Every finding on record at Louisiana Home Healthcare Partners, LLC

Elara Caring is in compliance with the federal emergency preparedness requirements.

Recertification Survey

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 agency failed to ensure the patient's written individualized POC (Plan Of Care) was followed as evidenced by the SN (Skilled Nurse) failing to obtain weights and/or measurements as ordered for 3 (#2, #4, and #8) out of 13 (#1-#13) sampled patients. Patient #8. Review of the patient’s electronic clinical record revealed the start of care date was 02/22/2025. The patient diagnosis included Hypertensive Heart Disease with Heart Failure. The certification period reviewed was 06/22/2025 to 08/20/2025. Review of the patient’s POC for certification period 06/22/2025 to 08/20/2025 revealed the following orders: SN 1wk3, 1every2wk6 (skilled nurse visit one time a week for three weeks, one visit every two weeks for six weeks). Further review of the POC revealed orders, “Skilled nurse for o/a (observation and assessment), teaching and self-management related to heart failure, instruct patient/caregiver on signs and symptoms of exacerbation to report and importance of obtaining and recording daily weight and/or measurements. Patient is unable to weigh, SN or trained patient/caregiver to obtain measurement of left calf in cm (centimeters) daily and report an increase of 2 cm or > (greater) to physician…” Review of the patient’s SN visit notes dated 06/24/2025, 07/02/2025, and 07/10/2025 revealed no evidence the patient’s weight or left calf measurement was obtained for those visits. On 07/14/2025 at 1:54 p.m., an interview was conducted with S1Admin (Administrator) and after a review of the patient's electronic clinical records, she verified there was no evidence the SN ensured the patient’s weight or left calf measurement was obtained for those visits made on 06/24/2025, 07/02/2025, and 07/10/2025. Patient #4. Review of the patient's electronic clinical record revealed the start of care date was 03/27/2025. The patient's diagnoses included cellulitis of the right lower limb and unspecified systolic (congestive) heart failure. The certification period reviewed was 05/26/2025-07/24/2025. Review of the patient's POC for certification period 05/26/2025- 07/24/2025 revealed orders for skilled nurse visits. Further review of the patient's POC revealed orders for: “Skilled nurse for observation/assessment….related to heart failure…instruct patient on…importance of obtaining and recording daily weight and/or measurements. Patient is unable to weigh, SN to obtain measurement of left thigh …" Review of the patient's skilled nurse visits dated 06/06/2025, 06/20/2025, 06/23/2025, and 07/02/2025 revealed no evidence that an assessment of the patient’s weight or measurements of patient's left thigh was obtained for those visits. Further review of the patient’s skilled nurse visits dated 06/02/2025, 06/09/2025, 06/13/2025, 06/16/2025, 06/27/2025, 07/04/2025, and 07/07/2025 revealed that the patient's measurements were obtained from his right thigh. On 07/15/2025 at 11:55 a.m., an interview and record review was conducted with S1ADM. She confirmed there was no evidence to reflect that an assessment was done on the patient's weight or left thigh measurements for the above referenced dates. She stated the orders read that patient #4 was to have his left thigh measured if unable to obtain his weight, and the documentation reflected the right thigh was measured. Patient #2: Review of the patient's electronic clinical record revealed the start of care date was 05/30/2025. The patient's diagnoses included in part, Hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure and lymphedema. The certification period reviewed was 05/30/2025 to 07/28/2025.Review of the patient's POC for certification period 05/30/2025 to 07/28/2025.revealed an order for skilled nurse 1wk1, 3wk8, 1wk1 (skilled nurse visits one time a week for one