Every finding on record at Rest Haven Illiana Christian Convalescent Home

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/25/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 02/25/26. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients POC = Plan of Care SOC = Start of Care BP, B/P = Blood Pressure SN = Skilled Nurse/Nursing RN = Registered Nurse PT = Physical Therapy/Therapist mmHg = millimeters of Mercury COVID-19 = Coronary Virus Disease 2019 MD = Medical Doctor PTA = Physical Therapy Assistant AM = morning PM = afternoon MSW = Medical Social Worker

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 clinical records and staff interviews, for 7 of 13 (Pts. #9, 12, 13, 3, 4, 10 and 11) clinical records, the Agency failed to ensure that the orders in the POC were followed. 7. Pt. 11 was admitted to home health services on 08/23/23 with diagnosis of but not limited to Laceration without Foreign Body of Left Buttock and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/24/26. The POC effective 12/15/24 to 02/12/25, required: "....Orders / Treatments:.... Contact MD for blood sugars less than 60 or greater than 400...." The Skilled Nursing Notes dated 12/23/24. 12/30/24, 01/02/25 and 01/06/25, lacked blood sugar monitoring / assessments, as ordered in the POC. 8. During staff interviews with the Administrator, Director of Quality and Clinical Supervisor on 02/24/26 at 12:45 PM and with the Administrator, Director of Quality, Clinical Supervisor and Vice President of Home and Community Based Services on 02/25/26 between 1:15 PM to 2:15 PM, the Administrative staff confirmed the above findings. 4. Pt. #3 was admitted to home health services on 02/04/26 with the diagnosis of Hypertensive chronic kidney disease with stage 1-4. The POC effective 02/04/26 required/documents under Additional Services: Vital ranges: “Notify MD with B/P greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, start date 02/04/26.” The SN note date 02/04/26 documents B/P 98/58. As of 02/25/26, there was no documentation of Physician notification of B/P falling outside range, as ordered in the POC. 5. Pt. #4 was admitted to home health services on 01/21/26 with the diagnosis of Influenza due to other identified influenza virus with other respiratory manifestations. The POC effective 01/21/26 required/documents under Additional Services: Vital ranges: “Notify MD with B/P greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, start date 01/21/26.” The SN note date 01/21/26 documents B/P = 104/42. As of 02/25/26, there was no documentation of Physician notification of B/P falling outside range, as ordered in the POC. 6. Pt. #10 was admitted to home health services on 06/20/25 with the diagnosis Pressure ulcer of sacral region stage 2. The POC effective 06/20/25 required/documents under Additional Services: Vital ranges: “Notify MD with B/P greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, start date 01/21/26.” The RN- SOC Admission visit note dated 06/20/25 documents Pulse = 106. The PT Initial Evaluation visit note dated 06/22/25 documents B/P = 124/94 and Pulse = 116. The PTA visit note dated 06/25/25documents Pulse = 108. As of 02/25/26, there was no documentation of Physician notification of B/P and Pulse falling outside range, as ordered in the POC. Findings include: 1. Pt. #9 was admitted to home health services on 01/06/26 with the diagnosis of GERD (Gastroesophageal Reflux Disease) with esophagitis without bleeding. The clinical record was reviewed on 02/24/26. The clinical record included a POC effective 01/06/26 which required, “Notify MD with BP greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50…” The SN note dated 01/08/26 recorded “Blood pressure 82/60 mmHg” and on 01/12/26, “Blood pressure 97/58 mmHg.” Both SN notes also included the documentation, “Vital sign entered is outside the acceptable range for this patient… followed/documented appropriate care plan intervention.” The Physical Therapy note dated 02/02/26 and 02/13/26, included the documentation, “Pulse 110 beats per minute…” The clinical record lacked documentation the Physician was notified the vital signs were out of parameter range. 