Lifeway Healthcare Inc.

“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 interview, and record review the agency failed to ensure all medications currently used by the Patient were reviewed by a skilled professional for 2 of 3 active Patients whose records were reviewed (Patient #1, #2) in that: The agency did not perform a drug regimen review that accurately reflected all the medications Patient #1 and Patient #2 were currently taking. DON and LVN-A failed to accurately review medications for certification period from 01/10/2026-03/10/2026 for Patient #1 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included orders for anti-hypertensive medication (medication used to lower the blood pressure). DON and LVN-A failed to accurately review medications for certification period from 12/12/2025-02/09/2026 for Patient #2 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included orders for anti-convulsant medication (medication used to treat seizures, a temporary, unstoppable surge of electrical activity in your brain). This failure could place Patients at risk of not receiving medications as ordered, deterioration, failure to improve or maintain health and staff not identifying any potential adverse effects and drug reactions, or duplicate drug therapy. Patient #1 Review of active Patient #1 electronic medical record (EMR) , revealed an agency document titled “ Home Health Certification and Plan of Care” with orders for skilled nursing services with Start of Care date 07/14/2025 with current certification period from 01/10/2026-03/10/2026 with primary diagnosis of Pressure ulcer ( prolonged pressure on your skin ) of right heel, stage 2 ( an open area of the skin, with swelling, discoloration, and pain), and hypertensive chronic kidney disease ( a progressive condition characterized by kidney damage caused by long-term high blood pressure, creating a cycle that exacerbates both conditions), Gastroesophageal reflux disease (GERD reflux disease happens when stomach acid flows back up into the esophagus and causes heartburn), and Bilateral Primary Osteoarthritis of hip (a degenerative joint disease that can affect the many tissues of the joint). Further review of the POC revealed orders for skilled nursing (SN) one visit weekly, and 1-2 additional prn visits this period for reassessment. SN to teach on any new or changed diagnosis or medications or any dietary changes every visit for 9 weeks. Record review of active Patient #1 on 01/14/2026, agency document titled, “Medication Profile” dated 01/10/2026- 03/10/2026 revealed the following medications: amlodipine 10mg daily (antihypertensive medication), amiodarone 200mg daily (antihypertensive medication), hydroxyzine hydrochloride 10mg daily as needed ( antianxiety medication), levothyroxine 125UG daily (thyroid medication), acetaminophen and codeine 300mg-30mg twice daily as needed for pain, lisinopril 5mg daily (antihypertensive medication), meloxicam 15mg daily (osteoarthritis medication), pantoprazole 20mg daily ( GERD medication), and vitamin D3 50mcg daily. Review of active Patient #1 medications on hand revealed changes in 8 current medications. Patient #1 amlodipine 10mg daily did not have any on hand, acetaminophen and codeine 300mg-30mg had an expirations date of 12/2025, hydroxyzine hydrochloride 10mg had an expiration date of 10/10/2025, lisinopril 5mg daily had an expiration date of 11/2023, meloxicam 15mg had an expiration date of 04/10/2021, pantoprazole 20mg daily had an expiration date of 11/2025 and vitamin D3 50mcg was not available. Patient #1 was ordered levothyroxine 125UG and did not have any on hand but had levothyroxine 150mc on hand. The DON was the assigned skilled nurse case manager. Record review of DON personnel file on 11/02/2006 revealed a hire date of 11/02/2006. An agency document titled “Job Description Title of Position: Director of Nursing.” The document was signed by the DON dated 11/03/2025. A document was revealed titled “Verification of Orientation to Agency” was signed and dated 11/02/2006 by DON. This document read in part… “I have received an employee handbook, and I have received orientation to the agency in all the areas listed below: Agency Policies and Procedures, and Patient Care Responsibilities. An additional document signed by the DON, titled “PEER/SUPERVISOR ASSESSMENT OF SKILLED NURSING CORE COMPETENCIES” and it read in part…Required skills: Assessment of Medication regimen and noted as satisfactory performance for the DON. An agency document titled “employee Acknowledgment” read in part... Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 03/31/2027. An interview on 01/14/2026 at 11:05 am with FM #1 revealed that she was the person who assisted Patient #1 with her medications. She reported that she had given the patient all her morning medications prior to surveyor’s arrival. FM #1 stated that the SN checks medications, vital signs, and wound care with each visit. Surveyor asked were there any additional medications for the patient in the home. FM #1 replied no. FM #1 stated that she had been having trouble getting to the pharmacy and or trouble getting the medications called in to the pharmacy correctly. She stated that she had informed the DON last week on her visit with the patient. Surveyor showed the expired medications to FM #1and she said she did not know the medications were expired. An interview on 01/14/2026 at 11:15 am with the DON revealed that she was the assigned RN case manager for Patient #1 and did the recertification the prior week. The DON stated that she did check the medications and did not know that some of the medications had expired. Surveyor asked what steps she took to perform the medication reconciliation. The DON stated that she checked the medication bottles against the medication profile on hand. Surveyor asked what the agency policy was as it relates to comprehensive assessments and medication reconciliation/review. The DON stated that the skilled nurse is required at each visit to perform a comprehensive reassessment and medication reconciliation/review is part of that process. DON stated that she missed the dosage changes for levothyroxine when she checked the medications last week. Surveyor asked about the medication availability and the DON stated that she attempted to get the medications last week but was unsuccessful. DON did not provide a reason why she was unable to obtain the needed medications. Surveyor asked about the medications being expired for an extended period. The DON stated that she was unaware of the medications had expired. Surveyor asked about the potential effects on the patient taking expired medications. The DON stated that the potential for reduced efficacy, uncontrolled diseases, and potentially worsening of current conditions. DON stated that the assigned nurse should have checked the medications with each visit. However, the DON stated she is ultimately responsible for ensuring all policies and procedures are followed as the DON as well as being the Admin. Patient #2 Review of active Patient #2 electronic medical record (EMR) , revealed an agency document titled “ Home Health Certification and Plan of Care” with orders for skilled nursing services with Start of Care date 10/13/2025 with current certification period from 12/12/2025 to 02/09/2026 with primary diagnosis of chronic pain (pain that lasts for over three months), Epilepsy (a long-term (chronic) disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), and essential hypertension (abnormally high blood pressure that’s not the result of a medical condition). Further review of the POC revealed orders for skilled nursing (SN) one visit weekly, and 1-2 additional prn visits this period for reassessment. SN to teach on any new or changed diagnosis or medications or any dietary changes every visit for 8 weeks. Record review of active Patient #2 on 01/14/2026, agency document titled, “Medication Profile” dated 12/12/2025- 02/09/2026 revealed the following medication: losartan potassium 100mg daily (antihypertensive medication). Review of active Patient #2 medications on hand revealed changes in 2 current medications. Patient #2 did not have losartan 100mg available. Patient #2 also had Dilantin 300mg available. Record review of LVN A personnel file on 01/15/2026 revealed a hire date of 09/07/2023. An agency document titled “Acknowledgement of Receipt of Job Description: LVN.” The document was signed by LVN A dated 09/07/2023. A document was revealed titled “Verification of Orientation to Agency” was signed and dated 09/07/2023 by LVN A. This document read in part… “I have received an employee handbook, and I have received orientation to the agency in all the areas listed below: Agency Policies and Procedures, and Patient Care Responsibilities. An additional document signed by LVN A, titled “PEER/SUPERVISOR ASSESSMENT OF SKILLED NURSING CORE COMPETENCIES” and it read in part…Required skills: Assessment of Medication regimen and noted as satisfactory performance for LVN A. An agency document titled “Employee Acknowledgment” read in part... Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 08/31/2026. An interview on 01/14/2026 at 12:45 pm with Patient # 2 revealed that she did not require assistance with her medications. She stated that she could manage medications on her own. Patient #2 stated that no skilled nurse from the agency had asked for her medications. Patient #2 stated that the surveyor was the only person who has asked about her medications. Surveyor asked Patient#2 if she was taking the Dilantin 300mg that she had on hand and she stated that she has taken that medication almost all her life and if she doesn’t, she will have seizures. Surveyor asked about the losartan and why she was not taking that medication and she stated that when she was discharged from the hospital a few months back, she was told to stop taking that medication, so she did. An interview on 01/14/2026 at 1:05 pm with the DON revealed that she was the assigned RN case manager for Patient #2, but the primary nurse was LVN A. The DON stated that the agency policy is that the skilled nurse performs a comprehensive assessment of every patient on every visit. She continued to say that a medication reconciliation is part of a comprehensive assessment and is also part of the skilled nurse visit. The DON stated that LVN A had been trained by her on the agency policy. DON stated that she is ultimately responsible for ensuring all policies and procedures are followed as the DON as well as the Admin. An interview on 01/15/2026 at 1:33 pm with LVN A revealed that she was the primary nurse assigned to Patient #1 and Patient #2. LVN A stated that she works part time and only has a caseload of three patients. LVN A began to raise her voice and ask why she was being asked questions, and then she declined to answer any further questions. LVN A ended the interview abruptly. Review of agency’s policy undated and titled “General Medications” pg. 2 of 2, reads in part… “Purpose: To establish guidelines for the administration of medications....: Procedure: 15. Medication monitoring will be as follows: On the initial admission visit, on an ongoing basis, and at recertification, the RN will obtain a medication profile of medications (both prescription and over the counter medications and home remedies) the client is currently taking, whether administered by the Agency nurses or self-administered by client or family.” No further information was provided prior to the end of the survey.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review and interviews the agency administrator failed to ensure all day-to-day operations of the agency. The administrator did not ensure that care was provided according to a client’s needs as written in the plan of care for 2 of 3 (Patient #1, #2) active patients reviewed in that: The agency administrator did not ensure that a comprehensive assessment was performed to include a drug regimen review with each visit, that accurately reflected all the medications Patient #1 and Patient #2 was currently taking. DON and LVN-A failed to accurately review medications for certification period from 01/10/2026-03/10/2026 for Patient #1 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included orders for anti-hypertensive medication (medication used to lower the blood pressure). DON and LVN-A failed to accurately review medications for certification period from 12/12/2025-02/09/2026 for Patient #2 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included orders for anti-convulsant medication (medication used to treat seizures, a temporary, unstoppable surge of electrical activity in your brain). This failure could place Patients at risk of not receiving medications as ordered, deterioration, failure to improve or maintain health and staff not identifying any potential adverse effects and drug reactions, or duplicate drug therapy. Patient #1 Review of active Patient #1 electronic medical record (EMR) , revealed an agency document titled “ Home Health Certification and Plan of Care” with orders for skilled nursing services with Start of Care date 07/14/2025 with current certification period from 01/10/2026-03/10/2026 with primary diagnosis of Pressure ulcer ( prolonged pressure on your skin ) of right heel, stage 2 ( an open area of the skin, with swelling, discoloration, and pain), and hypertensive chronic kidney disease ( a progressive condition characterized by kidney damage caused by long-term high blood pressure, creating a cycle that exacerbates both conditions), Gastroesophageal reflux disease (GERD reflux disease happens when stomach acid flows back up into the esophagus and causes heartburn), and Bilateral Primary Osteoarthritis of hip (a degenerative joint disease that can affect the many tissues of the joint). Further review of the POC revealed orders for skilled nursing (SN) one visit weekly, and 1-2 additional prn visits this period for reassessment. SN to teach on any new or changed diagnosis or medications or any dietary changes every visit for 9 weeks. Record review of active Patient #1 on 01/14/2026, agency document titled, “Medication Profile” dated 01/10/2026- 03/10/2026 revealed the following medications: amlodipine 10mg daily (antihypertensive medication), amiodarone 200mg daily (antihypertensive medication), hydroxyzine hydrochloride 10mg daily as needed ( antianxiety medication), levothyroxine 125UG daily (thyroid medication), acetaminophen and codeine 300mg-30mg twice daily as needed for pain, lisinopril 5mg daily (antihypertensive medication), meloxicam 15mg daily (osteoarthritis medication), pantoprazole 