week; skilled nurse visits three times a week for eight weeks; and skilled nurse visits one time a week for one week.) Further review of the patient's POC revealed an order that read in part, “…SN to weigh at visits if not yet obtained per patient or caregiver…” Review of the SN (skilled nurse) note visit report dated 06/30/2025 revealed no assessment of the patient’s weight and/or left calf measurement was obtained during the visit. On 07/15/2025 at 1:15 p.m., a record review and interview was conducted with S1ADM (Administrator). She confirmed that the patient’s weight and/or left calf circumference was not obtained during the SN visit on 06/30/2025.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient's needs as evidenced by the SN (skilled nurse) failing to communicate a change in the patient’s condition to the physician for 1 (#2) out of 13 sampled patients. Review of the agency’s policy titled “Plan of Care and Coordination of Care”, with a revision date of 03/01/2025, read in part: Policy: (provider’s name) will ensure that the physician or allowed practitioner is promptly notified to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered…(provider name) coordinates care by: Ensuring communication with all physicians or allowed practitioners involved in the plan of care. Integrating orders for all physicians and allowed practitioners involved in the plan of care to ensure the coordination of all services and interventions provided to the patient…Coordination of care will be documented in the clinical record or in minutes of case conferences… Patient #2: Review of the patient's electronic clinical record revealed the start of care date was 05/30/2025. The patient's diagnoses included in part, Hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure and lymphedema. The certification period reviewed was 05/30/2025 to 07/28/2025. Review of the patient's POC (Plan of Care) for certification period 05/30/2025 to 07/28/2025 revealed an order for skilled nurse 1wk1, 3wk8, 1wk1 (skilled nurse visits one time a week for one week; skilled nurse visits three times a week for eight weeks; and skilled nurse visits one time a week for one week.) Further review of the patient's POC revealed an order that read in part, “A weight gain of 2 lbs (pounds) or > (more) overnight or 5 lbs or > in 1 week to be reported to physician/provider. SN to weigh at visits if not yet obtained per patient or caregiver. If unable to weigh, SN or trained caregiver to obtain baseline measurement of left calf in CM (centimeter) daily and report an increase of 2 cm or > to physician/provider. Review of the patient’s SN visit note report dated 06/16/2025 revealed the patient’s weight was 264.1 pounds. Review of the patient’s SN visit note report dated 06/18/2025 reveled the patient’s weight was 271 pounds ( a 6.9 pound weight gain in 48 hours) Further review of the note under assessment/abnormal findings, the SN indicated the following, “…increased SOB (shortness of breath) with exertion or CP (chest pain) +1 pitting edema noted to BLE (bilateral lower extremities)…” Review of the patient’s SN visit note report dated 07/04/2025 revealed the patient’s left calf circumference was 50cm. Review of the patient’s SN visit note report dated 07/07/2025 revealed the patient’s left calf circumference was 52cm. Review of the patient’s clinical record revealed no documented evidence the patient’s physician was notified that the patient had a 6.9 pound weight gain in 48 hours and a 2cm increase in her left calf. On 07/15/2025 at 1:15 p.m., a record review and interview was conducted with S1ADM (Administrator). S1ADM verified there was no documented evidence in the patient’s clinical record that the SN notified the patient’s physician that the patient had a 6.9 weight gain in 48 hours and a 2cm increase in her left calf. She confirmed that the SN should have notified the physician.

Elara Caring is in compliance with federal emergency preparedness requirements.

