Every finding on record at Genesis Healthcare, LLC

The Oklahoma State Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 02/09/2026 to 02/12/2026. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/09/2026 to 02/12/2026. An entrance conference was conducted with RN1. The survey process was explained. Questions were answered. RN1 was identified as the contact person for administrative issues and clinical issues. Findings were discussed during an informal exit conference with RN1 and Administrative staff. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: RN Registered Nurse SN Skilled Nurse POC Plan of Care SOC Start of Care HHA Home Health Aide PT Physical Therapy

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview the Physical Therapist failed to conduct an initial evaluation within 5 days of the Start of Care as part of the comprehensive assessment for one (#12) of four (#4 - #6 and #9) records reviewed with orders for physical therapy services. Patient #12 Review of Patient #12 record for SOC certification period 12/24/2025 - 02/21/2026 showed a primary diagnosis of Congestive Heart Failure and orders for a Physical Therapy (PT) evaluation. Documentation by the PT showed the Initial Evaluation was conducted on12/31/25, 7 days after the SOC. Further review failed to provide documentation as to the reason the PT eval was delayed and not conducted within 5 days of the SOC as required. During an interview on 02/12/26 at 11:15 AM, RN1 stated the PT eval was not completed timely and the record did not contain documentation as to the reason for the delayed evaluation.

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 record review, observation and interview the staff failed to ensure a current and accurate medications list was maintained for four (#3, #11, #12 and #15) of seventeen (#1 - #17) records reviewed. Patient #3 Review of Patient #3 record for re-certification period 01/27/26 - 03/27/26 showed a primary diagnosis of Chronic Obstructive Pulmonary Disease and orders for SN visits 1 time a week for 9 weeks and SN to obtain PT/INR weekly. During a Home Observation visit on 02/10/26 , a review of the Medication List included Enteric Coated Aspirin 81 mg daily and Warfarin 2 mg tablet to be taken on Tuesday, Thursday, Saturday and Sunday. During an interview on 02/10/26 at 11:30, Patient #3 stated they were not taking Aspirin daily and was taking 2.5 mg Warfarin each day. Patient #11, Review of Patient #11 record for re-certification period 12/23/25 - 02/20/26 showed a primary diagnosis of Malignant Neoplasm of the Colon and orders for SN visits 1 time a week for 8 weeks and OT visits 1 time a week for 8 weeks. Further review of SN visit documentation for 01/26/26 stated Pt #11 received last round of Chemo 01/22/26. Review of the Medication List for this episode failed to provide evidence of any Chemo medications currently listed or discontinued. Patient #12 Review of Patient #12 record for SOC certification period 12/24/25 - 02/21/26 showed a primary diagnosis of Congestive Heart Failure and orders for SN visits 1 time a week for 9 weeks, PT visits 2 times a week for 2 weeks and 1 time a week for 6 weeks and HHA visits 1 time a week for 8 weeks. Further review of SN visit documentation for 02/06/26 showed Pt #12 currently using Oxygen at 3 liters per nasal cannula. Review of the Medication List for this episode failed to provide evidence of Oxygen as a current medication or listed on the POC as DME/Supplies. Patient #15 Review of Patient #15 record for SOC certification period 10/10/25 - 12/08/25 showed a primary diagnosis of Malignant Neoplasm of the Lung and orders for SN visits 1 time a week for 9 weeks. Further review of SN visit documentation for 11/15/25 stated,"...continues to get the immunotherapy weekly ...". Review of the Medication List for this episode failed to provide evidence of any immunotherapy medications Pt #15 was currently taking. During an interview on 02/12/26 at 11:15 AM, RN1 stated the staff failed to ensure a current and accurate Medication List was maintained for Pts #3, #11, #12 and #15.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the SN staff failed to conduct interventions and complete assessment and evaluation of the patient as ordered on the POC for one (#8) of seventeen (#1 - #17) records reviewed. Patient #8 Review of Patient #8 record for re-certification period 02/06/26 - 04/06/26 showed a primary diagnosis of Type II Diabetes Mellitus and a secondary diagnosis of Heart Failure. The POC showed orders for SN visits 2 times a week for 1 week, 7 times a week for 8 weeks and 2 times a week for 1 week and "SN to check weight at every visit...assess and evaluate weight gain or loss...". Further review of SN visit documentation failed to provide evidence of weights or assessment of weight gain or loss for visits 02/06, 02/08, 02/09, 02/10, and 02/11/26. During an interview on 02/12/26 at 11:15 AM, RN1 stated the SN staff failed to obtain weights and assess weight gain or loss as ordered for Pt #8