20mg daily ( GERD medication), and vitamin D3 50mcg daily. Review of active Patient #1 medications on hand revealed changes in 8 current medications. Patient #1 amlodipine 10mg daily did not have any on hand, acetaminophen and codeine 300mg-30mg had an expirations date of 12/2025, hydroxyzine hydrochloride 10mg had an expiration date of 10/10/2025, lisinopril 5mg daily had an expiration date of 11/2023, meloxicam 15mg had an expiration date of 04/10/2021, pantoprazole 20mg daily had an expiration date of 11/2025 and vitamin D3 50mcg was not available. Patient #1 was ordered levothyroxine 125UG and did not have any on hand but had levothyroxine 150mc on hand. The DON was the assigned skilled nurse case manager. Record review of DON personnel file on 11/02/2006 revealed a hire date of 11/02/2006. An agency document titled “Job Description Title of Position: Director of Nursing.” This document read in part... Position Summary: He/she directs and supervises professional and auxiliary personnel rendering client care services… Responsibilities: 12. Directs staff in performance of their duties. 14. Oversees the implementation and evaluation of client care services inclusive of regulatory licensure and certification criteria and accreditation standards. This document was signed and dated 11/02/2006 by the Director of Nursing. A document was revealed titled “Verification of Orientation to Agency” was signed and dated 11/02/2006 by DON. This document read in part… “I have received an employee handbook, and I have received orientation to the agency in all the areas listed below: Agency Policies and Procedures, and Client Care Responsibilities. An additional document signed by the DON, titled “PEER/SUPERVISOR ASSESSMENT OF SKILLED NURSING CORE COMPETENCIES” and it read in part…Required skills: Assessment of Medication regimen and noted as satisfactory performance for the DON. An agency document titled “employee Acknowledgment” read in part... Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 03/31/2027. An interview on 01/14/2026 at 11:05 am with FM #1 revealed that she was the person who assisted Patient #1 with her medications. She reported that she had given the patient all her morning medications prior to surveyor’s arrival. FM #1 stated that the SN checks medications, vital signs, and wound care with each visit. Surveyor asked were there any additional medications for the patient in the home. FM #1 replied no. FM #1 stated that she had been having trouble getting to the pharmacy and or trouble getting the medications called in to the pharmacy correctly. She stated that she had informed the DON last week on her visit with the patient. Surveyor showed the expired medications to FM #1and she said she did not know the medications were expired. An interview on 01/14/2026 at 11:15 am with the DON revealed that she was the assigned RN case manager for Patient #1 and did the recertification the prior week. The DON stated that she did check the medications and did not know that some of the medications had expired. Surveyor asked what steps she took to perform the medication reconciliation. The DON stated that she checked the medication bottles against the medication profile on hand. Surveyor asked what the agency policy was as it relates to comprehensive assessments and medication reconciliation/review. The DON stated that the skilled nurse is required at each visit to perform a comprehensive reassessment and medication reconciliation/review is part of that process. DON stated that she missed the dosage changes for levothyroxine when she checked the medications last week. Surveyor asked about the medication availability and the DON stated that she attempted to get the medications last week but was unsuccessful. DON did not provide a reason why she was unable to obtain the needed medications. Surveyor asked about the medications being expired for an extended period. The DON stated that she was unaware of the medications had expired. Surveyor asked about the potential effects on the patient taking expired medications. The DON stated that the potential for reduced efficacy, uncontrolled diseases, and potentially worsening of current conditions. DON stated that the assigned nurse should have checked the medications with each visit. However, the DON stated she is ultimately responsible for ensuring all policies and procedures are followed as the DON as well as being the Admin. Patient #2 Review of active Patient #2 electronic medical record (EMR) , revealed an agency document titled “ Home Health Certification and Plan of Care” with orders for skilled nursing services with Start of Care date 10/13/2025 with current certification period from 12/12/2025 to 02/09/2026 with primary diagnosis of chronic pain (pain that lasts for over three months), Epilepsy (a long-term (chronic) disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), and