Recertification Survey

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 agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the SN (skilled nurse) failing to report a weight gain of 2 pounds or more overnight for 1 (#1) patient, by failing to perform and record blood sugar readings for 2 (#6, #8) patients, and by failing to obtain pulse oximetry measurements for 3 (#7, #8, and #9) patients as ordered on the Plan of Care, out of a total sample of 13 patients. 1. Patient #1. Review of the patient’s electronic clinical records revealed the start of care date was 5/8/2022. The patient’s diagnoses included Open Wound of Left Elbow and Hypertensive Heart Disease with Heart Failure. The certification period reviewed was 9/5/2022 to 11/3/2022. Review of the patient’s POC (Plan of Care) for certification period 9/5/2022 to 11/3/2022 revealed an order for “SN 6wk1, 7wk2 (Skilled Nurse six times a week for one week, seven times a week for two weeks) and orders changed 9/25/2022 to SN daily. Further review of the patient’s POC revealed an order for “…Weight to be obtained daily and weight gain of 2# (pounds) overnight or 5# in 1 week to be reported to physician…” Review of the patient's SN Visit Note dated 9/18/2022 revealed that the patient’s weight was 143 pounds. Review of the patient’s SN Visit Note dated 9/19/2022 revealed that the patient’s weight was 146 pounds, which was a 3 pound weight gain overnight. There was no evidence that the SN notified the physician of the patient’s 3 pound weight gain per the POC orders. Review of the patient's SN Visit Note dated 9/23/2022 revealed that the patient’s weight was 142 pounds. Review of the patient’s SN Visit Note dated 9/24/2022 revealed that the patient’s weight was 146.9 pounds, which was a 4.9 pound weight gain overnight. There was no evidence that the SN notified the physician of the patient’s 4.9 pound weight gain per the POC orders. Review of the patient's SN Visit Note dated 9/28/2022 revealed that the patient’s weight was 143 pounds. Review of the patient’s SN Visit Note dated 9/29/2022 revealed that the patient’s weight was 146 pounds, which was a 3 pound weight gain overnight. There was no evidence that the SN notified the physician of the patient’s 3 pound weight gain per the POC orders. Review of the patient's SN Visit Note dated 9/30/2022 revealed that the patient’s weight was 144 pounds. Review of the patient’s SN Visit Note dated 10/1/2022 revealed that the patient’s weight was 146.1 pounds, which was a 2.1 pound weight gain overnight. There was no evidence that the SN notified the physician of the patient’s 2.1 pound weight gain per the POC orders. Review of the patient's SN Visit Note dated 10/5/2022 revealed that the patient’s weight was 143 pounds. Review of the patient’s SN Visit Note dated 10/6/2022 revealed that the patient’s weight was 146 pounds, which was a 3 pound weight gain overnight. There was no evidence that the SN notified the physician of the patient’s 3 pound weight gain per the POC orders. On 10/11/2022 at 12:05 pm, an interview was conducted with S1DON (Director of Nursing) and after a review of Patient #1's electronic clinical record, S1DON verified that there was no evidence that the physician was notified of the patient’s weight gain per the POC orders for those dates. 2. Patient #6. Patient #6’s start of care date was 6/18/2022. The certification period reviewed was 8/17/2022 to 10/15/2022. Diagnoses included Type 2 Diabetes Mellitus with Chronic Kidney Disease and Diabetic Polyneuropathy. A review of the Plan of Care revealed an order for a SN (Skilled Nurse) visit to be conducted 1WK9 (one time a week for 9 weeks). Further review of the orders on the PoC (Plan of Care) included SN to perform and record blood sugar reading per SNV (Skilled Nurse Visit). A review of the SNV (Skilled Nurse Visit) note dated 8/25/2022 by S3LPN was conducted. The vital signs assessed on the patient did not include a blood sugar assessment. Further review of the SNV note failed to reveal that a blood sugar was conducted or recorded. A review of the SNV (Skilled Nurse Visit) note dated 8/31/2022 by S3LPN was conducted. The vital signs assessed on the patient did not include a blood sugar assessment. Further review of the SNV note failed to reveal that a blood sugar was conducted or recorded. A review of the SNV note dated 9/6/2022 by S3LPN was conducted. The vital signs assessed on the patient did not include a blood sugar assessment. Further review of the SNV note failed to reveal that a blood sugar was conducted or recorded. A review of a Vital Signs Report with vital signs conducted from 8/25/2022 through 10/11/2022 was conducted. No blood sugar readings were dated 8/25/2022, 8/31/20222, or 9/6/2022. The first blood sugar on the report was dated 9/13/2022. On 10/1/2022 at 10:30 a.m., an interview was conducted with S1DON (Director of Nursing). She reviewed Patient #6’s chart and confirmed that the physician had included an admission diagnosis of Diabetes Mellitus. She reviewed the Vital Signs Report and confirmed that the first blood sugar obtained on Patient #6 was on 9/13/2022. She reviewed the SNV notes dated 8/25/2022, 8/31/2022, 9/6/2022, and confirmed that S3LPN did not follow the care plan order and did not obtain blood sugars as ordered by Patient #6’s physician. 