Every finding on record at Eternal Guardian Home Health Care

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 09/09, 09/10, and 09/11/2025. Active Census: 8 At this Emergency Preparedness survey, Eternal Guardian Home Health Care was found to be in compliance with Emergency Preparedness Requirements for a Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 9/17/2025.

This visit was for an Initial Federal Certification and State Licensure survey of a Home Health provider. Survey Dates: 09/09, 09/10, and 09/11/2025. 12 Month Unduplicated Skilled Admissions: 4 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA Home Health Aide OASIS Outcome and Assessment Information Set RN Registered Nurse SOC Start of care CM Clinical Manager SN Skilled Nursing POC Plan of Care QR completed by Area 3 on 9/17/2025.

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 record review and interview, the agency failed to ensure the individualized POC included all necessary interventions to address the underlying risk factors and the specific education and training to be provided, and patient specific education to be provided by the SN, measurable outcomes and goals identified by the home health agency and patient for 3 of 3 active patient records (Patients: #1, 3, and 10) receiving skilled nursing services. Findings Include: 1. A review of an agency policy effective date 05/16/2025, titled “Care Plan” indicated but was not limited to, “ … A care plain is essential to ensure patients’ needs are met adequately and appropriately and that services are adapted to their individual situation … developing the care plan include: … including diagnosis related to the order … discharge planning needs, … health needs/problems with which a patient/family needs assistance … goals to be achieved, what actions must be taken to achieve them … physician parameters for vital signs … ” 2. A review of the clinical record for Patient #1, SOC date 07/03/2025, contained a POC dated 09/02/2025, and signed by the Clinical Manager for the recertification period 09/01/2025 to 10/31/2025. The POC indicated, but was not limited to, diagnoses of Chronic Systolic (Congestive) Heart Failure (a condition when the heart’s left ventricle cannot pump blood effectively, leading to fluid buildup), and Essential Primary Hypertension (Increased blood pressure). Patient #1 had orders for Skilled nursing one time every other week for 60 days for medication set up, HHA supervisory visits, to educate patient and caregiver on symptoms, and to ensure Patient #1’s medication compliance with no missed medication doses. An HHA provides two hours daily, one day a week, for 60 days, for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS) (essential self-care tasks and daily tasks that individuals perform to live independently and maintain their well-being). The section titled “Medications” indicated but was not limited to, Apixaban (treatment to prevent blood clotting) 5 milligrams (mg), take one tablet by mouth two times a day, Aspirin 81 mg chewable, take one by mouth daily, Atorvastatin Calcium 9 treatment for high cholesterol) 80 mg take one tablet by mouth daily, Furosemide (treatment for fluid retention and high blood pressure increasing urine output) 40 mg take one by mouth as needed if weight increases above 150 pounds or if you notice with increasing for 3 days in a row, Metoprolol Succinate Extended Release 25 mg take one daily, Jardiance (treatment for diabetes risks of complications associated with cardiovascular and kidney disease) 10 mg take one daily by mouth daily, and Relugolix (treatment for prostate cancer) 120 mg take one daily. The POC failed to provide education and teaching to the patient/caregiver on medication setup, daily weights, and call parameters for temperature, pulse, oxygen saturations, and blood pressure readings, as well as all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. During an interview on 09/11/2025 at 3:05 PM, when questioned about the education and instructions Patient #1 had been provided on medications set up or observed for compliance, the Clinical Manager stated, “No, I set up his medication enough to know what the patient takes, and I read the labels. No, I have not educated or observed the patient set up their medications. I just set up his medications.” 