Every finding on record at Nhc/Op, L.P.

An Emergency Preparedness recertification and re-licensure survey was conducted on 3/30/2026-4/1/2026. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

A recertification survey was conducted on 3/30/2026 – 4/1/2026. An entrance conference was held on 3/30/2026 at 11:00 AM with the Administrator. An exit conference was held on 4/1/2026 at 11:15 AM with the Administrator, Clinical Manager, Director, Office Manager and Regional Administrator.

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 policy review, medical record review, and interview, the agency failed to update the medication profile for 1 of 7 (Patient #6) sampled patients observed during home visits. The findings included: 1. Review of the agency’s “Medication Review and Reconciliation” policy dated 5/2022, revealed, “…Medication review and reconciliation is completed as a part of call comprehensive assessments (at start of care, resumption of care, recertification, and discharge) and with every medication change…Medication compliance, effects and changes are assessed at every skilled visit…” 2. Medical record review for Patient #6 revealed a start of care date of 11/10/2025 with diagnoses including Urinary Tract Infection, Diabetes Mellitus, Hypertension, and Depression. Review of the “Home Health Certification and Plan of Care” for the certification period from 3/10/2026 to 5/8/2026, revealed the following medication orders: Amlodipine (used to treat high blood pressure) 2.5 milligrams (mg) orally daily Gemtesa (used to treat overactive bladder) 75 mg orally daily Lisinopril (used to treat high blood pressure) 20 mg orally daily Meclizine (used to treat dizziness) 25 mg orally as needed Metformin (used to treat high blood sugar) 500 mg orally daily Miralax (used to treat constipation) 17 grams (gm) orally as needed Senna Lax (used to treat constipation) 8.6 mg orally daily Systane (used to treat dry eyes) drops as needed Tylenol Extra Strength (used to treat pain) 500 mg (2 tablets) orally as needed Observations in Patient #6's home on 3/31/2026 at 11:15 AM, revealed the following medications in the home: Amlodipine 5 mg Over the Counter (OTC) D-Mannose (used to treat urinary tract infection) 500 mg OTC Aspirin 81 mg OTC Vitamin C (supplement) 500 mg 6/30/2025 (date dispensed) Nitrofurantoin Macro (used to prevent urinary tract infections) 50 mg 8/30/2025 Lisinopril 20 mg 11/4/2025 Meclizine 12.5 (1 individual pill pack) 11/8/2025 (Individual pill packs) with Amlodipine 5 mg, Gemtesa 75 mg, Lisinopril 20 mg, Metformin 500 mg 11/9/2025 (Individual pill packs) with Amlodipine 5 mg, Gemtesa 75 mg, Lisinopril 20 mg 11/10/2025 (Individual pill packs) with Amlodipine 5 mg, Gemtesa 75 mg, Lisinopril 20 mg 3. During a telephone interview on 3/31/2026 at 10:56 AM, Patient #6's son stated that his mother only took the Gemtesa and Metformin regularly and took the other medications as needed. During an interview on 3/31/2026 at 11:10 AM, the Director of Services from a sister facility stated that Patient #6’s medications needed to be reviewed and reconciled, and the nurse and therapy staff were responsible for reviewing and reconciling the Patient's medications.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on policy review, observation, and interview, the facility failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases when 1 of 7 (Registered Nurse (RN) #1) employees failed to wash their hands between glove changes. The findings included: 1. Review of the agency’s undated “Hand Hygiene” policy revealed “…Hand Hygiene is a general term that applies to hand washing, antiseptic hand wash, or antiseptic alcohol-based hand rub…It cannot be emphasized strongly enough that good hand hygiene is the single most important patient care activity that a home care staff member can do to prevent cross-contamination and home-acquired infections. Hand hygiene is indicated, at least…after glove removal…” 2. Review of the medical record revealed Patient #4 was admitted to the agency on 11/15/2025, with diagnoses including Cutaneous Abscess of Buttock, Osteomyelitis of Vertebra, and Chronic Kidney Disease Stage 4. Review of the physician order dated 3/15/2026, revealed “…cleanse wound to coccyx with Dakins solution [antiseptic solution used to treat and prevent skin infections in wounds]. Pack wound with Dakins soaked gauze, cover with border foam...” 3. Observations in Patient #6's home on 3/31/2026 at 9:00 AM, revealed RN #1performed wound care. She removed her gloves 6 times and redonned new gloves 6 times during the procedure without performing hand hygiene. 4. During an interview on 3/31/2026 at 9:55 AM, the Director of Services from a sister facility stated staff were supposed to hand sanitize between every glove change.