3. Patient #7. Patient #7’s start of care date was 8/27/2022. The certification period reviewed was 8/27/2022 to 10/25/2022. Diagnoses included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. An order for a SN (Skilled Nurse) visit to be conducted 1WK9 (one time a week for 9 weeks) was noted. A review of the care plan revealed an order for SN to obtain a pulse oximetry measurement PRN (as needed) for signs and symptoms of shortness of breath, activity intolerance and when oxygen is ordered was noted. A review of the SNV (Skilled Nurse Visit) note dated 9/22/2022 was conducted. A review of the SNV note revealed that the SN had assessed that Patient #7 had dyspnea with exertion. A review of the vital signs assessed failed to reveal that the SN had obtained a pulse oximetry assessment during the visit. On 10/11/2022 at 1:00 p.m., an interview was conducted with S2RA (Regional Administrator). She reviewed Patient #7’s Plan of Care dated 8/27/2022 and confirmed the order for the SN to obtain a pulse oximetry measurement PRN (as needed) for signs and symptoms of shortness of breath, activity intolerance and when oxygen is ordered was noted. She confirmed that the SN had assessed that Patient #7 had experienced dyspnea with exertion and had failed to follow the care plan order to obtain a pulse oximetry measurement during the visit. 4. Patient #8. Patient #8 had a start of care date of 9/24/2022. The certification period reviewed was 9/24/2022 to 11/22/2022. The patient was admitted with diagnoses including Anemia, Parkinson’s disease, Dementia, Anxiety, Metabolic Encephalopathy, and Diabetes Mellitus. An order for SN (Skilled Nurse) visits 1WK3 (once a week for 3 weeks), 2WK2 (twice a week for 2 weeks), then 1WK4 (once a week for 4 weeks) was noted. A review of the PoC (Plan of Care) revealed an order for the SN to perform and record blood sugar reading per SNV (Skilled Nurse Visit). Further review revealed an order for SN to obtain a pulse oximetry measurement PRN (as needed) for signs and symptoms of shortness of breath, activity intolerance and when oxygen is ordered was noted. A review of the SNV (Skilled Nurse Visit) note dated 9/24/2022 was conducted. The vital signs assessed on the patient did not include a blood sugar assessment. Further review of the SNV note failed to reveal that the SN had performed or recorded a blood sugar reading. A review of the SNV (Skilled Nurse Visit) note dated 10/5/2022 was conducted. A review of the SNV note revealed that the SN had assessed that Patient #8 had dyspnea at rest and with exertion. A review of the vital signs assessed failed to reveal that the SN had obtained a pulse oximetry assessment during the visit. On 10/11/2022 at 2:15 p.m., an interview was conducted with S1DON. She confirmed that Patient #8’s care plan included orders that the SN was to obtain a blood sugar on each SNV, and that the nurse should obtain a pulse oximetry measurement if the patient was assessed with activity intolerance. She reviewed the SNV dated 9/24/2022 and confirmed that the nurse had failed to follow the care plan order to conduct a blood sugar reading on each visit for the patient. She reviewed the SNV dated 10/5/2022 and confirmed that the nurse had assessed that Patient #8 had experienced dyspnea at rest and with exertion, and had failed to follow the care plan order to obtain a pulse oximetry measurement for signs and symptoms of activity intolerance. 5. Patient #9. Patient 9’s start of care date was 9/2/2022. The certification period reviewed was 9/2/2022 to 10/31/2022. Diagnoses included Type 2 Diabetes Mellitus and anemia. An order for a SN (Skilled Nurse) visit to be conducted 1WK9 (one time a week for 9 weeks) was noted. A review of the care plan revealed an order for SN to obtain a pulse oximetry measurement PRN (as needed) for signs and symptoms of shortness of breath, activity intolerance and when oxygen is ordered was noted. A review of the SNV (Skilled Nurse Visit) note dated 10/11/2022 was conducted. A review of the SNV note revealed that the SN had assessed that Patient #9 had dyspnea with exertion. A review of the vital signs assessed failed to reveal that the SN had obtained a pulse oximetry assessment during the visit. On 10/11/2022 at 3:30 p.m., an interview was conducted with S1DON. She confirmed the care plan order for the SN to obtain a pulse oximetry measurement PRN (as needed) for signs and symptoms of shortness of breath and activity intolerance for Patient #9. She reviewed the SNV dated 10/11/2022 and confirmed that Patient #9 was assessed as dyspneic with exertion during the SNV, and that the SN failed to follow the care plan order to obtain a pulse oximetry measurement.

