Horizon Home Health (Horizon Pediatric Home Care)

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview and record review it was determined that the home health agency (HHA) failed to ensure each patient’s comprehensive assessment was updated every 60 days or, within 48 hours of a patient’s return following a hospital admission, and the updates included a medication review. The HHA failed to ensure that all patient medications were reviewed every 60 days as part of the comprehensive assessment. (Refer to tag G536) The HHA failed to ensure that each patient’s comprehensive assessment was updated no less frequently than the last 5 days of every 60 days. (Refer to tag G546) The HHA failed to ensure that all patients had an updated assessment within 48 hours of the patient’s return from a hospital admission. (Refer to tag G548)”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to provide care planning, coordination of services, and quality of care as required. Findings include: The HHA failed to ensure each patient’s plan of care (POC) contained all the required elements. (Refer to tag G574) The HHA failed to ensure that all services and treatments were administered only as ordered by a physician. (Refer to tag G580) The HHA failed to ensure that POCs were reviewed and revised by the physician as frequently as the patient’s condition or needs required, but no less frequently than once every 60 days. (Refer to tag G588)”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to assume full legal authority and responsibility for the governance and operation of the agency. Findings include: The HHA failed to ensure each patient’s comprehensive assessment was updated every 60 days or, within 48 hours of a patient’s return following a hospital admission, and the updates included a medication review. (Refer to tag G510) The HHA failed to provide care planning, coordination of services, and quality of care as required. (Refer to tag G570) The HHA failed to ensure the quality assessment and performance improvement program included tracking and analysis of quality indicators. (Refer to tag G642) The HHA failed to ensure infection control education was provided to agency employees. (Refer to tag G686) The HHA failed to ensure skills competency training was completed for their employees. (Refer to tag G952) The HHA failed to ensure discharge and/or transfer summaries were completed for patients who had been discharged or transferred. (Refer to tag G1022) The HHA failed to ensure individual emergency plans were developed for patients. (Refer to tag E0017) The HHA failed to provide training in emergency preparedness policies and procedures to new and existing staff. (Refer to tag E0036)”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure individual emergency preparedness plans (IEPs) were developed for patients during a natural or man-made disaster or emergency. Specifically, the HHA did not provide evidence of IEPs for each patient as part of the comprehensive assessment for 7 of 7 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, and 7.) Findings Include: Surveyors reviewed the medical records of patients 1, 2, 3, 4, 5, 6, and 7 from April 6, 2026, through April 15, 2026. IEPs could not be located in any of the 7 patients’ medical records. On April 8, 2026, at 1:30 PM, an interview was conducted with the director of nursing (DON). The DON stated they did not develop individualized emergency preparedness plans for their patients.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure that personnel received training in its emergency preparedness policies and procedures. Specifically, training was not provided to 5 of 5 sampled personnel. (Personnel identifiers: 2, 3, 4, 5, and 6.) Findings include: Surveyors requested the agency’s staff training documentation for emergency preparedness policies and procedures on April 7, 2026. The agency was unable to provide this documentation for 5 of 5 requested employees: employees 2, 3, 4, 5, and 6. Surveyors interviewed the director of nursing (DON) on April 14, 2026 at 10:19 AM. The DON confirmed that the home health agency had not completed initial competency or in-service training for any employees on the personnel roster for emergency preparedness.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure the quality assessment and performance improvement (QAPI) program included tracking and analysis of quality indicators. Findings include: During entrance on April 7, 2026, surveyors requested the agency’s QAPI program including the tracking and analysis of quality indicators. The agency was unable to provide the requested documentation. Surveyors interviewed the administrator (ADM) on April 13, 2026, at 9:26 AM. The ADM stated they track their performance improvement projects “informally” and discuss them in their weekly meetings but they do not document the data.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure that infection control education was provided to staff. Specifically, education was not provided to 5 of 5 sampled personnel. (Personnel identifiers: 2, 3, 4, 5, and 6.) The surveyor requested employee files for infection prevention training on April 7, 2026. The agency was unable to provide the requested documentation. Surveyors interviewed the director of nursing (DON) on April 14, 2026, at 10:19 AM. She stated that the HHA did not have any initial competency training or in-service training completed for any of the sampled personnel for infection prevention.”

