmed that it is important to follow infection control procedures to avoid spreading infection and cross-contamination to other patients and their homes. LVN A further attests that patients could be at risk for infection, sepsis, and infection could spread to the bone if infection control procedures are not followed. 2. Review of Patient # 3 “Home Health certification and plan of care” documented a 71-year-old geriatric (older adult population aged 65 or older) female with primary diagnosis of pressure ulcer of right heel stage 2 (partial-thickness skin loss and part of the skin leading to a shallow, open wound). Other diagnosis include pressure ulcer to left heel stage 2, Type II Diabetes Mellitus with hyperglycemia (blood sugar elevates to dangerous levels), Heart failure (occurs when the heart muscle is unable to pump blood effectively), Chronic kidney disease (gradual decline in kidney function and its ability to filter waste from your blood), anemia (not having enough health red blood cells to carry oxygen to the bodies tissues), Chronic respiratory failure with hypoxia (occurs when respiratory system fails to maintain adequate gas exchange leading to low oxygen levels), hyperkalemia (elevated potassium levels, affecting heart and muscles), hyperlipidemia (blood has too much fat), and hypothyroidism (thyroid gland does not produce enough hormones). The form also documented a start of care as 03/14/24 and a “current episode” or certification period as 09/05/25-11/03/25 with skilled nurse visits once a week times seven weeks, twice a week times one week, and three PRN visits. Safety: Prone to skin breakdown precaution, and standard precautions/infection control. Form titled “physician order” dated 09/10/25 documented wound care orders as follows: SN using aseptic (set of practices used in healthcare to prevent the spread of infection while maintaining a sterile environment) technique and sterile supplies to perform wound care to wound right and left heel: Cleanse with wound cleanser (cleanser used to fight bacteria and prevent infections by wounds) wound cleanser using 4x4 gauze, pat dry with 4x4 gauze, using cotton tip applicator apply topical ointment (helps clean wound by breaking down damaged collagen in dead tissue) to wound bed, cover with 4x4 gauze, wrap with gauze bandage and secure with tape daily. An observation was made of LVN B performing wound care during a home visit with patient #3 on 09/18/25 at 11:00 am. Brief introductions were made, and consent was signed by patient #3. LVN B placed three barriers 1) on couch 2) on floor 3) table. LVN B placed her nursing bag on the first barrier. Washed hands per CDC guidelines. LVN B asked about her morning blood sugar check and patient responded with 116mg/dl (milligrams per deciliter). LVN B verified with the glucometer (measures blood sugar levels) and gathered supplies. LVN B donned (put on) gloves and removed insulin pen of Tresiba (ultra-long-acting insulin that helps lower blood sugar levels), removed cap, and cleansed Tresiba with alcohol wipe. Applied needle, cleansed back of patient’s right arm and administered 70 units subcutaneously (under skin) to the back of patient’s right arm. LVN B removed needle and placed in biohazard bin located in patient’s kitchen. LVN B cleansed right lower abdomen with alcohol wipe and administered Mounjaro (helps lower blood sugars) 0.5ml subcutaneously to right lower abdomen. LVN B did not change gloves or hand sanitize in between administration injections. LVN B doffed (took off) gloves. Hand sanitized. Donned new gloves. LVN B pulled down flap from right side of her bag and removed pulse oximetry, stethoscope, BP cuff, and thermometer and placed them on 3rd barrier. LVN B assessed blood pressure (pressure of circulating blood against the walls of blood vessels) to right arm, assessed lungs, heart, and abdomen with stethoscope (used to listen to the sounds made by the heart, lungs or intestines, as well as blood flow in arteries and veins). Doffed gloves put gloves onto 2nd barrier. Donned gloves. No handwashing or use of hand sanitizer in between glove change. LVN B cleansed pulse oximetry, stethoscope, BP cuff, and thermometer and placed them on right side of nursing bag. Doffed gloves and put them onto 2nd barrier. Donned new gloves. No handwashing or use of hand sanitizer in between glove change. LVN B gathered wound care supplies and cut tape, placed supplies and tape on 3rd barrier. LVN B placed a 4th barrier under the feet of patient. LVN B used scissors to cut off kerlix (woven gauze dressing) to left foot and placed kerlix on 2nd barrier. Doffed gloves. Donned gloves. No handwashing or use of hand