2. Pt. #12 was admitted to home health services on 04/23/25 with the diagnosis of Pressure Ulcer other site stage 2. The clinical record was reviewed on 02/24/26. The clinical record included a POC for the certification period of 04/23/25 to 06/21/25, which required, “Notify MD with BP greater than 160/90 or less than 100/50…” The SN note dated 05/23/25 recorded “Blood pressure 92/52 mmHg” and on 05/30/25, “Blood pressure 108/58 mmHg.” Both SN notes included documentation, “Vital sign entered is outside the acceptable range for this patient… followed/documented appropriate care plan intervention.” The clinical record lacked documentation the Physician was notified the vital signs were out of parameter range. 3. Pt. #13 was admitted to home health services on 04/11/25 with the diagnosis of Traumatic subdural hemorrhage without loss of consciousness. The clinical record was reviewed on 02/25/26. The clinical record included a POC for the certification period of 04/11/25 to 06/09/25 which required, “Notify MD with BP greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50…” The SN note dated 04/25/25 recorded “Blood pressure 118/58 mmHg…Pulse 54” and on 05/02/25, “Blood pressure 102/58 mmHg and Pulse 58.” Both SN notes included documentation, “Vital sign entered is outside the acceptable range for this patient… followed/documented appropriate care plan intervention.” The clinical record lacked documentation the Physician was notified the vital signs were out of parameter range.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record and staff interviews, for 1 of 4 (Pt. #12) Pts. reviewed who were receiving wound care, the Agency failed to ensure that the treatment used for wound care was ordered by the Physician. Findings include: 1. Pt. #12 was admitted to home health services on 04/23/25 with the diagnoses of but not limited to Pressure ulcer of other site stage 2, Pressure ulcer of right buttock stage 2, Pressure ulcer of the left buttock stage 2. The clinical record was reviewed on 02/25/25. The following are the physician orders for the wound treatment, from 04/23/25 to 06/12/25: “Decubitus/Pressure Ulcer/Midline Buttocks Cleanse with normal saline or wound cleanser. Apply Medi honey to open area and cover with bordered foam…. Decubitus/Pressure Ulcer/Left Foot Cleanse with normal saline or wound cleanser. Apply xeroform gauze to open area and cover with bordered foam…” The SN notes included the following documentation: 04/25/25 – “Coccyx wound the, same, less erythema to peri wound. SN applied honey and hydrocolloid dressing.” 04/29/25 – “Left Foot/ Decubitus/Pressure Ulcer: Dressing/Wound Vac: Cleansed with wound cleanser, Application/Packing/Other: Medi honey.” 05/16/25 – “Midline Buttocks/Decubitus/Pressure Ulcer: Dressing/Wound Vac: Cleansed with normal saline. Application/Packing: Calcium Alginate, Other: Honey alginate rope.” Narrative: “Sacral wound…applied skin prep to peri wound, packed calcium alginate with honey into wound bed and covered with bordered foam…” 05/30/25 – “Midline Buttocks/Decubitus/Pressure Ulcer: Dressing/Wound Vac: Cleansed with wound cleanser. Application/Packing, Other: Honey alginate.” 06/03/25 - “Midline Buttocks/Decubitus/Pressure Ulcer: Dressing/Wound Vac: Cleansed with normal saline. Application/Packing, Other: Hydrocolloid, covered with Hydrocolloid gauze.” The clinical record lacked physician orders for all the above wound treatments used by the RN. 2. The policy, “Verification of Physician Orders” revised 5/11 was reviewed on 02/25/26 and required, “Orders will be obtained from a licensed physician for care and services to be provided to home health patients…” 3. During a staff interview conducted with the Administrator, Clinical Supervisor, Director of Quality and Vice President of Home and Community Based Services on 02/25/26 at 2:15 PM, the above findings were confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, for 4 of 13 (Pts. 7, 8, 9 and 10) clinical records reviewed, the Agency failed to conduct complete assessments of patients' Influenza and Pneumonia vaccination status. Findings include: 1.The following clinical records were reviewed from 02/23/26 to 02/25/26: Pt. #7 SOC 04/29/25, lacked Influenza vaccination assessment. Pt. #8 SOC 10/03/25, lacked Pneumonia vaccination assessment. Pt. #9 SOC 01/06/26, lacked Influenza vaccination assessment. Pt. #10 SOC 06/20/25, lacked Pneumonia vaccination assessment. The records lacked documentation that the Influenza or Pneumonia vaccination was assessed. 