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 provider failed to ensure that the individualized Plan of care included measurable outcomes for 1 (Patient #7) of 13 (#1-13) sampled patients by failing to include established parameters of blood sugars to report for a patient admitted for management and monitoring of Diabetes. Patient #7’s start of care date was 8/27/2022. The certification period reviewed was 8/27/2022 to 10/25/2022. Diagnoses included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A review of the Plan of Care revealed parameters of normal and abnormal for vital signs to be reported to the physician for temperature, pulse, respirations, blood pressures, pain, and Oxygen saturations. The plan of care did not address parameters for reporting blood sugars for Patient #7. An order for a SN (Skilled Nurse) visit to be conducted 1WK9 (one time a week for 9 weeks) was noted. A review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) assessment conducted on 8/27/2022 revealed an RBS (Random Blood Sugar) of 363. The Endocrine assessment included the diagnosis of Diabetes and that the patient’s blood sugars were checked daily. The nurse’s narrative included Patient #7 was being admitted for SN management and monitoring of Diabetes. Instructions included to check Blood Sugars daily, maintain a log, and use a glucometer. Further review revealed in addition to the RN assessment on 8/27/2022, SNV (Skilled Nurse Visits) were conducted on 8/31/2022, 9/7/2022, 9/15/2022, 9/22/2022, 9/30/2022, and 10/5/2022 with blood sugars ranging from 98-323 on those visits. No evidence of reportable parameters were noted on the SNVs. On 10/11/2022 at 1:00 p.m., an interview was conducted with S2RA (Regional Administrator). She reviewed Patient #7’s Plan of Care dated 8/27/2022. S2RA confirmed there were no parameters for Blood sugar reporting on the Plan of Care. She confirmed that Patient #7 had a diagnoses of Diabetes Mellitus and was admitted for management of the disease. She reviewed the SNVs and echart (Electronic chart) and confirmed that the nurse had failed to include parameters for the licensed professionals to report for blood sugars for Patient #7 upon admission.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure that accepted standards of practice were followed as evidenced by S3LPN (Licensed Practical Nurse) failing to ensure that equipment used to provide wound care was appropriately discarded for one (#1) of five (#1, #2, #3, #4, #5) patients that home visits were conducted with, out of a total sample of 13 patients reviewed. Patient #1. Review of Medscape (medical online journal) revealed an article on wound irrigation that was dated 8/27/2021. The technique used included, “… Hold the filled syringe just above the top edge of the wound and gently instill fluid into the wound, slowly and continuously until the syringe is empty… Remove and discard … equipment in trash bag…” Review of the patient’s electronic clinical records revealed the start of care date was 5/8/2022. The patient’s diagnoses included Open Wound of Left Elbow and Hypertensive Heart Disease with Heart Failure. The certification period reviewed was 9/5/2022 to 11/3/2022. Review of the patient’s POC (Plan of Care) for certification period 9/5/2022 to 11/3/2022 revealed an order for “SN 6wk1, 7wk2 (skilled nurse six times a week for one week, seven times a week for two weeks) and orders changed on 9/25/2022 to SN daily. Further review of the patient’s POC revealed an order for “…Skilled nurse or trained patient/caregiver to perform wound care using aseptic technique… acetic acid and insert into wound bed…” On 10/10/2022 at 11:48 am, a home visit was made to Patient #1’s house. S3LPN was observed preparing to perform wound care to the patient’s open wound on her left elbow. S3LPN was observed taking a syringe