Every finding on record at Patient Care of Hudson County, LLC

This report is the result of an unannounced Federal Recertification survey, completed December 12, 2025, at Bayonne Visiting Nurse Association. It was determined the facility is in substantial compliance with the requirements of Emergency Preparedness regulation 42 CFR 484.102 Condition of Participation for Home Health Agencies for this survey.

This report is the result of an unannounced condition-level Federal Recertification survey, completed on December 12, 2025, at Bayonne Visiting Nurse Association. It was determined the facility is not in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This STANDARD is not met as evidenced by: Based on facility policy, staff interview, observation, and medical record review, it was determined the facility failed to ensure patients with limited English proficiency are provided a translator in their preferred language (Patient (P6)). On 12/10/25 at 12:31 PM, Staff (S)13 was observed providing care to Patient (P)6. P6’s family member was present during the visit and identified him/herself as P6’s primary caregiver. At 12:36 PM, while S13 provided care and education to P6, it was observed P6 had a limited understanding of English. S13 spoke to P6 in English and P6 would respond in a mix of Spanish and English. S13 was observed conducting P6’s medication reconciliation and education on medications in English accompanied with limited Spanish. At 12:45 PM, conducted a comprehensive assessment of P6. Throughout the assessment surveyors observed P6’s family member providing English to Spanish translation for questions that involved complex vocabulary. At 1:25 PM, S13 was observed providing diabetes education to P6. While providing the education, P6’s family member stated, “[he/she] won’t understand you, I’ll tell [him/her] what you’re saying.” S13 was agreeable and continued educating P6 in English. Surveyors did not observe S13 ask P6 during the visit if P6’s family member was an acceptable option for interpretation from English to Spanish. A review of P6’s medical record was conducted and revealed the following: On 11/19/25, P6’s admission visit and initial assessment were conducted by S13. In the “Assessment” section of the Visit Note Report, S13 documented P6’s response to the question, “What is your preferred language?” as “Spanish”. S13 documented P6’s response to the question, “Do you need or want an interpreter to communicate with a doctor or health care staff?” as “Yes”. On 11/26/25 at 6:28 PM, an In-Home Visit Note Report was documented by a physical therapist that stated, “… Patient is … Spanish speaking …" On 12/10/25 at 11:46 PM, an In-Home Visit Note Report written by S13 stated, “…Educationm [sic] was done with son present and explaining to patient in Spanish …” P6’s medical record lacked evidence that P6 requested to use his/her family member as an interpreter. P6’s medical record lacked evidence that an agency-provided language interpreter was offered to P6. On 12/11/25 at 12:53 PM, an interview was conducted with S1 and S9. When asked how a situation with a patient who has limited English proficiency should be handled, S1 stated, staff should utilize the interpreter application found on the facility provided tablet. S1 stated, staff are able to open the application and choose which language is needed for interpretation services. When asked what occurs if a patient requests to utilize a family member as their interpreter, S9 stated, “we try not to use family and encourage an interpreter.” At 2:30 PM, S1 confirmed that a Limited English Proficiency (LEP) patient should be offered the option of having an interpreter during his/her visit. S1 stated, if the patient requests to have his/her family member as an interpreter, the staff member must document the request in the patient's medical record. Facility policy titled, “Limited English Proficiency Persons (LEP)” (revised 07/01/24) stated, “…Policy … The agency will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits … All interpreters, translators, and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients/clients and their families will be informed of the availability of such assistance free of charge … Language assistance will be provided through use of competent bilingual staff, staff interpreters, contact or formal arrangements with organizations providing interpretation or translation services, or technology and telephonic interpretation services … Procedure … 5. Family and friends may not be used to interpret or translate unless client/LEP person is made aware of the availability of interpreters … When a family member or friend is specifically requested by the patient to provide language interpretation, the agency will encourage the addition of an agency-provided language interpreter to be available to the family/patient … Such an offer and the response will be documented in the patient’s medical record.” On 12/11/25 at 12:53 PM, an interview was conducted with S1 and S9. When asked how a situation with a patient who has limited English proficiency should be handled, S1 stated staff should utilize the interpreter application found on the facility provided tablet. S1 stated staff are able to open the application and choose which language is needed for interpretation services. When asked what occurs if a patient requests to utilize a family member as their interpreter, S9 stated, “we try not to use family and encourage an interpreter.” On 12/11/25 at 2:00 PM, P6’s medical record was reviewed and revealed the following: On 11/19/25, during P6’s initial assessment and admission to the facility, an assessment note by a Registered Nurse (RN) was documented and stated: “What is your preferred language? Spanish Do you need or want an interpreter to communicate with a doctor or health care staff? 