essential hypertension (abnormally high blood pressure that’s not the result of a medical condition). Further review of the POC revealed orders for skilled nursing (SN) one visit weekly, and 1-2 additional prn visits this period for reassessment. SN to teach on any new or changed diagnosis or medications or any dietary changes every visit for 8 weeks. Record review of active Patient #1 on 01/14/2026, agency document titled, “Medication Profile” dated 12/12/2025- 02/09/2026 revealed the following medication: losartan potassium 100mg daily (antihypertensive medication). Review of active Patient #2 medications on hand revealed changes in 2 current medications. Patient #2 did not have losartan 100mg available. Patient #2 also had Dilantin 300mg available. Record review of LVN A personnel file on 01/15/2026 revealed a hire date of 09/07/2023. An agency document titled “Acknowledgement of Receipt of Job Description: LVN.” The document was signed by LVN A dated 09/07/2023. A document was revealed titled “Verification of Orientation to Agency” was signed and dated 09/07/2023 by LVN A. This document read in part… “I have received an employee handbook, and I have received orientation to the agency in all the areas listed below: Agency Policies and Procedures, and Patient Care Responsibilities. An additional document signed by LVN A, titled “PEER/SUPERVISOR ASSESSMENT OF SKILLED NURSING CORE COMPETENCIES” and it read in part…Required skills: Assessment of Medication regimen and noted as satisfactory performance for LVN A. An agency document titled “Employee Acknowledgment” read in part... Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 08/31/2026. An interview on 01/14/2026 at 12:45 pm with Patient # 2 revealed that she did not require assistance with her medications. She stated that she can manage medications on her own. Patient #2 stated that no skilled nurse from the agency had asked for her medications. Patient #2 stated that the surveyor was the only person who has asked about her medications. Surveyor asked patient#2 if she was taking the Dilantin 300mg that she had on hand and she stated that she has taken that medication almost all her life and if she doesn’t, she will have seizures. Surveyor asked about the losartan and why she was not taking that medication and she stated that when she was discharged from the hospital a few months back she was told to stop taking that medication, so she did. An interview on 01/14/2026 at 1:05 pm with the DON revealed that she was the assigned RN case manager for Patient #2, but the primary nurse was LVN A. The DON stated that the agency policy is that the skilled nurse performs a comprehensive assessment of every patient on every visit. She continued to say that a medication reconciliation is part of a comprehensive assessment and is also part of the skilled nurse visit. The DON stated that LVN A had been trained by her on the agency policy. DON stated that she is ultimately responsible for ensuring all policies and procedures are followed as the DON as well as the Admin. An interview on 01/15/2026 at 1:33 pm with LVN A revealed that she was the primary nurse assigned to Patient #1 and Patient #2. LVN A stated that she works part time and only has a caseload of three patients. LVN A began to raise her voice and ask why is she being asked questions and then she declined to answer any further questions. LVN A ended the interview abruptly. Review of agency’s job description for an Administrator and Alternate Administrator, reads in part… Job duties and Responsibilities: Supervises total operation of the Agency. The Administrator is responsible for overall administration and management of the Agency. This document was signed and dated 11/02/2006 by the Administrator. Review of agency’s document titled job for a Director of Nursing, reads in part… Position Summary: He/she directs and supervises professional and auxiliary personnel rendering client care services… Responsibilities: 12. Directs staff in performance of their duties. 14. Oversees the implementation and evaluation of client care services inclusive of regulatory licensure and certification criteria and accreditation standards. This document was signed and dated 11/02/2006 by the Director of Nursing. Review of agency’s policy undated and titled “General Medications” pg. 2 of 2, reads in part… “Purpose: To establish guidelines for the administration of medications....: Procedure: 15. Medication monitoring will be as follows: On the initial admission visit, on an ongoing basis, and at recertification, the RN will obtain a medication profile of medications (both prescription and over the counter medications and home remedies) the Patient is currently taking, whether administered by the Agency nurses or self-administered by Patient or family.” No further information was provided prior to the end of the survey.”