3. A review of the clinical record for Patient #3, SOC date 07/16/2025, contained a POC dated 07/21/2025, and signed by the Clinical Manager, for the certification period 07/16/2025 to 09/13/2025. The POC indicated but was not limited to diagnoses of Hypertension (HTN) (high blood pressure), Angina Pectoris with documented Spasm (a condition of temporary tightening of the muscles within the artery walls which can reduce blood flow to the heart and cause chest pain and discomfort) and Other Seizures (a sudden surge of electrical activity in the brain that can temporarily affect consciousness, muscle control, and behavior), but failed to list Type 2 Diabetes Mellitus. The POC contained orders for Skilled Nursing, one time a week every other week for 60 days for medication setup, and every 14 days for HHA supervision. An HHA provides two hours daily, one day a week, for 60 days, for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS) (essential self-care tasks and daily tasks that individuals perform to live independently and maintain their well-being). The section titled “Medications” indicated but was not limited to, Plavix ( treatment to prevent blood clotting) 75 mg take one by mouth daily, Amlodipine Besylate (treatment for high blood pressure and chest pain) 10 mg take one by mouth daily, Carvedilol (treatment for to lower blood pressure and heart rate) 25 mg- 0.5 mg take by mouth two times a day, Glucagon (treatment for low blood sugar) Injection 1 mg intramuscular in shoulder or thigh injection with noon meal, Roseram (treatment for insomnia) 8 mg take by mouth at bedtime, Vimpat (treatment for seizures) 50 mg take by mouth two tablets every morning and three tablets at bedtime, Lisinopril (treatment for high blood pressure) 40 mg take one by mouth daily, Lipitor (treatment for high cholesterol) 40 mg take by mouth daily, and Hydralazine HCI (treatment for high blood pressure) 50 mg take by mouth 3 times a day. The POC failed to provide education and teaching to the patient/caregiver regarding seizures, medication setup, a seizure plan, call parameters for temperature, pulse, oxygen saturations, blood pressure readings, blood sugars, and all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. During an interview on 09/10/2025 at 9:15 AM, the Clinical Manager confirmed Patient #3 had a seizure during their visit and needed to be transported for treatment to an acute care facility. The Clinical Manager further indicated the POC had not contained a seizure plan for Patient #3 and were unaware of the knowledge base of the family who had provided care for Patient #3 regarding seizure planning, education, and interventions. 4. A review of the clinical record for Patient #10, SOC date 06/27/2025, contained a POC dated 08/25/2025, and signed by the Clinical Manager, for the recertification period 08/26/2025 to 10/24/2025. The POC indicated, but was not limited to, diagnoses of Essential Hypertension (high blood pressure), Nonrheumatic Aortic Valve Stenosis (a condition of narrowing of the heart valve reducing blood flow), and Unspecified Osteoarthritis (a condition of joint degeneration leading to pain and stiffness of the joints). Patient #10 had an order for Skilled Nursing every other week for 60 days for medication setup. Patient #10’s goals were to manage hypertension, be independent with ADLs, and comply with medications. The POC failed to evidence education and teaching to the patient/caregiver regarding hypertension, pain, medication setup, call parameters for temperature, pulse, oxygen saturations, and blood pressure readings, and all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. During an interview on 09/11/2025 at 11:21 AM, when reviewing the missing call parameters for vital signs, education, and the POCs interventions being patient-specific for Patients #1, 3, and 10, the Clinical Manager and Interim Administrator confirmed call parameters were to be on the POC per their policy and reviewed the chart in the electronic record. The Interim Administrator confirmed all the diagnoses were not pulled over from the comprehensive assessment. 410 IAC 17-13-1(a)(1)(D)(ii, xi, xiii)