1. Yes …” On 11/26/25 at 6:28 PM, an In-Home Visit Note Report was documented by a physical therapist that stated, “… Patient is … Spanish speaking …" On 12/10/25 at 11:46 PM, an In-Home Visit Note report was documented by S13 stating, “…Educationm [sic] was done with son present and explaining to patient in Spanish …” On 12/10/25 at 12:31 PM, arrival at Patient (P)6’s residence occurred. Entrance to P6’s residence occurred in the presence of Staff (S)13. P6 was accompanied by his/her son/daughter. On 12/10/25 at 12:36 PM, S13 was observed providing care for P6. While S13 provided care and education to P6, it was observed P6 had a limited understanding of English and that P6’s son/daughter was providing translation to Spanish throughout the visit. S13 was observed educating P6 in English accompanied with limited Spanish. On 12/10/25 at 1:25 PM, S13 was observed providing education to P6. While providing education, P6’s son/daughter stated, “[he/she] won’t understand you, I’ll tell [him/her] what you’re saying.” S13 was agreeable and continued educating P6 in English. S13 failed to confirm with P6 if utilizing P6’s son/daughter was an acceptable option for interpretation from English to Spanish. P6's medical record lacked evidence of P6's son/daughter as being utilized as P6's interpreter. S13 failed to offer a facility provided interpreter as an option for interpreting English to Spanish due to P6’s limited English proficiency. P6's medical record lacked evidence of an interpreter being utilized . On 12/11/25 at 2:30 PM, S1 confirmed that a LEP patient should be offered the option of having an interpreter during his/her visit. S1 stated if the patient requests to have his/her family member as an interpreter, the staff member must document this in the patient's medical record. NJAC 8:42-13.2 (5) Findings include: Facility policy titled, “Limited English Proficiency Persons (LEP)” (revised 07/01/24) stated, “…Policy … The agency will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits … All interpreters, translators, and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients/clients and their families will be informed of the availability of such assistance free of charge … Language assistance will be provided through use of competent bilingual staff, staff interpreters, contact or formal arrangements with organizations providing interpretation or translation services, or technology and telephonic interpretation services … Procedure … 5. Family and friends may not be used to interpret or translate unless client/LEP person is made aware of the availability of interpreters … When a family member or friend is specifically requested by the patient to provide language interpretation, the agency will encourage the addition of an agency-provided language interpreter to be available to the family/patient … Such an offer and the response will be documented in the patient’s medical record.” On 12/10/25 at 12:31 PM, Staff (S)13 was observed providing care to P6. P6’s family member was present during the visit and identified him/herself as P6’s primary caregiver. At 12:36 PM, while S13 provided care and education to P6. S13 spoke to P6 in English and P6 would respond in a mix of Spanish and English. S13 was observed conducting P6’s medication reconciliation and education of medications in English and using limited Spanish words. At 12:45 PM, S13 conducted a comprehensive assessment of P6. Throughout the assessment, surveyors observed P6’s family member providing English to Spanish translation for questions that involved complex vocabulary. At 1:25 PM, S13 was observed providing diabetes education to P6. While providing the education, P6’s family member stated, “[he/she] won’t understand you, I’ll tell [him/her] what you’re saying.” S13 was agreeable and continued educating P6 in English. Surveyors did not observe S13 ask P6 during the visit if P6’s family member was an acceptable option for interpretation from English to Spanish. A review of P6’s medical record was conducted and revealed the following: On 11/19/25, P6’s admission visit and initial assessment were conducted by S13. In the “Assessment” section of the Visit Note Report, S13 documented P6’s response to the question, “What is your preferred language?” as “Spanish.” S13 documented P6’s response to the question, “Do you need or want an interpreter to communicate with a doctor or health care staff?” as “Yes.” On 11/26/25 at 6:28 PM, an In-Home Visit Note Report was documented by a physical therapist that stated, “… Patient is … Spanish speaking …" On 12/10/25 at 11:46 PM, an In-Home Visit Note Report written by S13 stated, “…Educationm [sic] was done with son present and explaining to patient in Spanish …” P6’s medical record lacked evidence that P6 requested to use his/her family member as an interpreter. P6’s medical record lacked evidence that an agency-provided language interpreter was offered to P6. On 12/11/25 at 12:53 PM, an interview was conducted with S1 and S9. When asked how a situation with a patient who has limited English proficiency should be handled, S1 stated that staff should utilize the interpreter application found on the facility provided tablet. S1 stated that staff are able to open the application and choose which language is needed for interpretation services. When asked what occurs if a patient requests to use a family member as their interpreter, S9 stated, “we try not to use family and encourage an interpreter.” At 2:30 PM, S1 confirmed that a Limited English Proficiency (LEP) [understanding of English] patient should be offered the option of having an interpreter during his/her visit. S1 stated, if the patient requests to have his/her family member as an interpreter, the staff member must document the request in the patient's medical record.