Every finding on record at Saint Anthony Medical Center

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/04/25. 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 12/04/25. Standard level deficiencies cited. Abbreviations: - = to x = times wk = week # = number AM = morning SN = Skilled Nurse POC = Plan of Care SOC = Start of Care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist COTA = Certified Occupational Therapy Assistant OASIS = Outcome and Assessment Information Set

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder and staff interviews, the Agency failed to provide the name of the Administrator. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) clinical records reviewed. Findings include: 1. The Agency Pt. admission folder was reviewed on 09/29/25. The folder lacked information identifying the Administrator’s name. 2. The clinical records of the following Pts. were reviewed on 09/30/25, 12/02/25, and 12/03/25. Pt. #1. SOC 06/26/25. Pt. #2. SOC 08/31/23. Pt. #3. SOC 09/15/25. Pt. #4. SOC 09/26/25. Pt. #5. SOC 11/30/25. Pt. #6. SOC 09/16/25. Pt. #7. SOC 02/16/25. Pt. #8. SOC 11/08/25. Pt. #9. SOC 10/26/25. Pt. #10. SOC 12/11/23. Pt. #11. SOC 11/10/25. Pt. #12. SOC 09/30/25. Pt. #13. SOC 04/09/25. Pt. #14. SOC 05/15/25. Pt. #15. SOC 01/24/25. Pt. #16. SOC 03/03/25. Pt. #17. SOC 02/10/25. The clinical records reviewed lacked the Administrator’s name. 3. The following home visits were conducted on 09/30/25 and 12/02/25. Pt. #1. SOC 06/26/25. Pt. #2. SOC 08/31/23. Pt. #3. SOC 09/15/25. Pt. #4. SOC 09/26/25. Pt. #5. SOC 11/30/25. Pt. #6. SOC 09/16/25. Pt. #7. SOC 02/16/25. 4. During an interview on 12/03/25 at 12:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.

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 clinical record review and staff interviews, for 1 of 2 (Pt. #8) Pts. reviewed requiring a gastrostomy tube, the Agency failed to ensure that the POC was followed. Findings include: 1.Pt. #8 was admitted for Home Health services on 11/08/25 with the diagnoses of but not limited to, Sepsis, Unspecified Organism and Encounter for Attention to Gastrostomy. The clinical record was reviewed on 12/02/25 and included the POC effective 11/08/25 which required, “Skilled Nursing: Skilled Nurse to assess tube site… Tube site care: Cleanse daily with soap and water. Cover with gauze dressing and secure with tape as needed. Skin barrier film wipes as needed to protect skin from tape/moisture.” The clinical record lacked documentation the above intervention was implemented. 2. During an interview on 12/03/25 at 12:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.

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 review and staff interviews, the Agency failed to assess the need for Pneumococcal Pneumonia vaccines in 2 of 17 (Pts. #10 and 13) clinical records reviewed. 2. Pt. #13 was admitted for Home Health services on 04/09/25 with multiple diagnoses, but not limited to, “Acute Cystitis without Hematuria, Metabolic Encephalopathy, Other Specified Chronic Obstructive Pulmonary Disease, Bilateral primary Osteoarthritis of Knee, Unspecified Anxiety Disorder, and Unspecified Depression. The clinical record was reviewed on 09/30/25 and 12/03/25. The clinical record contained the SN – OASIS Start of Care form completed by the RN and dated 04/09/25. The form lacked documentation the RN assessed the Pt. for the Pneumococcal Pneumonia vaccine. 3. During the entrance interview conducted on 09/29/25 (10:46 AM) with the Home Health Manager, Clinical Rehabilitation Supervisor, and the Supervisor. The Clinical Rehabilitation Supervisor stated, during the SOC visit the admitting clinician assesses the need for the Pneumonia vaccine, and the information is documented in the SOC form. 4. During interviews on 12/03/25 at 12:00 PM and 1:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director and Interim Home Health Manager confirmed the above findings. Findings include: 1. Pt. #10 was admitted for Home Health services on 12/11/23 with the diagnosis of Strain of Muscle, Fascia and Tendon of Right Hip. The clinical record was reviewed on 12/03/25. The record lacked documentation of a Pneumococcal Pneumonia immunization assessment.