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 record review, observation and interview the SN staff failed to adhere to infection control standards of practice while providing care to two (#1 and #4) of seven ( #1 - #7) patients observed during SN home visits. Review of the agency policy # IC.15 titled, "Hand Hygiene", referenced to CDC.gov/infection-control/hcp/hand-hygiene, stated at Item II D. "...use an alcohol based hand rub for routinely decontaminating hand in the clinical situations..1) Prior to initial entry into the supply bag 2) Immediately before touching patient/client and 8) After removing gloves". Review of agency policy # IC 60 titled, "Bag Technique", referenced CDC Control and Prevention Practices 5F. Reprocessing of reusable Medical Equipment, and stated at item C. After cleansing hands, the supplies and/or equipment needed for the visit are removed from the bag and D. When the visit is completed, reusable equipment if cleaned using alcohol, disinfectant wipe...and placed on a clean surface, hands are cleansed...and clean equipment and supplies are returned to the bag". Patient #1 Review of Patient #1 record for re-certification period 12/16/25 - 02/13/26 showed a primary diagnosis of Iron Deficiency Anemia and orders for SN visits 1 time a week for 2 weeks, 1 time every 2 weeks for 6 weeks and 1 time a week for 2 weeks . During a Home Observation visit on 02/10/2026 at 08:30 AM, the SN failed to sanitize her hands after removing gloves, before entering clinical bag and before donning new gloves. Vital signs equipment was not disinfected and placed on a clean surface prior to returning to the bag. Patient #4 Review of Patient #4 record for SOC certification period 01/31/26 - 03/31/26 showed a primary diagnosis of Type II Diabetes Mellitus and orders for SN visits 1 time a week for 9 weeks. During a Home Observation visit on 02/10/2026 at 02:30 PM, the SN failed to sanitize her hands after removing gloves and the vital signs equipment was not disinfected and placed on a clean surface prior to returning to the bag During an interview on 02/12/26 at 11:15 AM, RN1 stated the SN failed to adhere to agency policy and procedure for hand hygiene and infection control in the home for Pt #1 and Pt #4.

The Oklahoma State Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 01/24/23 to 01/25/23, No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 01/24/23 to 01/25/23. An entrance conference was conducted with Alternate Admin1, VPO and HR Director. The survey process was explained. Questions were answered. VPO was identified as the contact person for clinical issues and administrative issues. Findings were discussed during an informal exit conference with VPO, HR Director and DCS. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: Admin Alternate Administrator VPO Vice President of Operations DCS Director of Clinical Services HR Human Resources Director RN Registered Nurse SN Skilled Nurse POC Plan of Care SOC Start of Care