“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, it was determined that the home health agency (HHA) did not ensure that all patient medications had been reviewed in order to identify any potential adverse effects and drug reactions as part of the comprehensive assessment. Specifically, 5 of 7 sampled patients did not have a medication review every 60 days as part of the comprehensive assessment. (Patient identifiers: 1, 2, 5, 6, and 7.) Findings include: During the review of patient records, the survey team found that a medication review for patients 1, 2, 5, 6 and 7 was not completed every 60 days as part of the comprehensive assessment. Medication reviews were documented by agency staff every 180 days. Surveyors interviewed the director of nursing (DON) on April 9, 2026 at 3:00 PM. The DON stated they only completed medication reviews when comprehensive assessments were performed, and they completed comprehensive assessments every 180 days for patients on certain health insurance plans.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure that each patient’s comprehensive assessment was updated no less frequently than the last 5 days of every 60 days beginning with the start-of-care date. Specifically, 5 of 7 sampled patients did not have a comprehensive assessment completed every 60 days as required. (Patient identifier: 1, 2, 5, 6, and 7.) Findings include: During the review of patient records, the survey team found that the comprehensive assessments for patients 1, 2, 5, 6 and 7 were not updated every 60 days. Updates were completed by agency staff every 180 days. Surveyors interviewed the director of nursing (DON) on April 8, 2026, at 1:30 PM. The DON stated they updated comprehensive assessments every 6 months (180 days) for patients on certain health insurance plans.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure that all patients had an updated assessment within 48 hours of the patient’s return from a hospital admission. Specifically, 1 of 7 sampled patients did not have an updated comprehensive assessment within 48 hours of returning from a hospital stay. (Patient identifier: 5.) Findings include: Surveyors completed patient 5’s medical record review on April 15, 2026. Patient 5 was admitted to the agency on January 9, 2016, with a diagnosis of congenital malformation syndrome. Patient 5 did not receive any nursing visits for the weeks of February 28, 2026 through March 28, 2026. Surveyors reviewed a nursing note dated March 28, 2026. The note stated patient 5 was discharged from the hospital on March 24, 2026. (Note: This was the only nursing documentation in patient 5’s medical record indicating patient 5 was admitted to the hospital during that time.) No documented evidence of an updated comprehensive assessment within 48 hours could be provided. Surveyors interviewed the director of nursing (DON) on April 14, 2026 at 12:57 PM. The DON stated patient 5 did not have an updated comprehensive assessment completed after their hospital admission.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure each patient’s plan of care (POC) contained all the required elements for 7 of 7 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, and 7.) Findings include: 1. Surveyors reviewed patient 1’s most recent POC for the certification period of November 17, 2025 through May 15, 2026. The POC did not include the following elements: psychosocial and cognitive status, frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, risk for emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, and information related to any advanced directive. 2. Surveyors reviewed patient 2’s most recent POC for the certification period of October 25, 2025 through April 23, 2026. The POC did not include the following elements: mental, psychosocial, and cognitive status, frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, risk for emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient and information related to any advanced directive. 3. Surveyors reviewed patient 3’s most recent POC for the certification period of February 9, 2025 through April 10, 2026. The POC did not include the following elements: psychosocial and cognitive status, frequency and duration of visits to be made, rehabilitation potential, and a description of the patient’s risk for emergency department visits and hospital re-admission. 4. Surveyors reviewed patient 4’s most recent POC for the certification period of January 10, 2026 through March 11, 2026. The POC did not include the following elements: psychosocial and cognitive status, frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, risk for emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, and information related to any advanced directive. 5. Surveyors reviewed patient 5’s most recent POC for the certification period of November 17, 2025, through May 16, 2026. The POC did not include the following elements: psychosocial and cognitive status, rehabilitation potential, emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, and information related to any advanced directive. 6. Surveyors reviewed patient 6’s most recent POC for the certification period of November 6, 2025 through May 5, 2026. The POC did not include the following elements: psychosocial and cognitive status, patient and caregiver education and training to facilitate timely discharge, and information related to any advanced directive. 