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 clinical record review, document review, and staff interviews, the Agency failed to ensure the MSW coordinated care to reduce the risk of hospitalization, and/or injury. This was found in 1 of 2 (Pt. #13) closed clinical records reviewed, wherein MSW service was provided. Findings include: 1. Pt. #13 was admitted for home health services on 04/09/25 with multiple diagnoses, but not limited to, “Acute Cystitis without Hematuria, Metabolic Encephalopathy, Other Specified Chronic Obstructive Pulmonary Disease, Bilateral primary Osteoarthritis of Knee, Unspecified Anxiety Disorder, and Unspecified Depression. The closed clinical record was reviewed on 09/30/25 and 12/03/25. The closed clinical record contained the SN – OASIS Start of Care form completed by the RN and dated 04/09/25. The form included documentation the Pt. was alert and oriented, the Pt. had reported “25 falls in 3 months”. The pain assessment included the Pt. experienced pain that rated 6 out of 10 (pain rating: 0 = no pain to 10 = severe pain). The neurological assessment included the Pt. experienced “Issues: anxiety, fatigue. The cardiovascular assessment included “Issues: dyspnea on exertion, fatigues easily, extremity pain. The risk for hospitalization screening included, “History of falls… Decline in mental, emotional, or behavioral status in the past 3 months… Currently taking 5 or more medications”. The section titled, “Admission Certification” included, “Patient lives in 2 bedroom apartment complex alone… home care aide that comes in 3 times a week… Patient has occasional assistance from… who lives over an hour away. Patient’s other… lived with patient previously but passed away… Patient reports that … is looking into assisted living facility for patient… Social Work Focus: Advance Care Planning, resources for assisted living facilities…” The PT Initial Evaluation dated 04/10/25 contained, “Patient stated that she had a fall prior to the physical therapy initial evaluation.” Pt. reported pain 5 out of 10. “Physical Therapy Evaluation… the patient was noted to be extraordinarily fatigued… only ambulate several feet at a time before needed to sit in her rollator walker… The patient stated that she feels that her current caregiver does not help with as much as she could be doing. The patient cannot cook on her own due to extreme fatigue and poor anxiety tolerance, and is unable to perform any cleaning or self-care duties… The patient is not appropriate for skilled home care physical therapy services. Due to the patient’s inability to take care of all household tasks, chores, responsibilities, and reporting poor caregiver compliance, the patient requires a higher level of care due to being unable to take care of herself…” The OT – Initial Evaluation conducted on 04/14/25 contained documentation that the Pt. complained of pain that rated 3 out of 10. “total dependence” (completely depending on another person to perform the task or function independently) for picking up objects from the floor, trash, bed making, laundry, light and heavy cleaning… reports her legs give out on her unexpectedly at times…” The SN visit note dated 04/14/25 completed by the RN and labeled as “Priority” contained documentation that the Pt. was “anxious, forgetful, disoriented/confused, dyspnea on exertion… fatigues easily, extremity pain”. The pain assessment included a pain rating of 8 out of 10. The MSW – Initial Evaluation dated 04/14/25 included documentation that the Pt. was “forgetful”. Interventions included “Advance Care Planning… We will complete HC (Healthcare) POA (Power of Attorney) at next visit… We discussed ALF (Assisted Living Facility) options…”. On 05/02/25 the PT completed the OASIS Transfer form that included, “Reason for Emergency Care… Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis…” The record lacked documentation that the MSW and/or other team members coordinated care with the family as the patient’s physical and cognitive status declined, or that the MSW notified the Agency’s Supervisor(s)/ Manager(s)/ Director of the patient’s declining status, or that the MSW coordinated with community resources, including making the appropriate referral(s) to prevent the patient’s hospitalization. 2. The job description for the “Medical Social Worker-HC” was reviewed on 12/03/25 at 10:00 AM and included, “Primary job responsibilities and accountability: Initiates a plan of treatment to reduce or alleviate problems to ensure the best possible care to the patient… Recommends other disciplines, program… as needed by the patient and/or family…” 3. During an interview on 12/03/25 at 1:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the Agency failed to ensure the supervising OT conducted the OT discharge. This was found in 1 of 3 (Pt. #4) closed clinical records, wherein OT services were provided. Findings include: 1. Pt. #4 was admitted for Home Health services on 09/26/25 with the diagnosis of, but not limited to, Acute and Chronic Respiratory Failure with Hypoxia. The closed clinical record was reviewed on 09/30/25 and 12/03/25. The closed clinical record contained the form titled, “OT – Discipline Discharge” completed by the COTA and dated 10/10/25. On 10/13/25, the OT completed the “OT – Discharge Summary” that indicated an onsite visit was not conducted, but that the Pt. was discharged from OT service on 10/10/25 based on the COTA's assessment/visit on 10/10/25. The record lacked documentation that the OT conducted an on-site visit/supervision of the COTA to determine whether an OT discharge was appropriate. 2. During an interview on 12/03/25 at 1:45 PM with the Home Health Director, Interim Home Health Manager, Supervisor, Home Health Operations Director, Chief Nursing Officer, Vice-President of Operations and Strategy for Home Care, Quality and Safety of North and Western Regions, Coordinator for Quality and Safety, Manager, Director of Safety, Quality and Safety Coordinator for Central Region, Quality and Safety Coordinator, Infection Preventionist, Supervisor – Peru, and the Supervisor – Ottawa; the Home Health Director, Interim Home Health Manager, and the Supervisor confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening HCA = Home Care Aide Pt./ Pts. = Patient/Patients

