Every finding on record at Lady of the Sea Hospital

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 observation, interview, and record review the agency failed to ensure a patient’s medication profile was complete and accurate for 1 (Patient #3) of 3 sampled patients reviewed for medication reconciliation. Findings: Review of the agency’s Medication Management Policy, revised on 11/2017 revealed, in part, the skilled nurse was to review the patient’s medication list on each skilled nurse visit. Review of Patient #3’s Home Health Certification and Plan of Care for the certification period of 11/13/2025 through 01/11/2026 revealed, in part, Patient #3 was to receive skilled nursing services once a week for eight weeks. Review of Patient #3’s Medication Profile dated 12/08/2025, which was provided to the surveyor as the most accurate medication list, revealed, in part, no documented evidence Methanamine Hippurate, Clopidogrel and Januvia were documented as current or discontinued medications. Observation on 12/16/2025 at 10:45 a.m. revealed the following medications were present in Patient #3’s home: Methanamine Hippurate (a medication used to prevent urinary tract infection) with a prescription fill date of 8/11/2025, re-fill date of 11/17/2025; Clopidogrel (a blood thinner used to prevent problems with heart and blood vessels) with a prescription fill date of 7/15/2025, re-fill date 10/9/2025; and, Januvia (a medication used to control blood sugar levels) with a prescription fill date of 8/18/2025, refill date 11/17/2025. In an interview on 12/16/2025 at 11:12 a.m., Patient #3’s caregiver indicated Patient #3 was currently prescribed Methanamine Hippurate, Clopidogrel, and Januvia daily. Patient #3’s caregiver further indicated the above-mentioned medications had been prescribed for a while now. In an interview on 12/16/2025 at 11:15 a.m., S3 Registered Nurse (RN) confirmed the above medications were not listed on Resident #3’s medication profile as required. In an interview on 12/16/2025 at 12:32 p.m., S2Director of Nursing (DON) indicated the nursing staff should have identified the prescriptions and updated Patient #3’s profile when performing medication reconciliation at each skilled nurse visit as required.

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 interview and record review, the agency failed to ensure medication orders contained the medication dose, frequency, route, and purpose as required by standards of practice for 1 (Patient #1) of 7 sampled patients reviewed for care and services. Findings: Review of National Coordinating Council for Medication Error Reporting and Prevention Recommendations to Reduce Medication Errors Alert dated 05/01/2025 revealed, in part, verbal orders for medication should include drug name, dosage, frequency, route, and purpose. Review of the agency’s Medication Management policy, revised on 11/2017, revealed medication orders should contain, in part, dosage, frequency, route, and purpose. Review of Patient #1’s verbal order received by S2Director of Nursing (DON) on 10/02/2025 revealed orders for, in part, doxycycline (medication used to treat infection) for five additional days, and to resume Farxgia (medication used to treat diabetes). Further review revealed neither medication order contained the dose, frequency or route. Interview on 12/6/2025 at 4:00 p.m., S2DON confirmed the above mentioned verbal orders did not contain the dose of medication, the frequency of medication, or the route of the medication as required.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 and interview, the agency failed to reconcile medications at every skilled nurse visit to maintain an accurate record of medications taken by patients. This deficient practice was identified for 3 (Patient #1, Patient #2, and Patient #3) of 7 patients sampled for accurate medication records in a total sample of 7. Review of the agencies Medication Management Policy and Procedure revealed, in part, medication lists will be reviewed on each skilled nurse visit. Review of Patient #1’s current medications taken at Patient #1’s home revealed the following medications not listed on the Medication Profile List: Aripiprazole (antipsychotic medication) 5 milligrams (mg) and Docusate Sodium (stool softener) 100mg. Further review revealed the following medications listed on the Medication Profile List not currently being taken by Patient #1: Albuterol Sulfate HFA Inhalation (medication for shortness of breath) 108 micrograms (mcg), Miralax (laxative) 17grams, Vitamin D3 125mcg, and Ferrous Sulfate (Iron supplement) 325mg. Review of Patient #2’s current medications taken at Patient #2’s home revealed the following medications not listed on the Medication Profile List: Aleve (anti-inflammatory medication) 220mg. Further review revealed the following medications listed on the Medication Profile List not currently being taken by Patient #2: OTC Slimming Gummy and Nystatin External (antifungal medication) 10,000 units/gram. Review of Patient #3’s Mediation Profile List revealed the following medications listed not currently being taken by Patient #3: Proair HFA Inhalation (medication for shortness of breath) 108 mcg and Fexofenadine HCL ER (antihistamine medication) 180mg. In an interview on 01/10/2023 at 2:25 a.m., S2Registered Nurse (RN) stated she only checks patient’s medications at home visits on a recertification visit or if the patient tells her they have any medication changes. In an interview on 01/11/2023 at 2:32 p.m., S3Registered Nurse (RN) stated she does not check medications in a patient’s home at each visit. S3RN further stated at each visit she asks the patient if they went to their physician recently or have any new medications. S3RN further stated also if she has not seen the patient in a few weeks she would do a medication review. In an interview on 1/12/2022 at 9:45 a.m., S1Director confirmed the nurses should complete a full medication reconciliation at each home visit.