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 policy review, medical record review, and interview, the agency failed to maintain a system of communication and integration in accordance with the home health agency’s own policies and procedures by failing to ensure clinical visit notes were documented in a timely manner for 5 of 12 (Patient #2, #3, #7, #10, and #11) patients reviewed. The findings included: 1. Review of the agency’s policy "…Medical Records CREATION, MAINTENANCE AND STORAGE,” last revised 10/23, revealed, "...TIMELY SUMISSION OF DOCUMENTATION…It is imperative that accurate and complete patient documentation is submitted in a timely manner; to maintain the flow of patient information…patient care…To ensure accuracy and thoroughness, all possible visit documentation is to be completed in the home or immediately after the visit...Compressive Assessments…must be completed and submitted with signature by 8:00 AM after the visit…Clinician signatures will be done at completion of the visit, after double check of the documentation…" 2. Review of the medical record revealed Patient #2 was admitted to the agency on 12/24/2025 with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure and Anxiety. Review of the Visti Note Report revealed a visit was made on 2/26/2026 at 9:53 AM. The documentation for the visit was completed on 3/1/2026 at 1:55 PM. Review of the medical record revealed Patient # 3 was admitted to the agency on 9/29/2025 with diagnoses including Impingement Syndrome of Shoulder, Pressure Ulcer and Hypertension. Review of the Visit Note Report revealed a visit made on 2/13/2026 at 2:00 PM. The documentation for the visit was completed on 2/14/2026 at 9:23 AM. Review of the medical record revealed Patient #7 was admitted to the agency on 12/16/2025 with diagnoses including Multiple Sclerosis, Dysphagia, Hypertension and Epilepsy. Review of the Visit Note Report revealed a visit was made on 12/18/2025 at 2:28 PM. The documentation for the visit was completed on12/22/2025 at 7:29 AM. Review of the Visit Note Report revealed a visit was made on 12/31/2025 at 11:18 AM. The documentation for the visit was completed on 1/2/2026 at 4:39 AM. Review of the Visit Note Report revealed a visit was made on 1/14/2026 at 11:57 AM. The documentation for the visit was completed on 1/16/2026 at 3:08 AM. Review of the Visit Note Report revealed a visit was made on 1/21/2026 at 2:18 PM. The documentation for the visit was completed on 1/23/2026 at 3:37 AM. Review of the Visit Note Report revealed a visit was made on 1/28/2026 at 2:46 PM. The documentation for the visit was completed on 2/1/2026 at 5:21 PM. Review of the Visit Note Report revealed a visit was made on 2/3/2026 at 12:18 PM. The documentation for the visit was completed on 2/5/2026 at 4:06 AM. Review of the Visit Note Report revealed a visit was made on 2/11/2026 at 2:37 PM. The documentation for the visit was completed on 2/14/2026 at 3:06 AM. Review of the medical record revealed Patient #10 was admitted on 12/9/2025, with diagnoses of Diabetes, Dysphagia, Depression, and Chronic Kidney Disease. Review of the Visit Note Report revealed a visit was made on 2/13/2026 at 4:00 PM. The documentation for the visit was completed on 2/16/2026 at 12:09 PM. Review of the medical record revealed Patient #11 was admitted to the agency on 2/17/2026, with diagnoses of Cerebral Infarction, Muscle Weakness, Attention and Concentration Deficit. Review of the Visit Note Report revealed a visit was made on 2/17/2026 at 2:32 PM. The documentation for the visit was completed on 2/19/2026 at 5:55 PM. Review of the Visit Note Report revealed a visit was made on 2/24/2026 at 11:11 AM. The documentation for the visit was completed on 2/28/2026 at 1:43 PM. 3. During an interview on 4/1/2026 at 9:37 AM, the Administrator stated the time frame for documentation of visit notes for Patient #2, #3, #7, #10, and #11 were not completed timely.

An unannounced onsite recertification survey was conducted on 6/5/2023-6/7/2023. An entrance conference was held on 6/5/2023 at 9:30 AM, with the Administrator. An exit conference was held on 6/7/2023 at 2:55 PM, with the agencies administration.