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Clinical Manager failed to ensure education and training, preparing the patient for discharge for 1 of 1 patients (Patient #1), who was able to complete medication setup. Findings Include: 1. A review of an agency policy effective date 05/16/2025, titled “Medication Profile” indicated, but was not limited to, “ … 1. The nurse performs ongoing medication monitoring … 5. The profile will also serve as a tool for the purpose of patient/caregiver education … ” 2. During a home visit at Patient #1’s residence on 09/10/2025 at 1:45 PM, observed the Clinical Manager set up Patient #1’s medication without referring to the POC or a medication profile. When the Clinical Manager informed Patient #1 that their PRN Lasix had been added to the medication planner, Patient #1 expressed their preference not to include it in their daily medications. Patient #1 further indicated they did not like the way the Clinical Manager set up their medications and could do it themselves. A review of the clinical record for Patient #1, SOC date 07/03/2025, contained a POC dated 09/02/2025, and signed by the Clinical Manager for the recertification period 09/01/2025 to 10/31/2025. The POC indicated Patient #1 had orders for Skilled nursing one time every other week for 60 days for medication set up, HHA supervisory visits, educate patient and caregiver on symptoms, and to ensure Patient #1’s medication compliance with no missed medication doses. During an interview on 09/11/2025 at 3:05 PM, when questioned about the education and instructions Patient #1 had been provided on medications set up or observed for compliance, the Clinical Manager stated, “No, I set up his medication enough to know what the patient takes, and I read the labels. No, I have not educated or observed the patient set up their medications. I just set up his medications.” 410 IAC 17-14(a)(1)(G)

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 observation, record review, and interview, the agency failed to ensure the RN adhered to standard precautions for preventing the transmission of infections and communicable diseases through proper hand hygiene and gloving for 1 of 2 RN’s providing medication setup and assessment. (Employee: Clinical Manager/RN) Findings Include: 1. A review of an agency policy effective date 05/16/2025, titled “Hand Hygiene Policy in Patients’ Homes” indicated, but was not limited to, “ … To improve hand-hygiene practices of agency staff and reduce transmission of pathogenic microorganisms to patients and personnel in the home care setting … SPECIAL INSTRUCTIONS … 2. When to use hand sanitizer … a. Before and after caring for patients or coming in contact with inanimate objects or equipment near the patient. … c. After removing gloves, d. After touching objects that are potentially contaminated, … ” 2. A review of an agency policy effective date 05/16/2025, titled “Bag Technique” indicated but was not limited to, “ … If additional supplies are needed during the visit, hands are to be cleansed before re-entering the bag … ” 3. During a home visit at Patient #1’s residence on 09/10/2025 at 1:45 PM, observed the Clinical Manager perform an assessment and medication setup. The Clinical Manager/RN performed hand hygiene, donned gloves, used hand sanitizer on gloved hands, reached into their bag, and obtained tweezers. Afterwards, cleaned the tweezers with a cleansing wipe, removed their gloves, performed hand hygiene, donned new gloves, used alcohol gel on gloved hands, proceeded using tweezers obtaining pills out of the pill containers, and placed the pills in the medication planner. The Clinical Manager/RN wiped their forehead, reached into their bag, obtained a paper towel, and wiped their face, without discarding their gloves, performing hand hygiene, and donning new gloves, prior to getting into their bag. Afterwards, the Clinical Manager/RN used alcohol gel on their gloved hands and continued to use the tweezers, obtaining the pills from the pill bottles and placing them in the medication planner. Patient #1 indicated they did not want their as-needed (PRN) Lasix added to the planner. The Clinical Manager/RN removed the Lasix pills from the planner and placed them on the lid of the medication planner. During an interview on 09/10/2025 at 3:10 PM, when questioned regarding glove changes and hand hygiene after removing gloves and prior to obtaining a paper towel out of their clean bag with their dirty gloves, and about infection control with placing pills removed from the medication planner on the lid of the medication planner, the Clinical Manager/RN stated, “I was sweating and needed the towel to wipe my face, should have removed my gloves before getting into my bag.” The Clinical Manager further indicated the patient touches the lid of the medication planner. 