that was wrapped with a paper towel from a zip lock bag, unwrapping the syringe and placing in it the workplace she had prepared. She was observed getting a bottle of acetic acid and placing in in the workplace. S3LPN was observed opening the bottle of acetic acid and pouring the solution into the bottle cap/lid and then placing it onto her workplace. S3LPN then used the syringe she had unwrapped to draw up the acetic acid and placed it onto the workplace then removed the dressing from the patient’s left elbow. S3LPN then used the syringe and instilled the acetic acid into the patient’s wound. Once S3LPN completed the wound care, she was observed discarding the acetic acid that was left in syringe in the trash can and then pouring the acetic acid remaining in the bottle cap back into the bottle of acetic acid. S3LPN was then observed wrapping the syringe into the same paper towel, and placing it back into the zip lock bag. On 10/10/2022 at 12:38 pm, an interview was conducted with S3LPN outside of the patient’s home. S3LPN confirmed that she poured the acetic acid that she had poured into the bottle cap for Patient #1’s wound care, back into the bottle of acetic acid. S3LPN stated that it should have been discarded and not placed back in the bottle of acetic acid. On 10/11/2022 at 9:00 am, an interview was conducted with S1DON (Director of Nursing) and with S2RA (Regional Administrator). They both confirmed the acetic acid that S3LPN poured into the bottle cap for Patient #1’s wound care should have been discarded and not poured back into the bottle of acetic acid. S2RA stated S3LPN should have used a new syringe for the wound care, and that the syringe should have been discarded.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to ensure communication with physicians involved in the plan of care for 1 (#6) out of 13 (#1-12) sampled patients as evidenced by failing to communicate with the physician regarding a disputed diagnosis. Patient #6’start of care date was 6/18/2022. The certification period reviewed was 8/17/2022 to 10/15/2022. Diagnoses included Type 2 Diabetes Mellitus with Chronic Kidney Disease and Diabetic Polyneuropathy. A review of the Plan of Care revealed an order for a SN (Skilled Nurse) visit to be conducted 1WK9 (one time a week for 9 weeks). Further review of the orders on the PoC (Plan of Care) included SN to perform and record blood sugar reading per SNV (Skilled Nurse Visit). A review of the SNV (Skilled Nurse Visit) note dated 8/25/2022 by S3LPN, revealed an Endocrine assessment with the question: does the patient have diabetes? The SN answered the question “No”. Under Interventions provided 3. Skilled Nurse to perform blood sugar readings: the SN documented “Patient denies DX (diagnosis) of DM (Diabetes Mellitus)”. A review of the SNV (Skilled Nurse Visit) note dated 8/31/2022 by S3LPN, revealed an Endocrine assessment with the question: does the patient have diabetes? The SN answered the question “No”. Under Interventions provided 3. Skilled Nurse to perform blood sugar readings: the SN documented “Patient denies DX of DM”. Further review of the patient’s electronic chart failed to reveal communication with the physician regarding the patient’s denial of the admission diagnosis of Diabetes Mellitus. On 10/1/2022 at 10:30 a.m., an interview was conducted with S1DON. She reviewed Patient #6’s chart and confirmed that the physician had included an admission diagnosis of Diabetes Mellitus. She reviewed the SNV notes dated 8/25/2022 and 8/31/2022 and confirmed that S3LPN’s assessment included that the patient denied having Diabetes Mellitus. S1DON stated that S3LPN should have communicated with the patient’s physician upon denial of the diagnosis. S1DON stated that there was no evidence that the nurse had communicated the patient’s disputed diagnosis with their physician.