Every finding on record at Assisted Healthcare Services

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION survey conducted from 2/23/26 to 2/26/26. Resident census was 240 . Final Sample was 17.

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 facility failed to ensure medications were reviewed and the current medication profile was updated to match the medications the patient was taking for one of 17 sampled patients (Patient 11). This facility failure has the potential for the patient to take medications that were not prescribed by the physician. Findings: During a home visit with the registered nurse (LN2) on 2/24/26 at 1:30 pm, the home health agency’s (HHA) medication list was compared to the patient's home medication list. The HHA medication list did not match the home medication list. The following medications were not included on the HHA medication list: Alpha-Lipoic acid (dietary supplement) 600 milligrams (mg) capsule, 1 capsule by mouth daily.Metheamine (urinary tract antiseptic) 1 gram tablet, 1 tablet by mouth daily.Venlafaxine (antideppresant) 37.5 milligrams capsule, 1 capsule by mouth in the morning. Wegovy (controls blood sugar and weight loss) 0.5 mg/ 5 ml , inject 0.5 mg every Thursday.Furosemide (a diuretic) 20 mg tab, 1 tab by mouth in the morning.Gemtesa (for over active bladder) 75 mg, give 75 mg by mouth at bedtime.Magnesium oxide (antacid and for constipation) give 1 tab by mouth at bedtime.Potassium chloride (to prevent low potassium level) 10 meq tab, give 1 tab by mouth in the morning.Presser vision (support eye health) capsules, give 2 caps by mouth twice a dayDuring an interview with the director of patient care services (DPCS) on 2/26/24 at 11:44 am, the DPCS stated the nurse should check the home medication and reconcile the list to ensure the agency knows what medications the patient is taking at home. The DPCS acknowledged the medication reconciliation had not been done. During review of the facility policy titled “Medication Management,” dated September 2022, indicated “All medication a patient may be taking will be documented on the medication profile to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated drugs."

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure ordered services were provided according to the physician’s plan of care and failed to ensure the physician was notified when ordered home visits were missed for three of 17 sampled patients (Patients 7, 13, and 17). These failures resulted in physicians not being aware that ordered services were not provided as prescribed, which had the potential to affect the physician’s management of the patients’ plans of care and compromise the patients’ health and safety. Findings: During a review of Patient 17's "Home Health Certification and Plan of Care," for the certification period 12/30/25 to 2/27/26, the "plan of care" indicated the home visit order, dated 2/9/26 - 2/22/26, "Physical therapy (PT) two (2) visits per week for two (2) weeks." During a review of Patient 17's "PT Visit Notes," for the certification period 12/30/25 to 2/27/26, a "Missed Visit Form (PT Visit)," dated 2/22/26, indicated Patient 17 missed a PT visit because she "attended a funeral." The form failed to indicate however that the physician was notified of the missed visit. During a concurrent interview and record review with the agency's Executive Director (ED) and DPCS on 2/26/26 at 12 p.m., Patient 17's "PT Visit Notes," for the certification period 12/30/25 to 2/27/26, were reviewed. ED and DPCS confirmed that Patient 17 missed a PT visit on 2/22/26 and acknowledged that there was no documentation in the patient's record that the physician was notified of the missed visit. The policy and procedure titled “Missed Visits or Shifts and Refusal of Services” dated September 2022 indicated “If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record". During review of Patient 7’s clinical record on 2/23/26 at 4:00 p.m., the physician order indicated skilled nursing visits two times per week for eight weeks during the certification period 12/28/25 through 2/25/26. During review of visit documentation for the week of 2/16/26 through 2/22/26, only one skilled nursing visit was documented, which did not meet the ordered visit frequency. The clinical record did not contain documentation of a missed visit or documentation indicating the physician was notified. During an interview on 2/26/26 at 11:59 a.m., the Director of Patient Care Services (DPCS) acknowledged the missed visit. During review of Patient 13’s clinical record on 2/24/26 at 4:30 p.m., the physician order indicated physical therapy visits of one visit per week for one week and two visits per week for seven weeks during the certification period 2/8/26 through 4/8/26. Documentation dated 2/16/26 and 2/18/26 indicated missed visits. The clinical record did not contain documentation indicating the physician was notified of the missed visits. During an interview on 2/26/26 at 11:54 a.m., the Director of Patient Care Services (DPCS) acknowledged the missed visit documentation did not indicate the physician was notified.

The following reflects the findings of the California Department of Public Health during a standard recertification survey conducted 06/20/23 through 06/23/23. The agency reported 5683 unduplicated admissions for the last 12 months. The total number of sampled patients was 17 and 7 home visits were conducted. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 39912, HFEN 44589, and HFEN 47849.