410 IAC 17-12-1(m)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the Clinical Manager/Case Manager failed to ensure the aide care plan was individualized and patient-specific for 1 of 2 active patients receiving SN and HHA services. (Patient: #3) Findings Include: 1. A review of an agency policy effective date 05/16/2025, titled “Care Plan” indicated, but was not limited to, “A care plan is essential to ensure patients’ needs are met adequately and appropriately, and that services are adapted to their individual situation … ” 2. A review of the clinical record for Patient #3, SOC date of 07/16/2025, contained a POC for the recertification period 07/16/2025 to 09/13/2025, electronically dated 07/21/2025, and signed by the Clinical Manager. The POC indicated but was not limited to diagnoses of Hypertension (HTN) (high blood pressure), Angina Pectoris with documented Spasm (a condition of temporary tightening of the muscles within the artery walls which can reduce blood flow to the heart and cause chest pain and discomfort) and Other Seizures (a sudden surge of electrical activity in the brain that can temporarily affect consciousness, muscle control, and behavior). The POC contained orders for Skilled Nursing, one time a week every other week for 60 days for medication setup, and every 14 days for HHA supervision. An HHA provides two hours daily, one day a week, for 60 days, for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS) (essential self-care tasks and daily tasks that individuals perform to live independently and maintain their well-being). A review of the HHA Care Plan dated 07/21/2025, and signed by the Clinical Manager, overseeing Patient #3’s care, indicated Patient #3 had diagnoses/problems right side hemiplegia (right side weakness) from a Cerebrovascular Vascular Accident (CVA)( a medical term for stoke which blood flow to part of the brain is stopped), Hypertension (HTN) (high blood pressure), Diabetes Mellitus Type 2 (a condition of a problem in the way the body regulates and uses sugar for fuel), and Seizure (a sudden surge of electrical activity in the brain that can temporarily affect consciousness, muscle control, and behavior). HHA frequency and duration were listed as one time weekly for two hours, covering dressing, light housekeeping, personal care (including bathing, showering, stand-by assist in a chair), and assistance with ambulation using an assistive device (walker), as well as repositioning in bed. HHA Care Plan failed to be individualized to the patient’s specific needs regarding safety needs for seizures, and seizure plan. During an interview on 09/11/2025 at 12:30 PM, when asked about Patient #3’s seizures, HHA 1 communicated Patient #3 had a seizure while the HHA had been assisting Patient #3 ambulating from the bathroom. HHA 1 further stated the Clinical Manager had been at the patient’s residence when it had happened, and they called out for the Clinical Manager to assist. When asked about the seizure plan on the HHA’s care plan for Patient #3, the HHA stated they were unaware of that and would call 911. During an interview on 9/10/2025 at 9:14 AM, when asked if they could show the seizure plan for HHA 1 while providing care for Patient #3, the Clinical Manager could not provide one. When asked about what their seizure protocol was for Patient #3, the Clinical Manager stated the agency did not have one. 410 IAC 17-13-2(a)

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Clinical Manager failed to ensure patients were appropriately and accurately assessed according to professional standards for 2 of 3 patients (Patients: #1 and 3) receiving Skilled Nursing services. Findings Include: 1. A review of an agency policy effective date 05/16/2025, titled “Medication Administration Guidelines” indicated, but was not limited to, “ … Verify the physician’s order for medication administration … ” 2. A review of an agency policy effective date 05/16/2025, titled “Medication Profile” indicated, but was not limited to, “ … 1. The nurse performs ongoing medication monitoring … 5. The profile will also serve as a tool for the purpose of patient/caregiver education … ” 3. Diabetes Mellitus: Nursing Care Management at https://nurseslabs.com/diabetes-mellitus/#nursing_management dated 6/5/2020 indicated " ... The nurse should assess the following for patients with Diabetes Mellitus: Assess the patient's history. To determine if there is presence of diabetes, assessment of history of symptoms related to the diagnosis of diabetes, results of blood glucose monitoring, adherence to prescribed dietary, pharmacologic, and exercise regimen, the patient's lifestyle, cultural, psychosocial, and economic factors, and effects of diabetes on functional status should be performed. Assess Physical Condition. Assess the patient's blood pressure while sitting and standing to detect orthostatic changes. Assess