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and review of facility policies, it was determined the facility failed to ensure staff communicate with the physician when there is a delay in services when a missed visit occurs, in seven of the 12 active medical records reviewed (Patient (P)1, P2, P3, P9, P10, P11, and P12). A review of P12’s medical record was conducted and revealed the following: P12’s Plan of Care Orders for the certification period beginning 11/10/25 showed visit orders for the SN as “effective 11/16/25 1 WK1 [one visit a week for one week] and…PT as “2WK1[two visits a week for one week], 1WK5 [one visit a week for five weeks]…” During the week of 11/10/25 to 11/15/25, the medical record showed that P12 only received one visit from the PT. P12 did not receive a second PT visit or a visit from the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. An updated order placed on 11/21/25 states, “Move RN01 [registered nurse] to next Medicare Week…SN EFFECTIVE 11/23/25 1WK1 [one visit a week for one week]” During the week of 11/23/25-11/29/25, the medical record showed that P12 did not receive any visits from the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. Findings include: Facility policy titled "Coordination of Care, From Admit Through Discharge," dated 12/01/25, stated, "… Procedure: … 4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: … c. When a missed visit occurs altering the Plan of Care …" Facility policy titled "Home Care Record," dated 10/01/25, stated, "… Procedure: … 2. The patient home care record shall contain the following clinical information: … p. Documentation and communication with the … physicians …" A review of P1's medical record was conducted and revealed the following: P1’s Plan of Care Orders for the certification period beginning 11/19/25 showed visit orders for the Physical Therapist (PT) as "… 1WK7 [one visit a week for seven weeks] …" beginning on 11/19/25. During the week of 11/23/25 to 11/29/25, the medical record showed that P1 did not receive any visits by the PT. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P2's medical record was conducted and revealed the following: P2’s Plan of Care Orders for the certification period beginning 10/29/25 showed visit orders for the PT as "… 3WK1 [three visits a week for one week], 2WK7 [two visits a week for seven weeks] …" beginning on 10/29/25. During the week of 10/26/25 to 11/01/25, the medical record showed that P2 received one visit by the PT on 10/29/25 and had one Missed Visit Notification Note by the PT for 10/31/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician for the third visit ordered for the week. During the week of 11/16/25 to 11/22/25, the medical record showed that P2 received only one visit by the PT on 11/18/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P3's medical record was conducted and revealed the following: P3’s Plan of Care Orders for the certification period beginning 09/13/25 showed visit orders for the Skilled Nurse (SN) as "… 1WK8 [one visit a week for eight weeks] …" beginning on 11/16/25. During the week of 11/23/25 to 11/29/25, the medical record showed that P3 did not receive any visits by the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P9's medical record was conducted and revealed the following: P9’s Plan of Care Orders for the certification period beginning 11/11/25 showed visit orders for the SN as "… 2WK7 [two visits a week for seven weeks] …" beginning on 11/23/25. During the week of 11/30/25 to 12/06/25, the medical record showed that P9 received only one visit by the SN on 12/03/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. A review of P10's medical record was conducted and revealed the following: P10’s Plan of Care Orders for the certification period beginning 11/10/25 showed visit orders for the Occupational Therapist (OT) as "… 1WK1 [one visit a week for one week] …" beginning on 11/10/25, for the SN as "… 1WK1 [one visit a week for one week], 2WK1 [two visits a week for one week], 1WK3 [one visit a week for three weeks] …" beginning on 11/10/25, and for the PT as "… 3WK2 [three visits a week for two weeks], 2WK1 [two visits a week for one week], 1WK3 [one visit a week for three weeks] …" beginning on 11/10/25. During the week of 11/09/25 to 11/15/25, the medical record showed that P10 did not receive any visits by the OT. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. During the week of 11/16/25 to 11/22/25, the medical record showed that P10 did not receive any visits by the PT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. During the week of 11/23/25 to 11/29/25, the medical record showed that P10 did not receive any visits by the PT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. During the week of 11/30/25 to 12/06/25, the medical record showed that P10 did not receive any visits by the PT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. A review of P11's medical record was conducted and revealed the following: P11’s Plan of Care Orders for the certification period beginning 10/16/25 showed visit orders for the OT as "… 1WK5 [one visit a week for five weeks] …" beginning on 10/26/25, for the SN as "… 3WK1 [three visits a week for one week], 2WK2 [two visits a week for two weeks], 1WK3 [one visit a week for three weeks] …" beginning on 10/26/25, and for the PT as "… 2WK2 [two visits a week for two weeks], 1WK5 [one visit a week for five weeks] …" beginning on 10/19/25. During the week of 10/26/25 to 11/01/25, the medical record showed that P11 received only two visits by the SN on 10/28/25 and 10/31/25. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visit and notification to the physician. During the week of 11/23/25 to 11/29/25, the medical record showed that P11 did not receive any visits by the OT and the SN. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. During the week of 11/30/25 to 12/06/25, the medical record showed that P11 did not receive any visits by the PT. The medical record lacked evidence of a Missed Visit Notification Note regarding the missed visits and notification to the physician. All findings were confirmed by Staff (S)1. On 12/11/25 at 12:40 PM, an interview was conducted with S1 and S9. When questioned about missed visits, S1 stated that a Missed Visit Notification Note is to be entered into Homecare Homebase and the medical provider must be notified when a missed visit occurs. S1 stated that the Missed Visit Notification Note should include the staff members discipline, the date of the missed visit, and information on the notification of the medical provider. Cross reference: NJAC 8:42-6.1(a)(6)