2. The Agency Policy titled: "Flu Plan" was reviewed on 02/25/26 and required: "....During the flu season, screen all patients for flu vaccination status and document in the comprehensive assessment. We will arrange for patients to receive the flu vaccine if they request it...." The Agency Policy titled: "Initial and Comprehensive Assessment" was reviewed on 02/25/25 and required: ".... Procedure....3. During the initial comprehensive patient assessments, all baseline data to be used in measuring the patient's progress towards goals and other relevant information will be documented in the patient's clinical record, including at least the following information....V. Immunizations...." 3. During staff interviews with the Administrator, Director of Quality, and Clinical Supervisor on 02/24/26 at 12:45 PM, and with the Administrator, Director of Quality, Clinical Supervisor, and Vice President of Home and Community Based Services on 02/25/26 between 1:15 PM PM to 2:15 PM, the Administrative team confirmed the above findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation during a home visit, a review of clinical records, policy reviews, and staff interviews, for 3 of 13 clinical records reviewed (Pts. #1, 9 and 13) the Agency failed to ensure that needs and concerns identified regarding Pt. care are communicated with other staff involved in the patient’s care. Findings include: 1. Pt. #1 was admitted to home health services on 01/15/26 with the diagnosis of COVID-19. A home visit was conducted with the PTA on 02/24/26 at 9:00 AM. During the home visit, the PTA obtained the patient's blood pressure. The blood pressure was 77/49 mmHg and out of parameter range. The PTA obtained two more blood pressures which were still out of range. It was observed that the PTA called the SN to report blood pressure reading and the SN recommended the Pt. go to urgent care and the home visit concluded. The clinical record was reviewed on 02/25/26. The record lacked documentation of coordination between care staff. During a staff interview conducted with the Administrator, Clinical Supervisor, and Director of Quality (administrative team) on 02/25/26 at 2:15 PM, it was confirmed that there was no documentation of the above-mentioned Pt. information in the clinical record, and it was stated that the administrative team was not aware of what happened, until it was brought up by the surveyor. 2. Pt, #9 was admitted to home health services on 01/06/26 with the diagnosis of GERD (Gastroesophageal Reflux Disease) with esophagitis without bleeding. The clinical record was reviewed on 02/24/26. The initial comprehensive assessment dated 01/06/26 included documentation the SN identified the need for the Pt. to be referred to MSW. The SN note dated 01/07/26 also included documentation that the SN attempted to call the physician regarding the MSW referral but was unavailable. The clinical record lacked documentation that the need for MSW services was communicated to the Clinical Supervisor and the physician. During a staff interview conducted with the administrative team on 02/25/06, the Clinical Supervisor, who coordinates MSW referral, confirmed that this information was not communicated and therefore there was no MSW referral. 3. Pt. #13 was admitted to home health services on 04/11/25 with the diagnosis of Traumatic subdural hemorrhage without loss of consciousness. The clinical record was reviewed on 02/25/26. The clinical record included documentation of an unplanned discharge from home health services effective 05/05/26. Pt. was transferred to hospice services. The record lacked documentation of coordination between staff members involved in Pt. care related to the need for hospice placement, and transfer or discharge process. 