the body mass index and visual acuity of the patient. Perform examination of foot, skin, nervous system, and mouth.... risk for unstable blood glucose level ... risk for infection ... deficient knowledge ... risk for disturbed sensory perception ... impaired skin integrity ... ineffective peripheral tissue perfusion .... " 4. During a home visit at Patient #1’s residence on 09/10/2025 at 1:45 PM, observed Patient #1 in their recliner, their ankles and feet were swollen. Observed the Clinical Manager/RN listen to Patient #1’s lung and heart sounds. During the visit, Patient #1 stated, "I gained weight, so I had to take my as-needed (PRN) Lasix today.” The Clinical Manager failed to assess Patient #1’s lower extremity pulses, edema, verify Patient #1’s weight, or educate on elevating their legs while in the recliner. Observed, the Clinical Manager set up Patient #1’s medication without referring to the POC or a medication profile. When the Clinical Manager informed Patient #1 that their PRN Lasix had been added to the medication planner, Patient #1 expressed their preference not to include it in their daily medications. Patient #1 further indicated they did not like the way the Clinical Manager set up their medications and could do it themselves. During an interview on 09/10/2025 at 2:52 PM, when questioned about their ankles and feet being swollen, Patient #1 indicated they had to take a PRN Lasix today due to weight gain, and they were swollen today and didn’t keep their feet up. A review of the clinical record for Patient #1, SOC date 07/03/2025, contained a POC dated 09/02/2025, and signed by the Clinical Manager for the recertification period 09/01/2025 to 10/31/2025. The POC indicated, but was not limited to, diagnoses of Chronic Systolic (Congestive) Heart Failure (a condition when the heart’s left ventricle cannot pump blood effectively, leading to fluid buildup), and Essential Primary Hypertension (Increased blood pressure). Patient #1 had orders for Skilled nursing one time every other week for 60 days for medication set up, HHA supervisory visits, to educate patient and caregiver on symptoms, and to ensure Patient #1’s medication compliance with no missed medication doses. An HHA provides two hours daily, one day a week, for 60 days, for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS) (essential self-care tasks and daily tasks that individuals perform to live independently and maintain their well-being). The section titled “Medications” indicated but was not limited to, Apixaban (treatment to prevent blood clotting) 5 milligrams (mg), take 1 tablet by mouth two times a day, Aspirin 81 mg chewable, take one by mouth daily, Atorvastatin Calcium 9 treatment for high cholesterol) 80 mg take one tablet by mouth daily, Furosemide (treatment for fluid retention and high blood pressure increasing urine output) 40 mg take one by mouth as needed if weight increases above 150 pounds or if you notice with increasing for 3 days in a row, Metoprolol Succinate Extended Release 25 mg take one daily, Jardiance (treatment for diabetes risks of complications associated with cardiovascular and kidney disease) 10 mg take one daily by mouth daily, and Relugolix (treatment for prostate cancer) 120 mg take one daily. During an interview on 09/11/2025 at 3:05 PM, when questioned the Clinical Manager about their cardiopulmonary assessment process when a patient reports weight gain and had taken a PRN Lasix, stated, “I should have weighed the patient to verify weight. Yes, fluid goes to edema in the lower extremities. I did not assess his feet.” When asked regarding the medication list referred to during medication setup and what if there had been medication changes not on the label, if the patient had been instructed on medications set up or observed for compliance, the Clinical Manager stated, “No, I set up his medication enough to know what the patient takes, and I read the labels on the medication bottles. No, I have not educated or observed the patient set up their medications. I just set up his medications.” The Clinical Manager failed to provide education and assess Patient #1’s knowledge and compliance with setting up their medications; failed to assess for edema and weight of Patient #1 when Patient #1 reported changes in their weight and needed to take their as needed Lasix per order: and failed to use a medication list or profile to set up Patient #1’s medications to ensure accuracy and review for any changes. 