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, SN staff failed to provide an individualized POC to include patient-specific interventions, education, outcomes and goals for seven (#1, #2, #5 - #7, #12 and #13) of thirteen (#1 - #13) records reviewed. Patient #1 A record review for Patient #1 certification period 12/15/22 to 2/12/23 revealed a primary diagnosis of Acute Chronic Respiratory Failure. The POC included orders for "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week". During an interview on 11/25/23 at 11:39 AM, Patient #1 Caregiver stated they do not get daily weights as the patient is too unstable to stand on scales and the nurse does not obtain weights during her visit. Further record review failed to provide evidence of patient-specific interventions or indications Patient #1 required daily or weekly weight monitoring and SN Visit Notes did not indicate weights were assessed. Patient #2 A record review for Patient #2 certification period 11/15/22 to 3/14/23 revealed a primary diagnosis of Vertebral Fracture. The POC included vital sign parameters for "SN to notify physician of: Weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week and Blood Sugar parameters: FBS 250 and RBS 300". During an interview on 11/25/23 at 10:50 AM, Patient #2 stated she does not have diabetes and does not monitor her blood sugar. In addition, she does not weight as she is too unstable to stand on scales and the nurse does not obtain weights during her visit. Further record review failed to provide evidence Patient #2 had a diagnosis of Diabetes Mellitus or patient-specific interventions or indications Patient #2 required daily or weekly weight monitoring. SN Visit Notes did not indicate blood sugar or weights were assessed. Patient #5 A review of the POC for Patient #5 for certification period 11/20/22 to 03/19/23 revealed a primary diagnosis of Fracture Right Humerus. The POC included orders for "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week ". During an interview on 11/25/23 at 11:25 AM, Patient #5 Caregiver stated they weight infrequently, and the nurse does not obtain weights during her visit. In addition, the Caregiver confirmed Patient # 5 utilizes Oxygen at night. Further record review failed to identify Oxygen on the current Medication List and failed to provide patient- specific interventions or indications Patient #5 required daily or weekly weight monitoring. SN Visit Notes did not indicate weights were assessed. Patient #6 A review of the POC for Patient #6 for certification period 12/25/22 to 2/22/23 revealed a primary diagnosis of Fractured Right Femur. The POC included orders for "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week ". Further record review failed to provide evidence of patient-specific interventions or indications Patient #6 required daily or weekly weight monitoring and SN Visit Notes did not indicate weights were assessed. Patient #7 A review of the POC for Patient #7 for certification period 12/21/22 to 2/18/23 revealed a primary diagnosis of Fractured Right Hip. The POC included orders for "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week ". Further record review failed to provide evidence of patient-specific interventions or indications Patient #7 required daily or weekly weight monitoring and SN Visit Notes did not indicate weights were assessed. Patient #12 A review of the POC for Patient #12 for certification period 11/21/22 to 01/19/23 revealed a primary diagnosis of Type II Diabetes Mellitus. The POC included orders for "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week ". Further record review failed to provide evidence of patient-specific interventions or indications Patient #12 required daily or weekly weight monitoring and SN Visit Notes did not indicate weights were assessed. Patient #13 A review of the POC for Patient #13 for certification period 10/22/22 to 12/23/22 revealed a primary diagnosis of Urinary Tract Infection. The POC included orders for "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week ". Further record review failed to provide evidence of patient-specific interventions or indications Patient #13 required daily or weekly weight monitoring and SN Visit Notes did not indicate weights were assessed. During an interview on 01/25/23 at 2:30 PM, VPO stated the SN staff failed to individualize each POC with individualized vital sign parameters and patient-specific interventions for Patients #1, #2, #5 - #7 #12 and #13.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, SN staff failed to assess patient weights as ordered by the physician on the POC for four (#3, #4, #8 and #9) of thirteen (#1 - #13) records reviewed. Patient #3 A review of the POC for Patient #3 for certification period 11/22/22 to 03/21/23 revealed a primary diagnosis of Hypertensive Chronic Kidney Disease and a secondary diagnosis of Congestive Heart Failure. The POC included orders for SN visit frequency of 1 time a week for 9 weeks and "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week ", "SN to check weight at every visit", and "SN to teach CHF self-management strategies, daily weights and zone tools". During an interview on 11/25/23 at 10:35 AM, Patient #3 Caregiver stated the scale is not working, they do not weight daily and the nurse does not obtain weights during her visit. Further review of SN Visit Notes failed to provide evidence weights were assessed as ordered for SN visits conducted during weeks #3, #4, #5, #7, #8 and #9. Patient #4 A review of the POC for Patient #4 for certification period 12/22/22 to 02/19/23 revealed a primary diagnosis of Chronic Venous Ulcer. The POC included an order for SN visit frequency of 1 time a week for 9 weeks, "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week " and "SN to teach patient/caregiver self-observation skills as appropriate including record keeping of intake and output, weight daily or weekly...". During an interview on 11/25/23 at 11:05 AM, Patient #4 Caregiver stated they weight daily because she does not have a good appetite and he is watching her weight. Further review of SN Visit Notes failed to provide evidence weights were assessed as ordered for SN visits conducted during weeks #2 - #6. Patient #8 A review of the POC for Patient #8 for certification period 12/28/22 to 2/25/23 revealed a primary diagnosis of Trigeminal Neuralgia. The POC included orders for SN visit frequency of 1 time a week for 9 weeks, "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week " and "SN to teach patient/caregiver self-observation skills as appropriate including record keeping of intake and output, weight daily or weekly...". Further review of SN Visit Notes failed to provide evidence weights were assessed as ordered for SN visits conducted during weeks #2 and #3. Patient #9 A review of the POC for Patient #9 for certification period 1/07/23 to 3/5/23 revealed a primary diagnosis of Asthma and secondary diagnosis of Hypertension. The POC included orders for SN visit frequency of 1 time a week for 9 weeks, "SN to notify physician of weight gain of 3 lbs. in 24 hours or 5 lbs. in 1 week " and "SN to check weight at every visit". Further review of SN Visit Notes failed to provide evidence weights were assessed as ordered for SN visits conducted during weeks #2- #5 and weeks #7 and #8. During an interview on 01/25/23 at 2:30 PM, VPO stated the SN staff failed to obtain and assess weights as ordered in the POC for Patients #3, #4, #8 and #9.