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 facility failed to ensure medications were reviewed and updated on current medication profile to match what patients are currently taking for 4 of 17 sampled patients (Patient 11, 12, 15 and 16) This facility failure has the potential for patients taking medications not prescribed by the physician. The policy and procedure titled “Medication Management” dated 9/22 indicates, “The medication profile is available to other skilled staff as necessary to ensure coordination of care and safe medication management. When changes or new medication are ordered, a supplemental order will be written to confirm the new/changed medication. The nurse will update the working medication profile (field copy) and submit a copy of the working medication profile to be placed in the medical record or update the original medication profile in the medical record as changes occur...” During a home visit on 6/21/23 at 9 a.m., Patient 12’s (Pt 12) home medication list was reviewed. Compared to the actual medication of Pt 12 at home, 2 medications were not on the list. Farxiga (used to treat diabetes) 5mg, 1 tab daily and Ropirinole (used to treat shakiness or tremors) 0.5 mg 1 tab bedtime. During an interview on 6/21/23 at 9:35 a.m., the licensed nurse (LN 1) acknowledged the 2 medications are not on the medication profile for the Pt 12. During a home visit on 6/21/23 at 10 a.m., Patient 13’s (Pt 13) home medication list was reviewed. Compared to the actual medication Pt 13 at home, 8 medications were not on the list. Sertraline 100mg, Metformin 500mg (used to treat diabetes), Gabapentin 300mg (an anticonvulsant), Tamsulosin 0.4 mg, frequency, and urgency) 1 cap daily, Losartan (used to treat hypertension), Famotidine (used to treat heartburn), Hydrocodone (pain medication), and Trazodone (antidepressant) During an interview on 6/21/23 at 10:42 am, the licensed nurse (RN2) acknowledged the medications are not on the list. LN 2 indicated the last time she did medication reconciliation was 3 weeks ago. During a home visit on 6/21/23 at 1:15 p.m., Patient 15’s (Pt 15) home medication list was was not found at the residence. There were unlabeled pill boxes of medication, Pt 15 indicated her son is the one preparing her medication for her to take. During an interview on 6/21/23 at 1:40 p.m., the occupational therapist (OT) indicated OT does not check patient’s medication the nurse does. During a home visit on 6/22/23 at 11:21 a.m., Patient 16’s (Pt 16) home medication list was reviewed. There were 7 medications not found on the list. Xtampza (pain medication), Pregabalin (used to treat anxiety and epilepsy), Hydromorphone (pain medication), Atorvastatin (used to lower bad cholesterol), folic acid (vitamin supplement), Tresiba (used to treat diabetes) and Humalog (used to treat diabetes). During an interview on 6/22/23 at 11:30 a.m., the licensed nurse (LN 3) acknowledged the medications were not on the list. LN 3 indicated Pt 16's medication were checked during admission and only checks it occasionally.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure two of 17 patients (Patient 1 and Patient 16) had physician notification documentation in the clinical record when: 1. Skilled nursing visits were not conducted 2. Physical Therapy (PT - medical treatment used to restore functional movements such as walking, standing, and moving different body parts) visits were missed. As a result, the physicians were unaware of the change in visit frequency, and the changes in the Plan of Care and had the potential to compromise the health and safety of Patient 1 and Patient 16. 1. During a review of Patient 1's (Pt 1) clinical record on 6/20/23 at 2 p.m., clinical records indicated Pt 1 had an order for 1 skilled nursing visit a week for 4 weeks for certification period 1/13/23 to 3/13/23. Only one visit was made dated 1/13/23. The clinical record indicated the family wanted to hold off skilled nursing visits. There was no hold order from the physician found in the clinical record. During an interview on 6/20/23 at 2:30 p.m., the director for patient care services (DPCS) acknowledged that if the family wanted to hold the visits, the physician should have been notified and a hold order should have been obtained. During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits or Shifts and Refusal of Services,” dated, 9/22, the “P&P” indicated, “Each patient must receive the home health services specified in their physician ordered, individualized plan of care. If a visit, treatment, or services is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician…Documentation of missed visits/shifts will include: Reason visit/shift not made, Notification of the Physician, Any new orders for care or service…” 2.During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits or Shifts and Refusal of Services,” dated, 9/22, the “P&P” indicated, “Each patient must receive the home health services specified in their physician ordered, individualized plan of care. If a visit, treatment, or services is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician…Documentation of missed visits/shifts will include: Reason visit/shift not made, Notification of the Physician, Any new orders for care or service…” During a review of Patient 16’s (Pt 16) Plan of Care (POC), Start of Care (SOC) dated 3/23/23, the POC indicated, Pt 16 had diagnoses that included infection (the invasion and growth of germs in the body) following a procedure, and disruption of external operation (surgical) wound. The POC further indicated, Pt 16 was to receive PT two times a week for five weeks for gait training (walking), and transfer training. During a review of Pt 16’s electronic calendar, dated 5/30 and 6/1, the electronic calendar indicated, Pt 16 was not seen due to patient’s cancellation. No additional information was documented. During interview on 6/22/23, at 4:15 p.m., with the Branch Manager (BM), the BM verbalized, the staff visiting the patient must notify the doctor and must document on the Clinical Note during missed visits. The BM reviewed the agency’s policy for missed visits and checked Pt 16’s clinical record for a doctor’s notification documentation, and acknowledged it was not done and documented. During interview on 6/23 /23, at 9:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS acknowledged there was no documentation that the doctor was notified of the missed visits on 5/30/23 and 6/1/23.