sanitizer in between glove change. Doffs gloves. Hand sanitizer. LVN B steps outside as she forgot to bring in anasept spray for wound care. LVN B returned. No handwashing or used of hand sanitizer before donning gloves. Donned gloves. LVN B uses a disinfectant wipe to clean anasept (cleanser used to fight bacteria and prevent infections by wounds) bottle. Opened package of gauze and sprayed gauze with anasept. LVN B cleansed left heel discarded gauze onto 2nd barrier. Pat dried with gauze. Discarded gauze onto 2nd barrier. Doffed gloves. Donned new gloves. No handwashing or use of hand sanitizer in between glove change. Applied topical ointment (helps clean wound by breaking down damaged collagen in dead tissue) to cotton-tip applicator, places CTA on 3rd barrier. Doffed gloves. Donned new gloves. No handwashing or use of hand sanitizer in between glove change. Applied CTA with Santyl to wound bed of left heel, covered with gauze, wraps left foot with kerlix, and secured with tape. Discarded trash onto 2nd barrier. Cleansed scissors with disinfectant wipe. No glove change or use of hand sanitizer after completing wound care to left heel. LVN B proceeds to cut off gauze bandage to right heel, no glove change or use of hand sanitizer, sprayed gauze with cleanser, cleansed right heel, discarded gauze onto 2nd barrier, applied CTA with topical ointment to right heel, discarded CTA, covered with gauze, wrapped with gauze bandage, and secured with tape. Removed barrier from under patient’s feet, placed on 2nd barrier, grabbed biohazard bag and discarded all barriers and trash in biohazard bag. Doffed gloves, trashed. Hand sanitized. Gathered clean supplies and placed them in nursing bag. Washed hands in sink according to CDC guidelines. In an interview with LVN B on 09/19/25 at 3:13 pm, surveyor presented the above infection control findings during home visits for patient #3 which included the following: Missed opportunities for glove changes/ Proper use of PPE (gloves) and missed opportunities for hand hygiene. LVN B agreed to these infection control findings. LVN B confirmed she is responsible for patient #3 and standard and infection control precautions are included in the plan of care for patient #3. LVN B further confirmed she was trained on infection control policies upon hire, every few months, and annually. LVN B also confirmed her last infection control trainings was conducted on 02/21/25. Surveyor asked why she did not follow infection control policies regarding proper procedures for hand hygiene and glove changes. LVN B stated, “It’s because it was different, and I was out of my element during the visit. I don’t see this patient often. I was nervous due to your presence. It was me wanting to make sure I did my best.” LVN B confirms that these infection control issues can affect the patient’s immunity and make them more susceptible to infections. It may also place them at higher risk for infection from cross-contamination and the patient may have a poor outcome. In an interview with the Adm, Alt Adm, DON, and Alt DON on 09/24/25 at 1:00 pm, surveyor presented the above infection control findings during home visits for patients #2, and #3 which included the following: Missed opportunities for glove changes/Proper use of PPE, proper use of barriers, and missed opportunities for hand hygiene. Adm, Alt Adm, DON, and Alt DON agreed to these infection control findings and further confirmed clinical staff were to use infection control precautions such as handwashing, use of hand sanitizer, appropriate use of PPE, and barriers at every home visit. Adm, Alt Adm, and DON revealed that staff is trained on infection control policies upon hire, every few months, and annually. Adm, Alt Adm, DON, and Alt Adm confirmed that these infection control issues can affect patients by getting infections, more complications, bigger wounds, and have a negative effect on their quality of life. Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Hand Hygiene, home care” revision date 02/19/23 contains the following in part: “Using an alcohol-based hand rub is appropriate for decontaminating the hands…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 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”. 