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: A. Based on clinical record review, observation during a home visit, and staff interview, it was determined the Agency failed to ensure HCA’s were supervised by an RN every 14 days. This was found in 2 of 6 (Pts. #5 and #6) clinical records reviewed of Pts. that received HCA services. Findings include: 1. Pt. #5. SOC 7/5/22. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 8/9/22 at 2:00 PM. The record included documentation the HCA provided service on 7/12/22, 7/15/22, 7/18/22, 7/22/22, 8/2/22, 8/4/22, and 8/9/22. The record lacked documentation the RN provided any HCA supervision. 2. Pt. #6. SOC 7/24/22. Primary Diagnosis: Panlobular Emphysema. The clinical record was reviewed on 8/9/22 at 11:20 AM. The record included documentation the HCA provided service on 7/26/22 and 8/3/22. The record lacked documentation the RN provided any HCA supervision. A home visit was conducted on 8/9/22 at 1:00 PM, along with E #1, who performed a skilled assessment of Pt. #6. During this home visit, the RN did not conduct a HCA supervisory visit. 3. During an interview on 8/10/22 at 12:35 PM with the Home Health Manager – Northern Region, Regulatory Coordinator – Quality & Safety, Clinical Rehabilitation Supervisor - Rockford #1, Home Health Manager – Ottawa, Clinical Rehabilitation Supervisor –Ottawa, Clinical Rehabilitation Supervisor – Rockford #2, Nursing Supervisor –Rockford, Nursing Supervisor – Ottawa, and the Manager of Quality and Safety – Peoria, the above findings were confirmed.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on clinical record reviews, review of Agency policy and staff interviews, it was determined the Agency failed to ensure that wound care assessment documentation was complete. This was found in 2 of 6 (Pts. #11 and #16) clinical records reviewed wherein Pts. required wound care. 2. Pt. #16. SOC 10/21/21. Primary Diagnosis: Encounter for Surgical Aftercare following Surgery on the Circulatory System. The clinical record was reviewed on 8/10/22 at 10:40 AM. The record contained the SOC Comprehensive Assessment, performed by the RN on 10/21/21. This SOC assessment included documentation the Pt. was discharged from the hospital two days prior to admission to the Agency, where he had a coronary artery bypass graft surgery. This assessment also contained documentation the Pt. was admitted to the Agency with a midline sternal incision wound, left medial leg laparoscopic puncture wounds, and upper abdominal puncture wounds; however, there were no documentation of wound measurements, appearance, or the presence of drainage of any of these wounds. The record also included SN visit notes dated 10/23/21, 10/25/21, 10/29/21, and 11/4/21. None of these SN visit notes contained any documentation of wound measurements, descriptions of appearance, or the presence of drainage. 3. The Agency policy titled “Wound Assessment and Care, Home Care” was reviewed on 8/10/22 at 2:00 PM. The policy required: “…Assess wound with each dressing change to include location, evidence of tunneling/undermining, tissue type, condition of surrounding skin, color, type and amount of drainage, possible signs of infection, presence of sutures or other closure devices. Measure wounds upon admission and then weekly thereafter unless the visit frequency is ordered less than weekly…Document assessment in the patient’s medical record…” 4. During interviews on 8/10/22 at 11:10 AM and 12:35 PM with the Home Health Manager – Northern Region, Regulatory Coordinator – Quality & Safety, Clinical Rehabilitation Supervisor - Rockford #1, Home Health Manager – Ottawa, Clinical Rehabilitation Supervisor –Ottawa, Clinical Rehabilitation Supervisor – Rockford #2, Nursing Supervisor –Rockford, Nursing Supervisor – Ottawa, and the Manager of Quality and Safety – Peoria, the above findings were confirmed. Findings include: 1. Pt. #11. SOC 12/10/21. Primary Diagnosis: Venous Insufficiency (Chronic, Peripheral). The clinical record was reviewed on 8/9/22 at 1:00 PM. The record included documentation that Pt. #11 had a wound on the right lower leg and wound care was provided by the home health SN twice a week from 6/6/22 through 8/1/22. The record lacked documentation of wound measurements for the weeks of 6/6/22 to 6/11/22, 6/12/22 to 6/18/22, 6/19/22 to 6/25/22, 7/3/22 to 7/9/22, 7/24/22 to 7/30/22 and 7/31/22 to 8/6/22.