4. The policy, "Care Coordination" revised on 12/25, was reviewed on 02/25/25 and required: "To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting or duplicated services...Written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient's clinical records...4. Care coordination will include, but not limited to: E. Timely documentation of coordination of care activities...H. Proper communication upon 'hand-off' of patient, including the opportunity for questions between the giver and receiver of patient information...7...Documentation of all communications will be included in the clinical record on a communication note, case conference summary or clinical note... Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication..." 4. During staff interviews with the Administrator, Clinical Supervisor, Director of Quality, and Vice President of Home and Community Based Services on 02/25/26 at 2:15 PM, the above findings were confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: SOC = Start of Care SN = Skilled Nurse POC / PsOC = Plan of Care / Plans of Care Pt / Pt.s = Patient / Patients MD = Medical Doctor DM = Diabetes Mellitus PT = Physical Therapy PTA = Physical Therapy Assistant OT = Occupational Assistant

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: A. Based on clinical record review, observations and Pt. interviews made during home visits, and staff interview, it was determined the Agency failed to ensure PsOC include all current Pt. medications. This was found in 3 of 13 (Pt. #1, 2, and 3) clinical records reviewed. Findings include: 1. Pt # 1 SOC 10/13/2022.Diagnoses: Longstanding persistent Atrial Fibrillation, Chronic Diastolic Congestive Heart Failure. During a home visit on 11/01/2022 with Occupational Therapy at 10:30 AM. Pt#1 provided a list the current medication she is taking. The list was a printout from Pt #1 physician’s office. The medication list contained atenolol 25mg every day, and diltiazem hcl 120mg every day. The clinical record for Pt. #1 was reviewed on 11/01/2022 at 12:00 PM. The clinical record contained a POC dated 10/13/2022 to 12/11/2022 that contained atenolol 50mg tablets once a day, and the POC lacked diltiazem hcl 120mg every day. No modification orders were found in the clinical record. 2. Pt. #2. SOC 04/14/2022. Primary Diagnosis: Basal Cell Carcinoma of the Skin. The clinical record was reviewed on 11/01/2022 at 10:30 AM. A home visit was conducted on 10/31/2022, along with the RN. During this home visit, Pt. #2’s medications were reviewed along with Pt. #2, and compared with the POC effective 08/12/2022 to 10/10/2022, and the POC effective 10/11/2022. Pt. #2 stated she takes Atorvastatin 20 mg daily “for more than a year.” The PsOC did not include a Physician’s order for Atorvastatin. Pt. #2 also stated she no longer takes Hydrocodone 5/325 mg every 8 hours, as needed for pain “since at least April;” however, this medication is listed on the PsOC. 3. Pt. #3. SOC 09/29/2022. Primary Diagnosis: Spinal Stenosis Lumbar Region. The clinical record was reviewed on 11/01/2022 at 1:00 PM. A home visit was conducted on 10/31/2022 at 2:30 PM, along with the PTA. During this home visit, Pt. #3’s medications were reviewed along with Pt. #3 and compared to the POC effective 09/29/2022. Pt. #3 stated he takes Fenofibrate 145 mg by mouth daily “for 20 years,” and Metolazone 2.5 mg by mouth every Tuesday and Friday “for a couple of years.” Neither Fenofibrate nor Metolazone were listed on Pt. #3’s POC. 4. During an interview with the Administrator, Clinical Supervisor, and Quality Assurance Director on 11/02/22 at 2:03 PM and on 11/03/2022 at 10:00 AM with the Administrator and Clinical Supervisor findings of the PsOC not containing the current patient medications were confirmed.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure it provided services as ordered by the Physician in the POC. This was found in 6 of 13 (Pts. #2, 3, 7, 12, 6, and 5) clinical records reviewed. Findings include: 1. Pt. #2. SOC 04/14/2022. Diagnoses include: Basal Cell Carcinoma of the Skin and Type 2 Diabetes with Diabetic Peripheral Angiopathy. The clinical record was reviewed on 11/01/2022 at 10:30 AM. The record included the POC effective 08/12/2022 to 10/10/2022, and the POC effective 10/11/22. Both of these PsOC included the Physician’s order: “Contact MD for blood sugars less than 60 or greater than 400.” The record contained SN visit notes dated 09/06/2022, 09/08/2022, 09/12/2022, 09/16/2022, 09/19/2022, 09/21/2022, 09/26/2022, 09/28/2022, 09/30/2022, 10/03/2022, 10/05/2022, 10/10/2022, 10/12/2022, 10/14/2022, 10/17/2022, 10/19/2022, 10/21/2022, 10/25/2022, and 10/27/2022. All of these SN visit notes lacked documentation of Pt. #2’s blood sugar level. 