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…. Perform hand hygiene before and after patient care; before putting on and after removing gloves; when moving from a contaminated boy site to a clean body site; after contact with inanimate objects in the patient’s environment… Change your gloves and perform hand hygiene if your gloves become damaged or heavily soiled and when moving from a contaminated to a clean site during patient care to avoid cross-contamination…” Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Personal protective equipment (PPE), putting on, home care” revised date 08/18/22 contains the following in part: Following standard and transmission-based precautions helps prevent the spread of infection from patient to patient, patient to health care worker, and health care worker to patient… Put on the gloves…Avoid touching your face and your other PPE with your gloved hands during patient care. Also limit touching other surfaces or items to those needed for direct patient care. If your gloves become damaged or heavily soiled, remove them immediately, perform hand hygiene, and put on a new pair of gloves…” Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Wound dressing application, home care” revised date 02/19/24 contains the following in part:…”Perform hand hygiene…organize the equipment and supplies on a clean surface….arrange the equipment and supplies according to the order of use to avoid cross-contamination while performing wound care…perform hand hygiene…put on gloves…remove old dressing…discard the soiled dressing…remove and discard soiled gloves…perform hand hygiene…put on gloves…clean the wound…discard soiled gauze…remove and discard your soiled gloves…perform hand hygiene…put on new gloves…pat the surrounding skin dry with gauze….apply topical treatments to the wound bed…apply prescribed dressing…secure…remove and discard gloves…perform hand hygiene…” Record review of a report from the CDC Morbidity and Mortality Weekly Report titled “Guideline for Hand Hygiene in Health-Care Settings” dated 10/25/22 (RR5116-Front Cover.p32 (cdc.gov), quoted in part, “Recommendations…1. Indications for handwashing and hand antisepsis…C. Decontaminate hands before having direct contact with patients…F. Decontaminate hands after contact with a patient’s intact skin (e.g. when taking a pulse or blood pressure and lifting a patient)…G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled…H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care… J. Decontaminate hands after removing gloves”. Review of OSHA 29 CFR 1910.1030 contains the following in part with a date of 11/03/23: “Personal protective equipment… Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin …and when handling or touching contaminated items or surfaces.” 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 09/24/25.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure patients were free of neglect for 1 of 2 discharged patients (patient #7) by agency employee (LVN B) when LVN B documented 30 units of Lantus instead of the prescribed 20 units. . This failure had the potential to place all active patients at risk of neglect by agency staff and contributed to the deterioration of the patient’s health status, which required hospitalization. Findings included: Review of Patient # 7 “Home Health certification and plan of care” with a certification period of 05/15/25-07/13/25 documented a 74-year-old geriatric (older adult population aged 65 or older) female with primary diagnosis of Type II Diabetes Mellitus with hyperglycemia (blood sugar elevates to dangerous levels). Other diagnosis included dementia (decline in cognitive function that affects memory, thinking, and social abilities), delirium (acute disturbance in attention, awareness, and cognition), long-term use of insulin (medication used for blood sugar control), weakness, malignant neoplasm of left female breast (cancerous tumor of left breast), history of falling, and acquired absence of left breast and nipple. Further review of the plan of care included medication Lantus Solostar pen (medication that lowers the sugar in the blood) 100 units/ml solution 20 units every afternoon subcutaneous. Orders for discipline and treatment included: Using aseptic technique, SN to administer Lantus Solostar pen 100 units/ml 20 units subcutaneous injection QPM as per MD orders…SN may hold Lantus upon patient request or MD request or upon discontinuation of medication. Goals: Patient’s personal healthcare goals-to keep blood sugar control and to stay out of the hospital. Other goals included: Patient will receive and tolerate Lantus Solostar pen 100 units/ml solution 20 units subcutaneous injection QPM as per MD orders throughout certification. Review on 09/18/25 at 4:00 pm of the “Agency’s complaint binder” revealed a from titled “Patient Complain Form” of a complaint made on 06/04/24 signed by ex-employee J. Complainant I revealed “Complainant I noticed that nurse was documenting 30 units of Lantus (medication that lowers the sugar in the blood) QD on the flowsheet in patient #7’s