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, staff interview, and review of facility policies, it was determined the facility failed to ensure that facility policies to prevent the transmission of infections and communicable diseases, related to cleaning of equipment, hand hygiene, and bag protocol, in four of seven home visits (Patient (P)1, P2, P3, and P7) are adhered to by all staff. Facility policy titled “Hand Hygiene”, dated 09/05/25, stated, “… Procedure: 1. Staff performs hand hygiene by hand washing with soap and water or an alcohol-based hand sanitizer …” Facility policy titled "Bag Protocol Policy," dated 11/25/25, stated, "… Procedure … Infection Control Practices C. Perform hand hygiene before removing or returning supplies to the bag … G. Prior to returning equipment to the home care bag, equipment must be cleaned using gloves with the appropriate disinfectant (refer to Policy 8.006 – Cleaning of Re-Usable Equipment) …" On 12/09/25 at 1:05 PM, S3 was observed providing care for P3. At 1:07 PM, placed his/her tablet on a barrier pad on the living room table with his/her nursing bag. At 1:14 PM, P3’s family member picked up the tablet while searching for medications on the table. At 1:19 PM, S3 used scissors to remove dressings for the wound on P3’s left foot. At 1:21 PM, S3 placed the contaminated scissors next to the tablet on the barrier pad. At 1:42 PM, S3 began assessing P3’s vital signs. At 1:45 PM, S3 placed the contaminated vital signs equipment (blood pressure cuff, sphygmomanometer, stethoscope, pulse oximeter, thermometer) on top of the tablet on the barrier pad. At 1:52 PM, S3 cleaned the vital signs equipment with alcohol wipes and placed the equipment in his/her nursing bag. S3 did not clean the tablet. At 1:57 PM, S3 discarded the barrier pads and placed the contaminated tablet on P3’s table. At 2:05 PM, S3 exited P3’s home carrying the contaminated tablet in his/her hands. At 2:10 PM, an interview was conducted with S3. When questioned about the process for cleaning the tablet, S3 stated, he/she forgot to clean the tablet. S3 stated, the tablet should be cleaned after each patient visit. On 12/11/25 at 10:00 AM, S7 was observed providing care for P7. At 10:06 AM, S7 donned gloves and began assessing P7’s vital signs. At 10:10 AM, S7 completed vital signs. At 10:13 AM, S7 began conducting patient education on discharge with same gloves on from vital signs assessment. At 10:21 AM, S7 completed patient education and began conducting physical therapy exercises with P7 in his/her kitchen with same gloves on from vital signs assessment. At 10:29 AM, S7 doffed gloves and entered the central compartment of his/her nursing bag without hand sanitizing. At 10:41 AM, an interview was conducted with S7. When questioned about the facility policy for bag technique, S7 stated, staff must doff gloves and hand sanitize before entering the nursing bag. S7 confirmed that he/she did not hand sanitize prior to entering the bag at 10:29 AM. At 12:40 PM, an interview was conducted with S1 and S9. When questioned about bag technique, S1 stated, staff are taught to hand sanitize prior to accessing the bag and after every glove change. Findings include: Facility policy titled "Cleaning of Re-Useable Equipment," dated 06/01/25, stated, "… Definitions: 1. Low-Level Disinfection … Examples include at least 70% isopropyl alcohol/ethyl alcohol … 3. Non-Critical Items – Equipment that is only meant to come in contact with intact patient skin … (e.g., stethoscope, blood pressure cuffs, pulse-oximeters … tablet) … Non-critical items also include … (e.g., staff bags,) … Procedure: 1. Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use … 7. … tablet … should be wiped down with a low-level disinfectant at the … end of each visit …" On 12/09/25 at 1:17 PM, Staff (S)4 was observed providing care for P1. At 1:18 PM, S4 was observed setting up two barrier pads. S4 placed his/her bag on a barrier pad and removed a sphygmomanometer (blood pressure cuff), stethoscope, thermometer, and pulse oximeter from his/her bag placing them on the same barrier pad next to the bag. The second barrier pad remained empty. At 1:21 PM, P1 was observed touching both barrier pads with bare hands while searching for his/her admission packet, contaminating both barrier pads. At 1:22 PM, S4 took P1’s blood pressure and heart rate and then placed the contaminated equipment (sphygmomanometer, pulse oximeter, and stethoscope) on the empty barrier pad. At 1:27 PM, S4 took P1’s temporal (forehead) temperature and then placed the contaminated thermometer on the barrier pad with the sphygmomanometer, pulse oximeter, and stethoscope. At 1:37 PM, S4 cleaned the contaminated vital signs equipment (thermometer, pulse oximeter, sphygmomanometer, and stethoscope) with a disposable alcohol wipe and then placed the equipment back on the previously contaminated barrier pad next to his/her bag, re-contaminating the vital signs equipment. At 1:44 PM, P1 was observed touching the vital signs equipment and S4’s bag with bare hands while searching for his/her medication list, further contaminating the vital signs equipment and contaminating S4’s bag. At 1:45 PM, S4 placed the contaminated vital signs equipment back in his/her bag. At 2:00 PM, S4 was observed exiting P1’s home without re-cleaning the contaminated vital signs equipment and cleaning the contaminated bag. At 2:04 PM, an interview was conducted with S4. While reviewing the home visit, S4 confirmed the findings. On 12/09/25 at 2:31 PM, S5 was observed providing care for P2. At 2:33 PM, S5 took P2’s blood pressure and heart rate, with bare hands, and then placed the contaminated equipment (sphygmomanometer, pulse oximeter, and stethoscope) on a barrier pad. S5 then, with bare hands, accessed his/her tablet, contaminating the tablet. At 2:35 PM, S5 measured P2’s ankles, with bare hands, and then accessed his/her tablet, contaminating the tablet. At 3:24 PM, S5 cleaned the vital signs equipment (pulse oximeter, sphygmomanometer, and stethoscope) with a disposable alcohol wipe and then placed the equipment on a barrier pad. S5 then placed the contaminated tablet on the vital signs equipment, re-contaminating the vital signs equipment. At 3:28 PM, P2 was observed signing the tablet with his/her bare hands. S5 was then observed exiting P2’s home without re-cleaning the contaminated vital signs equipment and cleaning the contaminated tablet. At 3:29 PM, an interview was conducted with S5. While reviewing the home visit, S5 confirmed the findings. On 12/11/2025 at 12:40 PM, an interview was conducted with S1 and S9. While reviewing the findings for the home visits for P1 and P2, S1 and S9 stated, the vital signs equipment should have been cleaned again following re-contamination. S1 stated, staff tablets should be cleaned after every patient visit. NJAC 8:42-12.2(b) NJAC 8:42 – 12.3