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 record review and interview, the agency failed to notify the physician of changes in a patient’s condition. This deficient practice was identified for 1 (Patient #7) of 7 patients sampled for record review in a total sample of 7. Findings: Review of Patient #7’s Home Health Certification and Plan of Care with a certification period of 12/27/2021 thought 02/24/2022 revealed, in part, wound #1 right hip and wound #2 left ear. Review of Patient #7’s visit note dated 01/07/2022 revealed, in part, new wound found on skilled nurse visit, blister to left heel. Further review of the visit note revealed Patient #7’s daughter reported to the nurse of Patient #7 not eating or drinking. Further review of the visit note revealed Patient #7’s daughter requested the nurse to not notify the physician. Review of Patient #7’s visit note dated 01/13/2022 revealed, in part, new wound found on skilled nurse visit, right ear scab. Further review of the visit note revealed Patient #7’s daughter reported to the nurse of Patient #7 not eating or drinking. In an interview on 01/12/2023 at 9:38 a.m., S1Director stated the physician was not notified of the changes in Patient #7’s condition or the new wounds due to the patient’s daughter requesting not to contact the physician. S1Director confirmed the Registered Nurse should have notified the physician of the new wounds and change in condition even if Patient #7’s daughter requested not to.

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 record review, observation, and interview the facility failed to ensure: 1.) Proper hand hygiene was performed by a nurse during wound care after removing dirty gloves and prior to donning clean gloves for 1 (Patient #2) of 3 patients sampled for home visits and; 2.) Proper cleaning and disinfecting of reusable patient vital sign equipment after use for 1 (Patient #3) of 3 patients sampled for home visits. Findings: Patient #2 Review of the agency’s Hand Hygiene Policy and Procedure revealed, in part, this facility has implemented the Centers for Disease Control (CDC) Category I Recommendations for hand hygiene. Review of the CDC Category I Recommendations for hand hygiene revealed, in part, healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately after glove removal. Observation of in home visit on 01/10/2023 at 2:20 p.m. revealed S2Registered Nurse (RN) getting prepared to start Patient #2’s wound care to his right leg venous ulcer. Further observation revealed S2RN sanitize her hands with an alcohol based solution and donned clean gloves. Further observation revealed S2RN removed dirty dressings from Patient #2’s right leg and then removed dirty gloves. Further observation revealed S2RN donned clean gloves without hand sanitizing or washing hands. S2RN then cleaned the wound with normal saline and gauze and removed dirty gloves. S2RN then reached into her pocket of her shirt and took out her personal telephone to take pictures of the Patient #2’s wounds without using hand sanitizer or washing hands. S2RN then donned clean gloves to cover the wound. S2RN finished by removing her dirty gloves and using an alcohol based hand sanitizer to clean her hands. In an interview on 01/11/2023 at 9:50 a.m., S2RN stated she usually sanitizes her hands before wound care, before going from dirty to clean during wound care, and after wound care. In an interview on 01/12/2023 at 9:45 a.m., S1Director confirmed S2RN should have sanitized her hands every time she removed dirty gloves and donned clean gloves per the agency’s policy on hand washing. Patient #3 Observation of an in home visit on 01/11/2023 at 9:04 a.m., revealed S3Registered Nurse (RN) remove reusable vital sign equipment out of her home health bag and use the equipment to check Resident #3’s vital signs. Further observation revealed after S3RN used the reusable equipment she placed the equipment back her home health bag in an outside compartment without cleaning or sanitizing the equipment. In an interview on 01/11/2023 at 2:32 a.m., S3RN stated she cleans her reusable equipment after each visit in her car. S3RN further stated after using the vital sign equipment she puts it in a compartment in her bag separated from everything else. S3RN further stated she only cleans her bag and vital sign equipment compartment once a day after seeing all her patients. In an interview on 01/12/2023 at 10:44 p.m., S1Director confirmed all nurses reusable vital sign equipment used in a patient home visit should be cleaned and sanitized prior to returning the equipment into the nurse’s bag or car.