home folder since 05/31/24…No order noted in chart as to if a change in insulin (hormone that helps your body use glucose for energy and manage blood sugar levels)…Action taken: nurse switched to LVN A…Resolution/Follow-up complainant #1 satisfied with change of nurse…” Form titled “Unusual occurrence/incident report” dated 06/04/24 revealed a description of the incident “Notified by complainant #1 that she initiated EMS due to low blood sugar of 43 mg/dl, patient was conscious but not really responding (blank stare) …Complainant I noticed on the vital sign flow sheet that nurse documented 30 units of Lantus instead of 20 units. Review of this complaint dated 06/04/24 revealed that the Agency had cause to believe that LVN B committed an act of neglect against patient #7. The concern of possible neglect was not reported to the Health and Human Services Commission (HHSC) or to the Department of Family and Protective Services (DFPS) within 24 hours per agency policy. Further review attached to complaint was a medical record from hospital XY dated 06/04/24 revealed history of present illness for patient #7 had a significant past medical history of diabetes mellitus type II (medical condition in which your body doesn’t use insulin properly, resulting in unusual blood sugar levels) currently taking Lantus 20 units as per her PCP came here today for glycemia (the presence of sugar in the blood) of 46. According to complainant I who is at bedside states that the nurse from home health accidently have been giving her the last five days 30 units of Lantus. Upon further review revealed a form of written “counseling session with LVN B regarding medication error made for patient #7 through the date range of 05/31/24-06/03/24…Upon checking patients vital sign flowsheet record from complainant I noticed LVN B documented administering 30 units of Lantus throughout the above date range. When skilled nurse was questioned, she was able to verbalize the correct order of 20 units of Lantus…The purpose of this counseling is to bring to the attention the importance of proper documentation and how improper documentation can lead to medication errors. Medication errors can be harmful and potentially life-threatening. The agency works diligently on preventing medication errors and holds errors of this type with utmost severity. LVN B has been re-educated on the rights of medication administration and has been provided material on ways to prevent medication errors…” LVN B did not deny or confirm administering 30 units of Lantus instead of the prescribed 20 units on this document. On 09/18/25 at 4:15 pm, surveyor made an initial attempt to contact patient #7. Surveyor made a 2nd attempt to contact patient #7 on 09/22/25 at 8:30 am and a 3rd attempt on 9/23/25 at 4:00 pm. On all attempts telephone did not ring and went straight to voicemail that had not been set-up. Surveyor unable to leave a message. On 09/18/25 at 4:30 pm, surveyor made an initial attempt to contact complainant I. Surveyor made a 2nd attempt to contact complainant I on 09/22/25 at 8:30 am and a 3rd attempt on 9/23/25 at 4:00 pm. No answer to all 3 attempts, surveyor left messages. As of 09/29/25 complainant I nor patient #7 had attempted to contact this surveyor. Record review of LVN B’s personnel record. LVN B has a license active and unencumbered with a date of hire of 11/14/16. LVN B received trainings on ANE on the following dates: 11/14/16, 01/10/22, 01/16/23, and 01/15/24. Further review revealed a competency skills checklist on 11/4/16. In an interview with LVN B on 9/24/25 at 9:45 am, LVN B confirmed that she was responsible for patient #7 at the time of the complaint and was trained on ANE upon hire and yearly thereafter. LVN B further confirmed documenting administering 30 units of Lantus on the flowsheet and indicates it was a mistake that was done out of habit. LVN B denied administering 30 units of Lantus. LVN B revealed she was removed from patient #7 and was re-educated on medication administration and medication errors. LVN B further revealed that inaccurate documentation and medication errors can have a negative effect on patient care which can cause harm to the patient, or a patient can end up in the hospital. In an interview with the Adm, Alt Adm, DON, and Alt DON on 09/24/25 at 1:00 pm, surveyor presented the findings of neglect and patients’ rights for patient #7. The administration agreed to these findings of neglect and confirmed that the patient has the right to be free of abuse, neglect, and exploitation. Surveyor asked if the agency believed the patients right were violated. Adm, Alt Adm, and DON stated, “Yes.” DON confirmed that this could