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure a Governing Body was established to oversee the Home Health Agency. §484.105(a): Governing Body §484.105(b)(1): Administrator §484.105(b)(2): Alternate Administrator §484.105(e)(2): Written Agreement

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure a Governing Body was established for the Home Health Agency. On 12/12/25 at 10:01 AM, S1 provided surveyors with facility document titled “OPERATIONAL BYLAWS AND RULES of Bayonne Visiting Nurse Association, INC./LLC”, Adopted: “December 11, 2025”. The document was signed by S9, Executive Director, on 12/11/25. While providing the document, S1 stated, “now we understand that this is necessary.” At 11:30 AM, surveyors requested an interview with S8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave today. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. When questioned about governing body documentation, S9 confirmed that the facility was unable to provide documentation of governing body meeting minutes or bylaws prior to December 11, 2025. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Governing Body Bylaws and meeting minutes were requested. Staff (S)1 asked the surveyor to explain what was meant by “Governing Body.” Governing Body was explained to S1. On12/10/25 at 12:14 PM, Governing Body Bylaws and meeting minutes were requested again of S1. The Governing Body regulation was reviewed with S1. S1 stated that he/she would check to see what they have. On 12/11/25 at 1:01 PM, Governing Body Bylaws and meeting minutes were requested again of S1 and S9. The Governing Body regulation was reviewed with both S1 and S9. S1 reported that the annual agency evaluation is part of the “executive summary” that is discussed at QAPI (Quality Assurance and Performance Improvement-Ongoing, data-driven program that identifies, monitors, and corrects systemic problems in care and operations to improve quality and patient safety) meeting. At 2:10 PM, S1 presented the facility’s QAPI minutes again, which included a one page document titled, “Annual Agency Report.” Upon review of these documents, there is no evidence of Governing Body duties discussed at these meetings. On 12/12/25 at 10:01 AM, S1 provided surveyors with a facility document titled, “OPERATIONAL BYLAWS AND RULES of Bayonne Visiting Nurse Association, INC./LLC”, Adopted: “December 11, 2025”. This document was signed by S9, the Executive Director, on 12/11/25. While providing the document, S1 stated, “now we understand that this is necessary.” This document did not exist when the surveyors started the survey on 12/9/25. On 12/12/25 At 11:30 AM, the surveyors requested an interview with S8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave today. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. When questioned about governing body documentation, S9 confirmed that the facility was unable to provide documentation of governing body meeting minutes or bylaws prior to December 11, 2025.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure the administrator was appointed by the facility's governing body. On 12/12/25 at 11:30 AM, surveyors requested an interview with Staff (S)8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. He/she is the Alternate Administrator.” A review of the organizational chart provided by the facility lacked evidence of S9 as Alternate Administrator. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. S9 stated, he/she was hired in June 2025. When questioned about who appointed him/her as Alternate Administrator, S9 stated that he/she was appointed by the Regional Vice President of Operations. S9 stated that his/her name should appear on the facility organizational chart as Alternate Administrator. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” At 02:40 PM, S1 provided surveyors with facility document titled "Administrative Appointments." The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In his/her absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointments of S8 as Administrator. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Staff (S) 8 was identified as administrator for the facility. On 12/12/25 at 11:30 AM, surveyors requested an interview with 8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. [He/she] is the Alternate Administrator.” At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” At 2:40 PM, S1 provided surveyors with facility document titled "Administrative Appointments." The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In [his/her] absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointments of S8 as Administrator.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure an alternate administrator was designated, in writing, by the facility's administrator and governing body. On 12/12/25 at 11:30 AM, surveyors requested an interview with Staff (S)8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. He/she is the Alternate Administrator.” A review of the organizational chart provided by the facility lacked evidence of S9 as Alternate Administrator. At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. S9 stated, he/she was hired in June 2025. When questioned about who appointed him/her as Alternate Administrator, S9 stated that he/she was appointed by the Regional Vice President of Operations. S9 stated that his/her name should appear on the facility organizational chart as Alternate Administrator. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” At 02:40 PM, S1 provided surveyors with facility document titled "Administrative Appointments." The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In his/her absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointment of S9 as Alternate Administrator. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Staff (1) identified him/herself as the alternate administrator for the facility. On 12/12/25 at 11:30 AM, surveyors requested an interview with S8, the Administrator. S1 stated that S8 was unavailable for interview as he/she had a medical emergency and was out on medical leave. S1 stated, “You can speak to S9. [He/she] is the Alternate Administrator.” At 1:28 PM, an interview was conducted with S9. S9 stated, he/she was the Alternate Administrator for the facility. S9 stated, he/she was hired in June 2025. When questioned about who appointed him/her as Alternate Administrator, S9 stated that he/she was appointed by the Regional Vice President of Operations. S9 stated that his/her name should appear on the facility organizational chart as Alternate Administrator. When questioned if there was any documentation from governing body meeting minutes that would provide evidence of the appointment of S8 or S9 as Administrator for the facility, S9 stated “No.” A review of the organizational chart provided by the facility lacked evidence of S9 as Alternate Administrator. At 2:40 PM, S1 provided surveyors with facility document titled "Administrative Appointments." The document stated, “The governing body appoints [S8] to serve as the agency Executive Director (Administrator and Supervising Nurse) … In [his/her] absence, [S9] is given the administrative authority and responsibility to carry out these same position responsibilities...” The document was dated “6/24/2025” and lacked a signature from S8. S1 confirmed that facility was unable to provide governing body meeting minutes documenting the appointment of S9 as Alternate Administrator.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure written agreements for social work services, that were provided to the home health agency's patients, by another home health agency. Findings include: On 12/09/25 at 9:51 AM, during entrance conference, Staff (S) 1 reported that the facility currently does not have social workers at this branch to provide services to the patients. At 10:15 AM, S1 reported that the parent company has eight branches, and if necessary, staff, social workers, can be borrowed from one of the other branches. When asked if any of these branches share the same license number with this facility, S1 reported that there are no other branches under their license. S1 reported that there are two social workers who cover patients at different branches. On 12/11/25 at 1:07 PM, S1 was asked to provide written agreements or contracts with other agencies/branches for use of their HHA or SW staff. On 12/12/25 at 10:32 AM, Staff (S)1 presented a document to surveyors titled “Shared Employee Form” for S15 and S16, the two social workers the facility uses from a separately licensed facility. The form for S15 stated “Effective Date: 04/20/25”. The form for S16 stated “Effective Date: 08/25/24”. The forms were only signed by the social worker and their supervisor at the other facility. At 4:00 PM, S1 presented a document to surveyors titled “Shared Employee Form” for S17, a home health aide the facility uses from a separately licensed facility. The form for S16 stated “Effective Date: 04/20/25”. The form was only signed by the home health aide and their supervisor at the other facility. S1 confirmed that the Shared Employee Forms were not signed by a representative from their agency, did not specify each party’s responsibilities, functions, and objectives, and did not contain a time during which the services were to be provided or the duration of the agreement.

The facility is in compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Conditions of Participation for Home Health Agencies for this survey.

Survey dates: 1/25/23, 1/26/23, and 1/27/23 This was a Federal Recertification survey and State Re-licensure survey. Bayonne Visiting Nurse Association is not in compliance with Federal requirements under 42 CFR Part 484 regulations for Home Health Agencies and State requirements under Title 8 - Chapter 42, Licensing Standards for Home Health Agencies. As a result of this survey, Standard level deficiencies were cited. In addition, a Mandatory Vaccination Investigation was completed during this survey.

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 observation, staff interviews, and review of five of 14 medical records (#3, #4, #5, #6, #13), it was determined that the agency failed to ensure: 1) physician orders indicated on the patient's plan of care, are implemented; 2) services ordered by the physician are provided as indicated in the plan of care. Findings include: On 1/26/23 at 11:30 AM, during medical record review, the following was revealed: Upon review of the "Home Health Certification and Plan of Care" for Patient (P) 5, dated 1/26/2023 to 1/23/2023, the following was noted:"Frequency/Duration of Visits" states "SN (skilled nursing) 2wk8 (two times a week for eight weeks)."The week of 12/25/22, the patient had one skilled nursing visit. The week of 1/1/23, the patient had one skilled nursing visit.Upon review of the Home Health Certification and Plan of Care for P13, dated 6/4/2022 to 8/2/2022, the following was noted:"Frequency/Duration of Visits" states "SN 1wk1 (one time a week for one week), 2wk3 (two times a week for three weeks), 1wk6 (one time a week for six weeks)."The week of 6/5/22, week two of the certification period, the patient had one skilled nursing visit. On 1/27/23 at 12:35 PM, the above findings were confirmed with Staff #1. On 1/27/23 at 1:00 PM, during medical record review, the following was revealed: Upon review of the "Home Health Certification and Plan of Care" for Patient (P) 6, dated 12/7/2022 through 2/4/2023, the following was noted: The indicated orders for physical therapy visits were: "1WK2 [one visit each week for two week], 2WK5 [two visits each week for five weeks], 1WK1 [one visit each week for one week.] and revised on 1/15/23 to 3WK1 [three visits each week for one week], 1WK1 [one visit each week for one week].” The week of 