7. Surveyors reviewed patient 7’s most recent POC for the certification period of September 14, 2025, through March 23, 2026. The POC did not include the following elements: psychosocial and cognitive status, rehabilitation potential, risk for emergency department visits and hospital re-admission, patient and caregiver education and training to facilitate timely discharge, and information related to any advanced directive. Surveyors interviewed the agency’s director of nursing (DON) on April 14, 2026, at 1:15 PM. The DON stated that if a clinician does not check the specific boxes addressing each element during the assessment, the elements will not carry over to the POC.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure that all services and treatments were administered only as ordered by a physician. Specifically, services and treatments were performed without physician orders for 3 of 7 sampled patients. (Patient identifiers: 1, 2, and 7.) Findings include: 1. Patient 1 was admitted to the agency on September 29, 2023, with diagnoses including long term drug therapy. Surveyors reviewed patient 1’s electronic medical record (EMR). The record review confirmed that a registered nurse performed weekly visits and administered intravenous medication. The EMR did not include a signed provider order specifying the frequency and duration of skilled nursing visits for the certification period, nor did it include a signed order for the route and duration of a weekly intravenous medication to be administered by the HHA staff. The surveyor interviewed the director of nursing (DON) on April 14, 2026, at 3:05 PM. She confirmed the EMR lacked valid orders for the period in question and stated she did not know why the current EMR omitted the frequency and duration of skilled nursing visits. 2. Patient 2 was admitted to the agency on February 14, 2016, with diagnoses that included cerebral palsy. Surveyors reviewed the EMR for patient 2 and identified that skilled treatments, including: enteral feedings and intake/output monitoring, equipment maintenance and medication management, tracheostomy, perineal, respiratory, and hygiene care, and passive range of motion exercises and repositioning every two hours, were being provided without physician orders.. The surveyor interviewed the DON on April 14, 2026, at 3:00 PM. She confirmed the electronic medical record lacked valid orders for the period in question. 3. Patient 7 was admitted to the agency on August 31, 2018, with a diagnosis of deletion from autosomes. Surveyors reviewed patient 7’s POC for the certification period of September 14, 2025 through March 23, 2026. The POC listed a skilled nursing frequency of one visit every 180 days for recertification and evaluation. Surveyors reviewed patient 7’s nursing notes. Patient 7 was receiving a skilled nursing visit once every week. An order for these additional skilled nursing visits could not be located. Surveyors interviewed the DON on April 14, 2026, at 12:57 PM. The DON confirmed there were no documented orders for the nurse to go out once every week. The DON stated that staff forgot the orders when creating the POC.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure that plans of care (POC) were reviewed and revised by the physician as frequently as the patient’s condition or needs required, but no less frequently than once every 60 days. Specifically, for 5 out of 7 sampled patients the agency did not ensure POCs were reviewed and revised every 60 days. (Patient identifiers: 1, 2, 5, 6, and 7.) Findings include: During the review of patient records, the survey team found that the POCs for patients 1, 2, 5, 6 and 7 were not reviewed every 60 days. Reviews were completed by agency staff every 180 days. Surveyors interviewed the director of nursing (DON) on April 14, 2026, at 12:57 PM. The DON stated they only review POCs every 60 days for patients with certain health insurance plans, and the rest were done every 180 days.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) did not ensure they hired qualified personnel. Specifically, the agency did not have any documentation to verify skills competency assessments were completed for 5 of 5 sampled employees. (Employee identifiers: 2, 3, 4, 5, and 6.) Findings include: Surveyors requested employee skills competency assessments on April 7, 2026, at 11:34 AM. The agency was unable to provide the requested documentation. Surveyors interviewed the director of nursing on April 14, 2026, at 10:19 AM. She stated that the HHA did not have any skills competency assessments completed for 5 of 5 sampled employees.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure discharge and/or transfer summaries were completed for patients who had been discharged or transferred. Specifically, the HHA did not ensure there was a transfer summary completed and sent to the receiving facility within 2 days of transfer for 1 of 7 sampled patients. (Patient identifier: 5.) Findings include: Surveyors completed patient 5’s medical record review on April 15, 2026. Patient 5 was admitted to the agency on January 9, 2016, with a diagnosis of congenital malformation syndrome. Surveyors reviewed patient 5’s certification period of November 17, 2025, through May 16, 2026. Patient 7 was transferred on March 1, 2026, to the hospital. There was no documented evidence that a transfer summary was completed or sent to the receiving facility. Surveyors interviewed the director of nursing (DON) on April 14, 2026, at 12:57 PM. The DON confirmed there was no documented transfer summary.”