have a negative impact on the quality of care for the patient and Alt DON further confirmed that the patient could lose trust with the health care system. According to the Texas Administrative Code, Title 26, Part 1, Chapter 558, Licensing Standards for Home and Community Support Services Agencies, §558.282(f)(6) “(f) A client has the following rights: (6) A client has the right to be free from abuse, neglect, and exploitation by an agency employee, volunteer, or contractor.” Review of an agency policy manual contained a policy titled “Patient’s rights and responsibilities” with no date, quoted in part, “[Agency name] is committed to promoting and protecting the rights of [agency name] patients…the consent form contains acknowledgement that patient has received a copy of patients’ rights, agency grievance procedure…rights of the elderly…the admitting RN and agency staff will provide assistance to the patient and family as needed for understanding and exercising patient rights…involving the patient in the care planning, changing, and goal evaluation…” Review of an agency policy manual contained a policy titled “Rights of the elderly” with no date, quoted in part, “[Agency name] will implement and enforce the human resources code, chapter 102 relating to the rights of the elderly …” Review of an agency policy manual contained a policy titled “Abuse, Neglect, and Exploitation” with no date, quoted in part, “…To protect and promote a patient’s right, which include the right to be free from verbal, mental, physical or sexual abuse, neglect, and exploitation from an agency employee, contractor or volunteer… According to the human resources code, Chapter 102, Rights of the elderly…(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual…(2) has the right to be free from abuse, neglect, and exploitation…” 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 09/24/25.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on record review and interview, the agency failed to report immediately, within 24 hours to the Health and Human Services (HHSC) and Texas Department of Family and Protective Services (DFPS) of an alleged act of neglect by an agency employee (LVN B) for 1 of 2 discharged patients (patient #7) reviewed in that: The agency first received knowledge of an allegation of neglect on 06/04/24 at 10:50 am alleging patient #7 had been hospitalized on 06/04/24 due to a low blood sugar, complainant I revealed that LVN B was documenting on the flowsheet an administration of 30 units of Lantus (medication that lowers the sugar in the blood) daily since 05/31/24 instead of 20 units of Lantus daily. Failure of the agency to immediately report occurrences of possible neglect has the potential to place all the agency’s active patients at risk of alleged acts of abuse, neglect or exploitation by agency employees. The findings included: Review the “Agency’s complaint binder” of revealed a from titled “Patient Complain Form” of a complaint made on 06/04/24 signed by ex-employee J. Complainant I revealed “Complainant I noticed that nurse was documenting 30 units of Lantus (medication that lowers the sugar in the blood) QD since 05/31/24…No order noted in chart as to if a change in insulin (hormone that helps your body use glucose for energy and manage blood sugar levels)…Action taken: nurse switched to LVN A…Resolution/Follow-up complainant I satisfied with change of nurse…” Form titled “Unusual occurrence/incident report” dated 06/04/24 revealed a description of the incident “Notified by complainant I that she initiated EMS due to low blood sugar of 43 mg/dl, patient was conscious but not really responding (blank stare) …Complainant I noticed on the vital sign flow sheet that nurse documented 30 units of Lantus instead of 20 units. Review of this complaint dated 06/04/24 revealed that the Agency had cause to believe that LVN B committed an act of neglect against patient #7. The concern of possible neglect was not reported to the Health and Human Services Commission (HHSC) or to the Department of Family and Protective Services (DFPS) within 24 hours per agency policy. Further review attached to complaint was a medical record from hospital XY dated 06/04/24 revealed history of present illness for patient #7 had a significant past medical history of diabetes mellitus type II (medical condition in which your body doesn’t use insulin properly, resulting in unusual blood sugar levels) currently taking Lantus 20 units as per her PCP came here today for glycemia (the presence of sugar in the blood) of 46. According to complainant I who is at bedside states that the nurse from home health accidently have been giving her the