1/15/23, P6 had physical therapy visits on 1/17/23 and 1/20/23. P6’s medical record lacked evidence of a third physical therapy visit for the week of 1/15/23. On 1/27/23 at 1:35 PM, Staff #11 stated “we are unable to reconcile that missed visit.” Based on observation, staff interview, review of two of three medical records (#3, #4) for the patient's individualized plan of care, and review of facility policy and procedure, it was determined the facility failed to ensure that physician orders indicated on the patient's plan of care, are implemented. Findings include: Review of the plan of care for Patient #3 (P3) on 01/26/23, for certification period 01/13/23 to 03/13/23, revealed the following: The section labeled, "Orders of Discipline and Treatments" states, " ... Therapist to assess lower extremities for presence of lesions on every visit. ... When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters ... Temp100.5 (temperature less than 96.5 degrees Fahrenheit and greater than 100.5 degrees Fahrenheit)." During a home visit for P3 on 01/26/23, in the presence of Staff #4 (Patient Care Manager), Staff #8 did not assess the patient's lower extremities for the presence of lesions. Staff #8 did not assess the patient's temperature to determine if it was less than 96.5 degrees Fahrenheit or greater than 100.5 degrees Fahrenheit. Review of the plan of care for Patient #4 (P4) on 01/26/23, for certification period 12/23/22 to 02/20/23, revealed the following: The section labeled, "Orders of Discipline and Treatments" states, " ... When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters ... Temp100.5 (temperature less than 96.5 degrees Fahrenheit and greater than 100.5 degrees Fahrenheit)." During a home visit for P4 on 01/26/23, in the presence of Staff #4, Staff #9 did not assess the patient's temperature to determine if it was less than 96.5 degrees Fahrenheit or greater than 100.5 degrees Fahrenheit. Upon interview on 01/27/23 at 12:45 PM, Staff #1 confirmed that physical therapists are licensed professionals and therefore, required to report temperatures outside of established parameters, as indicated in the patient's plan of care. N.J.A.C. 8:42-6.2(a)(6)

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, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure that acceptable standards of practice for hand hygiene, are implemented. Findings include: Facility policy titled, "Hand Hygiene," last revised 05/01/19 states, " … 1. Staff performs hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer: a. before direct contact with patients. … e. after contact with inanimate objects (including medical equipment but excluding the point of care device which is cleaned at the beginning and end of the patient visit) in the immediate vicinity of the patient. f. before and after removal of personal protective equipment (PPE)." During a home visit for Patient #1 P1) on 01/25/23, in the presence of Staff #1 (Executive Director) and Staff #6 (Physical Therapist), the following was observed: At 1:26 PM, Staff #6 doffed (removed) his/her gloves and began cleaning the pulse oximeter. Staff #6 did not perform hand hygiene after doffing his/her gloves. During a home visit for Patient #3 (P3) on 01/26/23, in the presence of Staff #4 (Patient Care Manager) and Staff #8 (Physical Therapist), the following was observed: At 10:38 AM, Staff #8's glasses fell on the floor. With ungloved hands, Staff #8 picked his/her glasses up from the floor and placed them on a barrier that was placed on a table. Staff #8 then resumed his/her activities with P3. Staff #8 did not perform hand hygiene after picking his/her glasses up from the floor. During a home visit for Patient #4 (P4) on 01/26/23, in the presence of Staff #4 and Staff #9 (Physical Therapist), the following was observed: At 11:45 AM, Staff #9 doffed his/her gloves, removed a tablet from his/her bag, and began documenting on the tablet. Staff #9 did not perform hand hygiene after doffing his/her gloves. Upon interview on 01/27/23 at 12:45 PM, Staff #1 stated that staff receive annual education on hand hygiene. N.J.A.C. 8:42-12.3(a)(4)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on staff interviews, and a review of one of five medical records (#14) of patients discharged from services, it was determined that the agency failed to ensure all needed skilled professional staff are involved in the patient's plan of care. Findings include: On 1/25/23 at 11:30 AM, Staff #1 stated that the agency employs one home health aide. Staff #1 stated that the agency's only home health aide is currently out on a medical leave, and that the agency is not offering home health services until the staff member returns to work. On 1/27/23 at 10:45 AM, a review of Medical Record #14 revealed the following: On 9/12/22, Staff #13, MSW (Masters of Social Work), documented in the "Client Communication Note Report" the following: "Patient is a 75 year old [male/female]. … Patient uses a wheel chair [sic], walker, shower chair, commode, and mechanical bed. Patient is hearing impaired. Patient's [wife/husband] is [his/her] primary care taker [sic] and assist [sp] with all of [his/her] ADLS [activities of daily living] and IADLS [instrumental activities of daily living]. … Patient's [wife/husband] relates the patient would benefit from additional support services such as a home health aide. MSW educated the patient's [wife/husband] on the [town name] Office on Aging [phone number]. MSW initiated a referral for the home health aide services and the [named] Program with the [town name] Office on Aging. …" On 9/14/22, Staff #13 documented "... Patient is pending HHA [Home Health Aide] services. MSW provided contact services. No additional MSW services needed at this time." The medical record lacked documentation that the patient received the services of a home health aide. These findings were confirmed by Staff #1 at 12:25 PM on 1/27/23.

This was a Federal Complaint Survey conducted March 15, 2022. Bayonne Visiting Nurse Association is in compliance with 42 CFR Part 416, Conditions of Participation. Standard Level deficiencies were identified during this survey (C #61992).