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 policy review, medical record review, and interview, the agency failed to update the medication profile for 7 of 7 (Patient #1, #3, #4, #5, #6, #7, and #13) sampled patients reviewed. The findings included: 1. Review of the agencies "Medication Review and Reconciliation," policy last revised 5/22 (2022), revealed "...Medication review and reconciliation is completed as a part of all comprehensive assessments (at start of care, resumption of care, recertification, and discharge) and with every medication change...Medication compliance, effects and changes are assessed at every skilled visit. The primary goals are optimal patient care, safety. and outcomes..." 2. Review of the medical record revealed Patient #1 was admitted to the agency on 1/25/2023 and recertified on 5/25/2023 with diagnoses of Congestive Heart Failure, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, and Atherosclerosis of Renal Artery. Review of the Client Medication Report (Physician Orders) dated 3/20/2023, revealed "...Ferrous Sulfate [Supplement] 325 mg [milligram]...daily...oral; Folic Acid 1 mg... daily...oral; Methocarbamol [Muscle Relaxer]500 mg...3 times daily...oral; Vitamin B-1 100 mg... daily...oral; Vitamin C 500 mg...2 times daily...oral; Venlafaxine [Antidepressant]...150 mg... daily... oral. During an observation on 6/6/2023 at 10:25 AM, revealed a pill bottle of Venlafaxine 75 mg po bid and Trelegy [treats COPD] 200 mcg [micrograms]/62.5 mcg/25 mcg 1-2 times a day. During an interview with Patient #1 on 6/6/2023 at 10:30 AM, confirmed he didn't take the vitamins and Trelegy was fairly new. During an interview with the Administrator on 6/6/2023 at 10:45 AM, confirmed Patient #1's medical record needed to be reconciled. 3. Review of the medical record revealed Patient #3 was admitted to the agency on 3/8/2023 and recertified on 5/7/2023 with diagnoses of Hypertensive Heart Disease, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of the Client Medication Report revealed, "Citalopram [Antidepressant] 20 mg... daily... oral..." During an observation of Patient #3's home medications on 6/6/2023 at 11:40 AM, revealed "...5/27/2023...Lasix 20 mg by mouth every day; 5/27/2023...Citalopram 40 mg by mouth daily; 5/27/2023...Bumetanide [Diuretic] 1 mg by mouth twice daily; 5/27/2023...Calcium 600 mg by mouth twice daily; 5/27/2023...Metoprolol [Antihypertensive] 50 mg by mouth every day; Prednisone [Steroid] 20 mg by mouth every day [DON NOT USE was written on the bottle]..." During an interview with the Administrator on 6/6/2023 at 12:00 PM, confirmed Patient #3's medical record needed to be reconciled. 4. Review of the medical record revealed Patient #4 was admitted to the agency on 5/30/2023 with diagnoses of Disruption of External Surgical Wound and Infection/Inflammation Reaction due to Internal Joint Prosthesis. Review of the Client Medication Report revealed, "...6/5/2023...Eliquis [Anticoagulant] 2.5 mg... daily... oral..." During observation of Patient #4's home medications on 6/6/2023 at 9:50 AM, revealed "...4/25/2023...Acetaminophen [Anti-inflammatory]...500 mg (2 Tablets) every 6 hours as needed; 3/11/2023...Meloxicam [Muscle Relaxer] 7.5 mg by mouth twice daily; 4/25/2023...Docusate [Stool Softener]100 mg by mouth twice daily; Aleve [Analgesic] PM 220 mg; Multivitamin with Minerals; Arthritis Pain 650 mg; Vitamin A 2400 mcg; Vit C + Zinc; and Iron 28 mg..." During an interview with Patient #4 on 6/6/2023 at 10:15 Am, she stated "...I still take the Eliquis...came in a weird designer package so I took them out and placed them in an Aspirin bottle. There is still Aspirin in the bottle..." During an interview with the Administrator on 6/6/2023 at 10:45 AM, confirmed Patient #1's medical record needed to be reconciled. "...we can look up the pill if there is a number on the pill but I agree, the medications shouldn't be mixed..." 