2. Pt. #3. SOC 09/29/2022. Diagnoses: Spinal Stenosis Lumbar Region, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Paroxysmal Atrial Fibrillation, and Atherosclerotic Heart Disease. The clinical record was reviewed on 11/01/2022 at 1:00 PM. The record included the POC effective 09/29/2022, which included the Physician’s order: “Contact MD for blood sugars less than 60 or greater than 400.” The record contained SN visit notes dated 09/29/2022, 10/06/2022, 10/13/2022, 10/20/2022, and 10/28/2022. These SN visit notes lacked documentation of Pt. #3’s blood sugar level. The POC also contained the Physician order: “Notify MD with…Apical greater than 100 or less than 50…” The record included the SN visit note dated 10/06/2022, which contained “Apical pulse rate 140. Pt. just came in from appointment.” This SN visit note lacked documentation of what action was taken, or if the Physician was notified of Pt. #3’s heart rate. 3. Pt #7. SOC 05/28/2022. Primary Diagnosis: Type 2 Diabetes with Skin Ulcer. The clinical record was reviewed on 11/02/2022 at 9:00 AM. The record included documentation Pt. #7 had four wounds since the SOC: a left distal arm/shoulder skin tear, a left medial forearm skin tear, a right leg/shin diabetic ulcer, and a left anterior leg/knee skin tear. The record contained the POC effective 07/27/2022 to 09/24/2022, which included “…SN to assess vitals and all systems…and perform wound care as ordered.” The record also included the POC effective 09/25/2022, which contained “…Patient is being recertified by SN due the need for continued wound management/monitoring…” The record also contained the SN visit notes dated 09/06/2022, 09/09/2022, 09/13/2022, 09/16/2022, 09/22/2022, 09/28/2022, 09/30/2022, 10/05/2022, 10/10/2022, 10/13/2022, 10/18/2022, 10/21/2022, and 10/25/2022. These SN visit notes contained documentation all of these wounds remain unhealed and still required dressing changes; however, these SN visit notes lacked documentation Pt. #7’s wounds were measured weekly. 4. Pt. #12. SOC 07/02/2022. Primary Diagnosis: Displaced Trimalleolar Fracture of Right Lower Leg. The clinical record was reviewed on 11/02/2022 at 11:30 AM. The record included the POC effective 07/02/2022 to 08/30/2022. This POC included the Physician’s order: “Occupational Therapy to assess and evaluate 06/29/2022 to 07/13/2022.” The record lacked documentation the Occupational Therapist ever evaluated the Pt., or that the Physician’s order was ever discontinued. 5. Pt. # 6. SOC 02/25/2022. Diagnoses: Venous insufficiency chronic peripheral, non-pressure chronic ulcer right lower leg. The clinical record was reviewed on 11/02/2022 at 11:30 AM. The clinical record contained a POC for certification period 08/24/2022 to 10/22/2022 that lacked wound assessment orders for weekly measurements. The SN visit notes for certification period beginning 08/24/2022 to 10/22/2022 lacked weekly wound measurements. 6. Pt. #5 SOC 08/06/2022Diagnoses: Venous Insufficiency, non-pressure chronic ulcer of left and right ankle, Type 2 Diabetes. The clinical record was reviewed on 11/02/2022 at 10:30 AM. The Plan of Care for certification period effective 08/06/2022 and 10/05/2022 include: “additional services to contact MD for blood sugar less than 60 or greater than 400….Teaching to continue on DMII…wound status and infection prevention.” The record included SN visit notes dated 09/06/2022, 09/09/2022, 09/27/2022, 09/30/2022, 10/04/2022, 10/07/2022, 10/14/2022, 10/21/2022 and 10/28/2022 and lacked blood glucose levels/monitoring. The record also included SN visit notes dated for the weeks of 09/04, 09/11, 09/18, 09/25, 10/02, 10/09, 10/16, 10/23 and 10/30/2022 and lacked weekly wound measurements as required per Agency policy. 