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on a review of one (1) of one (1) medical record (#1), staff interview, and review of facility documents, it was determined the facility failed to ensure a comprehensive assessment reflecting the patient’s current health status, including identification and assessment of relevant active medical problems, is performed at all times. Findings include: 1. On 3/15/22, upon review of Medical Record #1, the Home Health Certification and Plan of Care indicated the patient’s diagnoses included, but were not limited to, Type 2 Diabetes Mellitus w/ Diabetic Chronic Kidney disease, Type 2 Diabetes with Diabetic Peripheral Angiopathy w/o gangrene, etc. Upon review of the nursing assessments, the following was revealed: a. On 1/20/22, under ENDOCRINE, for the question "Does the patient have diabetes?", Staff #5 indicated "No." b. On 1/26/22, Staff #6’s nursing assessment indicated the patient is diabetic and follow-up assessment questions were addressed to include assessment of lower extremities and diabetic foot care. c. On 2/14/22, Staff #5’s nursing assessment, under ENDOCRINE, did not identify the patient as diabetic and indicated the following: (i) "Does the patient have diabetes?" "No." (ii) A review of the wound assessment documentation stated, "#1 Post – Heel RT DIAB ULCER LTD SKIN BKDWN - Change in Status – None, Wound Assessed – No, caregiver completed care … #2 – POST – HEEL LT. DIAB ULCER UNSP SEVERITY – Change in Status – None, Wound Assessed – No, client completed care, Wound Care Provided – Wound care not provided caregiver completed care." 2. The facility failed to perform an accurate and consistent assessment concerning the patient’s endocrine status, including wound assessment and care. 3. The above findings were confirmed with Staff #2.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on a review of one (1) of one (1) medical record (#1), and staff interviews, it was determined the facility failed to ensure the patient's needs concerning essential medical equipment needed for blood glucose monitoring is addressed. Findings include: 1. Review of Medical Record #1, on 3/15/22, revealed the following: a. The nursing assessment dated 1/26/22, under ENDOCRINE, indicated the patient’s glucometer was not in working order. The Client Coordination Note Report entered by Staff #6 on the day of the visit stated, “… Unable to perform blood glucose. Glucometer not in working order. Advised daughter to have PMD order another glucometer. …” b. Review of the nursing assessment dated 2/9/22, under ENDOCRINE, indicated the patient still did not have a functioning glucometer. Under the section EQUIPMENT/SUPPLIES, Staff #6 documented, “Indicate changes in equipment/equipment needs: N/A – no changes needed to equipment." c. Review of the nursing assessment dated 2/14/22, under ENDOCRINE, indicated the patient was not diabetic. Under EQUPIMENT/SUPPLIES, Staff #5 documented, “Indicate changes in equipment/equipment needs: N/A – no changes needed to equipment." 2. Upon interview, Staff #2 stated it would be expected for the nurse to call the physician to obtain an order for a new glucometer. 3. The above findings were confirmed with Staff #1 and Staff #2.

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 a review of one (1) of one (1) medical record (#1), staff interview, and review of facility documents, it was determined the facility failed to ensure patient-specific plan of care goals and interventions, based on patients' medical diagnosis, physician orders, comprehensive assessment, and patient input. Findings include: Reference: Facility policy titled, "Plan of care (POC)" states, "Policy: Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. PROCEDURE: ... 2. The POC includes: … e. Nutritional requirements … i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient … l. Patient/caregiver education and training for timely discharge. … 9. The patient is monitored for response to treatment and progress towards goals. …” 1. Review of Medical Record #1 conducted on 3/15/22 at 12:43 PM, for the start of care date 1/19/2022, revealed the patient’s diagnoses included, but are not limited to, acute systolic heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes with diabetic peripheral angiopathy without gangrene, peripheral vascular disease, and NSTEMI. a. Review of the patient’s plan of care for a nursing visit dated 1/20/22, failed to include goals and interventions specific to diabetes related issues such as medication, nutrition, patient/caregiver education. b. Review of nursing documentation dated 2/9/22 revealed Staff #6 identified bilateral heel pressure wounds. Upon review of the plan of care, Staff #6 failed to include goals and interventions concerning wound care, nutrition, and patient/caregiver education. 2. The above findings were confirmed with Staff #2.

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 a review of one (1) of one (1) medical record (#1), staff interview, and review of facility documents, it was determined the facility failed to ensure the implementation of facility policy concerning care coordination among various disciplines, to meet patients' needs. Findings include: Reference: Facility policy titled, "Coordination of Care, From Admit Through Discharge" states, "... 5. Coordination of care among disciplines: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge. This includes:... c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient's care regarding patient needs, goals, and care as well as changes in these.... significant changes in the patient condition... ." 1. On 3/15/22, during a review of Medical Record #1, it was revealed that on 2/7/22, Staff #7 (Physical Therapist) documented under INTEGUMENTARY ASSESSMENT, “Patient has bandages on bilateral feet which were just applied and he/she asked they not be removed.” a. Under CARE COORDINATION notes, Staff #7 documented that care coordination occurred with “supervisor” and indicated, “RN to eval B/L [bilateral] heel wounds." b. There was no evidence that Staff #7, or the supervisor, reported this finding to the nurse in charge of the case. c. Review of the CLIENT COORDINATION note dated 2/08/22, revealed the patient’s family member called to request a nursie because the patient had "a bedsore." Review of nursing assessment documentation on 2/9/22 indicated, “Post-Heel, RT [right], Diab [diabetic] Ulcer...” and “Post–Heel, LT [left], Diab [diabetic] Ulcer..." 2. This finding was confirmed with Staff #2.