last five days 30 units of Lantus. Upon further review revealed a form of written “counseling session with LVN B regarding medication error made for patient #7 through the date range of 05/31/24-06/03/24…Upon checking patients vital sign flowsheet record from complainant I noticed LVN B documented administering 30 units of Lantus throughout the above date range. When skilled nurse was questioned, she was able to verbalize the correct order of 20 units of Lantus…” An interview was conducted with Ex-employee J on 09/24/25 at 9:00 am, surveyor presented the above findings. Ex-employee J confirmed she was responsible for this complaint as she was the DON at the time of complaint. Ex-employee J had a last working day of 07/01/24. Surveyor asked why this complaint was not reported to HHSC within 24 hours. Ex-employee J revealed it may have been reported or it may be misfiled but was not sure. She further revealed that ex-employee K may have reported the complaint but would have to double check. Surveyor further asked how cannot reporting complaints of abuse, neglect, or exploitation affect patient care. Ex-employee J revealed it can lead to cause harm, death, and neglect to the patient. On 09/24/25 at 9:20 am surveyor reviewed TULIP to verify if this complaint was reported to HHSC within 24 hours. TULIP revealed 5 complaints and 4 incident intakes, however there were no complaint or incident intakes involving patient #7. An interview was conducted with Adm, Alt Adm, DON, and Alt DON on 09/24/25 at 1:00 pm, surveyor presented the above findings. The administration confirms that the agency is responsible for reporting to HHSC within 24 hours of a complaint of suspected ANE and agree with these findings. Administration confirmed that if the agency has cause to believe that an elderly person has been abused, neglected, or exploited it must be reported to HHSC within 24 hours. Adm, Alt Adm, and DON were unsure if it was reported to HHSC within the allotted timeframe of 24 hours. Surveyor presented the administration with the complaint binder and referred to the complaint regarding patient #7 and asked if there was an intake number or verification that this complaint was reported to HHSC within 24 hours. The administration confirmed there was not intake number or documentation attached to verify that the complaint was reported to HHSC within 24 hours. Surveyor asked why the agency did not report the complaint within 24 hours or by 09/05/24 per agency policy. Adm stated “I don’t know.” Alt Adm stated, “It might have been overlooked but I don’t know.” DON stated, “I don’t know as I was not DON at the time.” Alt DON revealed she did not know as well. The administration further confirmed that by not reporting the complaint within 24 hours it could affect the quality of care and safety of the patient. It further leaves a window for the negligence to continue and may lead to hospitalization for the patient. Review of an agency policy manual contained a policy titled “Self-Reporting Incidents of Abuse, Neglect and Exploitation” it was numbered TX.3 and had a revision date of 08/25/23, quoted in part, “If an agency has “cause to believe” abuse, neglect or exploitation of the patient has occurred by an Agency employee, representative, volunteer or contractor, information will be reported immediately, meaning within 24 hours, upon witnessing the act or upon receipt of the allegation through the HHSC complaint and Incident Intake reporting options:1. Consumer Rights and Services CRS Hotline at 1-800-458-9858 or 2. Tulip (Texas Unified Licensure Information Portal…Agency will notify appropriate authorities for any witnessed or suspected abuse, neglect, or exploitation of a patient… Department of Family and Protective Services (DFPS) at 1-800-252-5400 or through the DFPS secure website at www.txabusehotline.org...” Review of an agency policy manual contained a policy titled “Reportable conduct” with no date, quoted in part, “The administrator or the Clinical Manager/Supervising Nurse will immediately (within 24 hours) report to HHSC at 1-800-458-9858; and DFPS at 1-800-252-5400…if there is cause to believe an employee, contractor or volunteer of the agency has abused, neglected or exploited a patient at the agency…” Review of an agency policy manual contained a policy titled “Complaints” with no date, quoted in part, “It is the policy of agency name to provide competent care furnished by knowledgeable and respectful staffs that are trained on reporting complaints and findings immediately to the agency and other appropriate authorities in accordance with state law…” 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 09/24/25.”