7. The Agency’s policy titled “ Wound Assessment and Documentation” was reviewed on 11/02/2022 at 1:00 PM. The policy required…Procedure..3..a…Assess the wound location and its size; measure the length, width, and depth…Documentation Guidelines…Wound measurements (at least weekly), including the length, depth, and width of the wound in centimeters.” 8. During an interview with the Administrator, Clinical Supervisor, and Quality Assurance Director on 11/02/22 at 2:03 PM, and on 11/03/2022 at 10:00 AM with the Administrator and Clinical Supervisor the above findings were confirmed. The Clinical Supervisor stated all wounds should be measured weekly, and the measurements should be documented in the SN visit notes. Blood sugars should be documented on SN visit notes for Pts. with Diabetes who have Physician ordered parameters. If a Pt. declines a Physician’s order for Occupational Therapy, the clinician must obtain a Physician’s order to discontinue the Occupational Therapy evaluation.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review, and staff interview, it was determined the Agency failed to ensure Pts. were screened for the pneumococcal vaccine at the SOC and the influenza vaccine at the SOC and during influenza season, as per the Agency’s policy. This was found in 4 of 13 Pts. (Pts. #2, 3, 7, and 8) clinical records reviewed. Findings include: 1. Pt. #2. SOC 04/14/2022. Diagnoses include: Basal Cell Carcinoma of the Skin and Type 2 Diabetes with Diabetic Peripheral Angiopathy. The clinical record was reviewed on 11/01/2022 at 10:30 AM. The record lacked documentation of the Patient’s current influenza season vaccination status. 2. Pt. #3. SOC 09/29/2022. Diagnoses include: Spinal Stenosis Lumbar Region, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Paroxysmal Atrial Fibrillation, and Atherosclerotic Heart Disease. The clinical record was reviewed on 11/01/2022 at 1:00 PM. The record included the initial comprehensive assessment dated 09/29/2022. This assessment contained the section titled “Vaccinations and Screenings,” which lacked documentation of the status of the Patient's influenza and pneumococcal pneumonia vaccinations. 3. Pt. #7. SOC 05/28/2022. Primary Diagnosis: Type 2 Diabetes with Skin Ulcer. The clinical record was reviewed on 11/02/22 at 9:00 AM. The record included the initial comprehensive assessment dated 05/28/2022. This assessment contained the section titled “Vaccinations and Screenings,” which lacked documentation of the status of the Patient's influenza and pneumococcal pneumonia vaccinations. The record also lacked documentation of the Patient's current influenza season vaccination status. 4. Pt. #8. SOC 09/30/2022. Primary Diagnosis: Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record was reviewed on 11/02/2022 at 10:45 AM. The record included the initial comprehensive assessment dated 09/30/2022. This assessment contained the section titled “Vaccinations and Screenings,” which lacked documentation of the Patient’s pneumococcal pneumonia vaccination status. 5. The Agency policy titled “Initial Comprehensive Assessment” was reviewed on 11/03/22 at 9:30 AM. The policy required: “…During the initial and comprehensive assessments, all baseline data…and other relevant information will be documented in the patient’s clinical record including…immunizations…” 6. The Agency policy titled “Flu Plan” was reviewed on 11/03/22 at 10:00 AM. The policy required: “…Screen all new patients on our first visit for their interest in receiving a flu and pneumonia vaccine…Offer yearly flu clinics at all Agency Facilities…” 7. During an interview on 11/02/2022 at 2:03 PM with the Administrator, Clinical Supervisor, and Quality Assurance Director, the Clinical Supervisor stated all Pts. should be screened during the SOC initial comprehensive assessment for the status of the influenza and pneumococcal vaccines, and this information is to be documented in the patient’s clinical record. In addition, Pts. are offered the influenza vaccine during the influenza season, October 1 through March 31 annually. The Agency can administer the influenza vaccine, and can assist the Pt. in arranging to receive the pneumococcal pneumonia vaccine.