5. Review of the medical record revealed Patient #5 was admitted to the agency on 5/29/2023 with diagnoses of Orthopedic Aftercare, Arthrodesis, Chronic Obstructive Pulmonary Disease, and Hypertension. Review of the Client Medication Report revealed "...6/1/2023...Clonazepam [Sedative] 1 mg...2 times daily...oral; 6/1/2023...Gabapentin [Anticonvulsant] 300 mg...3 times daily...oral; and 6/1/2023...Metoclopramide 5 mg...2 times daily...oral; and 6/1/2023...Levofloxacin [Antibiotic] 750 mg... daily... oral..." Observations on Patient #5's home medications on 6/7/2023 at 9:00 AM, revealed "...12/26/2021...Metoclopramide 5 mg four times a day...oral; 5/19/2023...Gabapentin 300 mg four times a day oral as needed; 2/3/2023...Clonazepam 1 mg (1 1/2 tablet) by mouth three times a day; Over the Counter [OTC] D3 125 mcg (5,000 IU) by mouth every day; Calcium 600 mg oral every day; Chewable Aspirin 81 mg by mouth every day; Ferrous Sulfate 325 mg by mouth every day; Omeprazole 20 mg by mouth twice a day; and Elderberry Gummies 100 mg by mouth daily..." During an interview with Patient #5 on 6/7/2023 at 9:25 AM, Patient #5 stated "...What antibiotic?" During an interview with the Administrator on 6/7/2023 at 9:30 AM, confirmed Patient #5's medical record needed to be reconciled. 6. Review of the medical record revealed Patient #6 was admitted to the agency on 4/21/2023 with diagnoses of Diabetes Mellitus, Hypertension, and Benign Prostatic Hyperplasia. Review of the Client Medication Report revealed "...4/28/2023...Dicyclomine [Gut Antispasmodic] 20 mg...three times daily as needed...by mouth; and 5/4/2023...Tylenol 325 mg [2 tablets] every 6 hours by mouth as needed..." Observations of Patient #6's home medications revealed "...5/25/2023...Dicyclomine 20 mg by mouth three times a day for 30 days..." During an interview with Patient #6 on 6/7/2023 at 10:25 AM, he stated "...I don't have the Tylenol..." During an interview with the Administrator on 6/7/2023 at 10:35 AM, confirmed Patient #6's medical record needed to be reconciled. 7.Review of the medical record revealed Patient #7 was admitted to the agency on 6/1/2023 with diagnoses of Malignant Neoplasm of the Tongue. Review of the Client Medication Report revealed, "...6/1/2023...Baclofen [Muscle Relaxer] 5 mg...3 times daily...oral; 6/1/2023...Cetirizine [Antihistamine]10 mg... daily... oral..." Observations on Patient #7's home medications on 6/6/2023 at 1:15 PM, revealed "...Hydralazine [Vasodilator] 50 mg oral three times a day..." During an interview with Patient #7's wife on 6/6/2023 at 1:20 PM, stated :...ran out of the Baclofen when he was in therapy...The pharmacy had run out of the Cetirizine, and called 5/31/2023, but I haven't gone to pick them up..." During an interview with the Administrator on 6/6/2023 at 1:25 PM, confirmed Patient #7's medical record needed to be reconciled. 8.Review of the medical record revealed Patient #13 was admitted to the agency on 5/17/2023 with diagnoses of Diabetes Mellitus, Age Related Osteoporosis with Current Pathological Fracture of Left Femur, Hypertension, Spinal Stenosis, and Chronic Sinusitis. Review of the Client Medication Report revealed "...5/31/2023...Eliquis 5 mg...2 times daily by mouth and Tramadol [Narcotic] 200 mg...by mouth..." During observations of Patient #13's home medications on 6/7/2023 at 11:40 AM, revealed "...Folic Acid 1 mg by mouth every day; Xarelto 20 mg by mouth every day; B12 1000mcg by mouth every day; Tylenol PM as needed; and 9 unopened bottles of Nasal Relief..." During an interview with Patient #13 on 6/7/2023 at 11:45 AM, she stated "...the Eliquis was too expensive and the doctor change it to Xarelto...I order the nasal spray over Amazon...I stopped taking the Tramadol on my own..." 9. During an interview with the Administrator on 6/7/2023 at 11:55 AM, confirmed Patient #7's medical record needed to be reconciled.

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 policy review, medical record review and interview, the facility failed to ensure the plan of care (POC) was followed for social services for one of twelve (Patient #1) sampled active patients reviewed. The findings included: Review of the facility's "The Home Health Plan of Care" policy (revised 7/21) revealed, "...Each patient will receive the care and services written in their individualized plan of care, including any revisions or additions..." Medical record review for Patient #1 revealed a POC dated 3/26/2023-5/24/2023 with diagnoses that included Hypertensive Heart Disease and Heart Failure. A Resumption of Care (ROC) order dated 4/18/23 revealed an order for Medical Social Work evaluation, week of 4/16/23. There was no documentation a social work evaluation was performed for Patient #1. In an interview on 6/7/23 at 12:30 PM in the conference room, the facility's Administrator and Regional Administrator verified the social work evaluation was not performed.