5. During a home visit at Patient #3’s residence on 09/10/2025 at 3:45 PM, observed RN 1 complete an assessment and medication setup. RN 1, reviewing the medication profile from their tablet, set up the medication in the medication planner. Upon obtaining the bottle of Vimpat (treatment for seizures), noted a change in the dose on the medication bottle dated 08/07/2025, which listed Vimpat 200 mg, and compared it to the medication list dosage to be administered. The Clinical Manager reviewed the dose with the RN and noted the dose had changed to 200 mg twice daily from the medication list, which initially indicated 150 mg. The RN called the physician and left a message to verify the dosage. Afterwards, the RN checking the medication planner noted the new dosage had been placed in the other medication planner days that were not due yet. When questioned who set the medications up last, the RN indicated the Clinical Manager, who confirmed they had completed the previous medication setup. A review of the clinical record for Patient #3, SOC date 07/16/2025, contained a POC dated 07/21/2025, and signed by the Clinical Manager, for the certification period 07/16/2025 to 09/13/2025. The POC indicated but was not limited to diagnoses of Hypertension (HTN) (high blood pressure), Angina Pectoris with documented Spasm (a condition of temporary tightening of the muscles within the artery walls which can reduce blood flow to the heart and cause chest pain and discomfort) and Other Seizures (a sudden surge of electrical activity in the brain that can temporarily affect consciousness, muscle control, and behavior). The POC contained orders for Skilled Nursing, one time a week every other week for 60 days for medication setup, and every 14 days for HHA supervision. An HHA provides two hours daily, one day a week, for 60 days, for assistance with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS) (essential self-care tasks and daily tasks that individuals perform to live independently and maintain their well-being). The section titled “Medications” indicated but was not limited to, Plavix ( treatment to prevent blood clotting) 75 mg take one by mouth daily, Amlodipine Besylate (treatment for high blood pressure and chest pain) 10 mg take one by mouth daily, Carvedilol (treatment for to lower blood pressure and heart rate) 25 mg- 0.5 mg take by mouth two times a day, Glucagon (treatment for low blood sugar) Injection 1 mg intramuscular in shoulder or thigh injection with noon meal, Roseram (treatment for insomnia) 8 mg take by mouth at bedtime, Vimpat (treatment for seizures) 50 mg take by mouth 2 tablets every morning and 3 tablets at bedtime, Lisinopril (treatment for high blood pressure) 40 mg take one by mouth daily, Lipitor (treatment for high cholesterol) 40 mg take by mouth daily, and Hydralazine HCI (treatment for high blood pressure) 50 mg take by mouth 3 times a day. A review of a document titled “After Visit Summary” dated 08/07/2025, from Entity 1, an acute care facility, indicated Patient #3 had been transported for an emergency visit to Entity 1 for seizures and discharged home with a change in medication, increasing Vimpat to 200 mg twice a day. A review of the Skilled visit notes dated 07/24/2025 through 09/04/2025 evidenced Patient #3 on 08/07/2025 had been seen by the Clinical Manager during the seizure activity and sent via ambulance to Entity 1 for treatment. On 08/08/2025, the Clinical Manager made a return visit and documented in the section titled “General Notes” they had received an additional order to assess Patient #3 on a seizure incident that occurred on 08/07/2025, and the patient did not have any new medication orders. On 08/21/2025 the Clinical Manager completed Patient #3’s next visit and documented the patient had no new medication changes and medication setup had been completed. The Clinical Manager provided education to the patient and caregiver on seizure precautions. During an interview on 09/10/2025 at 9:15 AM, the Clinical Manager confirmed Patient #3 had a seizure during their visit and needed to be transported for treatment to an acute care facility. The Clinical Manager further indicated the POC had not contained a seizure plan for Patient #3 and were unaware of the knowledge base of the family who had provided care for Patient #3 regarding seizure planning and interventions. During an interview on 09/11/2025 at 9:11 AM, upon review of concerns of the visits and clinical record for Patient #3, the Clinical Manager indicated they should have updated the medication list and more closely monitored the patient by increasing visit frequency.