Every finding on record at Suncrest Hospice San Antonio LLC

It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure that the patient's plan of care included measurable outcomes. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/19/2024 with the diagnosis of congestive heart failure with comorbid conditions of chronic gout and constipation. The plans of care for the benefit periods from 08/20/2025 to 10/18/2025 and 10/19/2025 to 12/17/2025 were reviewed. On 10/27/2025, the skilled nurse (SN) visit note documented a pain score of 8, describing aching and throbbing in both lower extremities. On 11/03/2025, the SN documented the patient’s pain score was 4, worsening upon touching his lower extremities, and he was unable to lie flat due to hypoxia. Medications included tramadol 50 mg every 8 hours as needed. On 11/03/2025, new orders were added: Norco 325/5 mg, one tablet every 6 hours as needed, and gabapentin 300 mg four times daily. The plan of care documented the patient's goal for the pain as "acceptable." "Acceptable" pain was not defined and is not a measurable outcome. The plan of care addressed congestive heart failure and respiratory status, including assessments of lung sounds, breathing pattern, secretions, dyspnea, and cough. The plan of care goals documented "stable respiratory status and symptom management aligned with disease progression. "Stable" and "managed as well as possible" were undefined and are not measurable outcomes. The patient's medications for constipation included Colace 100 mg twice daily and as needed, polyethylene glycol 17 gm daily as needed, Fleet Enema every 3 days as needed, and Senna Plus 50 mg twice daily and every 8 hours as needed. The plan of care goal documented: "establish and maintain regular bowel habits and reduce constipation symptoms." "Regular bowel habits" and "decrease in symptoms" are not measurable outcomes. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/21/2025 with the diagnosis of senile degeneration of the brain with a secondary diagnosis of dementia with behavioral disturbances and anxiety. The plan of care for the benefit period from 08/21/2025 to 11/18/2025 was reviewed. On 10/01/2025, the SN visit note documented pain and anxiety scores of 7. The patient exhibited signs of awakening to stimuli, including immediate restlessness, tearfulness, and nonsensical speech. During a joint visit with the Hospice Aide, a bed bath was performed; the patient appeared anxious, cried out repeatedly, and was unresponsive to words or touch. On 10/10/2025, pain and anxiety scores were 6, with facial grimacing and moaning noted. The patient's medications included: trazodone 50 mg at noon for behavioral issues; lorazepam 0.5 mg, 1-2 tablets every 4 hours as needed; Depakote 250 mg twice daily; and bupropion 100 mg twice daily for behavioral management. For pain control, the patient's medications included: acetaminophen 500mg, two (2) capsules every 6 hours as needed for mild pain, and Norco 325mg-5mg, two (2) tablets every 4-6 hours for moderate to severe pain. The plan of care identified anxiety and stress as problems, with the POC goal documented as symptom control and reduction of anxiety through avoidance of stressors. "Stressors" were not defined and are not a measurable outcome. The plan of care goal addressing pain relief documented "being pain-free or achieving an acceptable pain level." "Acceptable" is not a measurable outcome. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/11/2025 with the diagnosis of heart failure and the comorbid condition of intracranial injury. The patient's plan of care for the benefit period from 09/11/2025 to 12/09/2025 was reviewed. The Registered Nurse (RN) visit note dated 09/27/2025 documented that the patient was reported to exhibit aggressive behavior, including grabbing and punching caregivers. An order was received for "Ativan and Benadryl (AB) compound 2mg-25mg topical cream to be applied every 4 hours as needed for agitation." The medication profile also included Seroquel 100 mg daily for behavioral disturbances. The plan of care identified end-stage dementia as a problem and documented interventions, including assessing mental status and orientation, evaluating caregiver ability, and screening for behavioral disturbances such as anxiety, fear, agitation, restlessness, and wandering. The plan of care documented that the caregiver's goal was to "minimize risks related to altered mobility and to manage the patient, knowing when to contact hospice effectively." However, these goals did not directly address the patient's behaviors and did not include measurable outcomes. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/23/2025 with the diagnosis of malignant neoplasm of the bone. The plans of care for the benefit periods from 07/23/2025 to 10/20/2025 and 10/21/2025 to 01/18/2026 were reviewed. During the admission visit, the RN documented the patient’s complaint of moderate abdominal and pelvic pain, rated at 4. By the visit on 09/23/2025, the pain score had increased to 5 out of 10, prompting medication adjustments. Initial medications included Norco 325/5 mg every 6 hours as needed and morphine 0.25–1 ml every 2 hours as needed. On 09/04/2025, Norco was increased to 325/10 mg every 6 hours, scheduled. On 09/14/2025, a new order was added for hydromorphone 4 mg every 4 hours as needed. Pain was identified as a problem in the plan of care, with interventions to educate the patient and family on pain management and conduct regular pain assessments using a 0-10 scale. The plan of care goal documented "being pain-free or verbalizing an acceptable pain level." "Acceptable" was not defined, and it is not a measurable outcome. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/05/2025 with the diagnosis of cirrhosis of the liver and a comorbid diagnosis of heart failure. The plans of care for the benefit periods from 08/05/2025 to 11/02/2025 and 11/03/2025 to 01/31/2026 were reviewed. On 10/23/2025, the nurse documented an anxiety score of 6, noting recent confusion and agitation. By 11/01/2025, the anxiety score decreased to 3, with the caregiver reporting a hallucination the previous day. The care plan identified liver disease as a problem, with interventions including medication education—dosing, administration, side effects, interactions, and symptom reporting—and assessing mental status for signs of delirium or confusion. The goal was to prevent complications and ensure symptoms aligned with the disease stage. The plan of care goals "free of preventable complications" and "symptoms consistent with disease stage" did not include measurable outcomes. CLINICAL RECORD 15: The patient elected the hospice benefit on 06/10/2025 with malignant neoplasm of the pharynx. The patient was discharged for cause due to non-compliance with narcotic medication orders. The plan of care for the benefit period 06/10/2025 to 08/08/2025 was reviewed. The patient was discharged on 06/27/2025 due to non-compliance with the plan of care. During the RN visit on 06/13/2025, the nurse documented that the hospice Medical Director ordered a 100 mcg Fentanyl patch every 72 hours for pain management. The physician offered no additional recommendations, as the patient was also on oxycodone 40 mg every 6 hours as needed for breakthrough pain. The patient refused the Fentanyl patches, and a Narcotic Agreement signed by the patient and spouse was in place. Narcotics in the home were counted and stored in a lockbox. On 06/19/2025, the nurse documented a witnessed narcotic count. On 06/20/2025, she noted a video conference narcotic count: the patient had 22 oxycodone 20 mg tablets and 24 lorazepam 1 mg tablets. The patient reported taking two extra oxycodone yesterday and acknowledged understanding the doctor’s orders and the importance of medication adherence. The nurse emphasized that prescriptions would not be filled earlier than ordered. A discussion with the patient and clinical leaders was documented regarding potential discharge plans due to non-compliance with the care plan and pain contract. At the 06/26/2025 Interdisciplinary Group Meeting, the nurse reported that non-compliance with the physician’s orders was a barrier to the patient's goals. The plan of care documented pain as a problem, with goals for the patient and caregiver to understand medication use and to be "pain-free or verbalize an acceptable pain level." "Acceptable" pain was undefined and is not a measurable outcome. There was no evidence that the patient or caregiver understood medication use. CLINICAL RECORD 19: The patient elected the hospice benefit on 05/05/2025 with the diagnosis of malignant neoplasm of the prostate with a secondary bone malignancy. The patient also had a comorbid condition of anxiety disorder. The plan of care for the benefit period from 05/05/2025 to 08/02/2025 was reviewed. The patient died on hospice services on 05/30/2025. During a routine RN visit on 05/06/2025, it was documented that the patient could drink fluids but vomited pureed foods. On the same day in 1938, an on-call visit noted the patient in severe pain and nausea. The nurse administered 4 mg of ondansetron and applied a newly ordered 25 mcg/hr Fentanyl patch. On 05/21/2025, the nurse documented the patient crying, anxious, and in moderate pain, despite receiving 1 ml of morphine and lorazepam earlier. The Fentanyl patch was increased to 50 mcg/hr. The patient's medications included lorazepam 2 mg every 6 hours as needed and morphine 20 mg/ml, 0.25–1 ml every 2 hours as needed. Pain was addressed in the care plan with assessments using a 0-10 scale and interventions to evaluate severity, location, and quality. Education on pain management and comfort measures was provided, but goals for patient and caregiver understanding lacked specificity and were unmeasurable. Nausea and vomiting were identified as issues, with interventions to monitor symptoms. Goals to maintain comfort during nausea and to achieve a peaceful death were not defined or measurable. Anxiety was addressed during the 05/14/2025 Interdisciplinary Group Meeting, where "comfort care" was listed as the goal. No specific or measurable pain or anxiety management goals were established. During an interview and a joint clinical record review on 11/14/2025, the Senior Director of Clinical Quality confirmed the findings and provided information that the agency had not had consistent clinical leadership, with the current clinical leaders beginning mid-year. Before exiting, the clinical records were being brought into compliance.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: a revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's plan of care was updated to reflect newly identified problems in the updated comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/27/2025 with the diagnosis of Alzheimer's disease. The plans of care for the benefit periods from 08/26/2025 to 10/24/2025 and 10/25/2025 to 12/23/2025 were reviewed. During a face-to-face visit on 10/11/2025, the Nurse Practitioner (NP) noted that the patient had difficulty swallowing, was on a pureed diet, and that the daughter used a syringe to give liquids. The physician’s terminal illness certification for 10/25/2025 through 12/23/2025 documented that the patient “exhibits signs of aspiration.” At the 10/22/2025 Interdisciplinary Group Meeting, the nurse documented that worsening dysphagia and increased aspiration risk led to deprescribing gabapentin and lisinopril. The patient remained on a pureed diet. However, the plan of care was not updated with interventions or goals for the dysphagia. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/21/2025 with the diagnosis of multiple sclerosis. The plans of care for the benefit periods dated 05/21/2025 to 08/18/2025 and 08/19/2025 to 11/16/2025 were reviewed. During the RN visit on 09/09/2025, the patient’s pain was recorded as 7, following a reported fall. The physician was notified, and an X-ray was ordered. On 09/10/2025, the pain score decreased to 4, with reports of knee and ankle discomfort. X-ray results suggested a likely left tibial fracture and were sent to the physician. The medication list included "pregabalin 75 mg three times daily" and "acetaminophen 325 mg (2 tablets every 4 hours as needed)." However, pain management was only addressed through discipline-specific interventions by Music and Massage Therapists. The plan of care was not updated to reflect the new pain associated with the fall. CLINICAL RECORD 15: The patient elected the hospice benefit on 06/10/2025 with a malignant neoplasm of the pharynx. The patient was discharged for cause due to non-compliance with narcotic medication orders. The plan of care for the benefit period dated 06/10/2025 to 08/08/2025 was reviewed. The patient was discharged on 06/27/2025 due to non-compliance with the plan of care. On 06/13/2025, the Registered Nurse (RN) documented that the hospice Medical Director ordered a 100 mcg Fentanyl patch every 72 hours for pain management. The physician had no additional recommendations, as the patient was also on oxycodone 40 mg every 6 hours as needed for breakthrough pain. The patient refused the Fentanyl patch, and the patient and spouse signed a Patient Safety Narcotic Agreement. Narcotics in the home were counted and stored in a lockbox. On 06/19/2025, the narcotic count was witnessed and documented. On 06/20/2025, the RN performed a video conference count, noting 22 oxycodone 20 mg tablets and 24 lorazepam 1 mg tablets. The patient reported taking two extra oxycodone tablets the previous day and confirmed understanding of dosing instructions. The RN emphasized that medications would not be refilled earlier than scheduled. During the 06/26/2025 Interdisciplinary Group Meeting, the nurse identified non-compliance with the physician’s orders as a barrier to the patient's goals. A discussion with the patient and clinical leaders was documented, and the patient was informed of discharge plans due to non-compliance with the care plan and pain contract. The plan of care was not updated to include interventions or goals addressing challenging behaviors or non-compliance. During a joint record review and interview on 11/14/2025, the Senior Director of Clinical Quality confirmed that the agency has lacked consistent clinical leadership, with current leaders assuming roles mid-year.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 4) and the Senior Director of Clinical Quality on November 11, 2025, it was determined that the average volunteer contribution for 01/01/2024 through 12/31/2025 was 1.43%, with a year-to-date average of 1.48% for 2025. These figures are below the established target, which requires volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This discrepancy prompted the initiation of a Performance Improvement Project (PIP) on October 22, 2025. The PIP includes monthly meetings with the Volunteer Coordinator and the Administrator to monitor recruitment and retention efforts, as well as the percentage and hours of volunteer service. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 4) and the Senior Director of Clinical Quality on November 11, 2025, it was determined that the average volunteer contribution for 2024 was 1.43%, with a year-to-date average of 1.48% for 2025. These figures are below the established target, which requires volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This discrepancy prompted the initiation of a Performance Improvement Project (PIP) on October 22, 2025. The PIP includes monthly meetings with the Volunteer Coordinator and the Administrator to monitor recruitment and retention efforts, as well as the percentage and hours of volunteer service. Recruitment strategies documented include outreach through trade schools and nursing programs, yoga studios, and informal interactions during the Volunteer Coordinator’s regular daily activities. Retention activities include individual and group luncheons with volunteers, invitations for volunteers to attend all staff meetings, and regular communication, primarily through text messages.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records reviewed, revealed that the agency did not ensure that the medication profile was updated to include oxygen. Clinical Record 1: A physician order on 5/28/2022 reads, "Oxygen via nasal cannula at 2 to 4 L per minute as needed for shortness of breath and comfort." Oxygen is not included on the medication profile dated 5/28/22 through 12/6/2022. 1 of 13 (7%) of clinical records reviewed revealed that agency did not ensure that medication profiles were updated to include oxygen.

It is required that the hospice designates a registered nurse member of the IDG to ensure continuous assessment of each patient’s and family’s needs and ensure the implementation of the interdisciplinary plan of care Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records, interviews and observation on home visits. 2 of 13 (15%) records reviewed revealed that the agency did not ensure continuous assessment and ensure the implementation of the interdisciplinary care plan at every visit. Clinical Record 8: The RN (registered nurse) assessment upon admission on 11/28/2022 and Plan of Care (POC) dated 11/28/2022 documented that the patient requires pain assessment and management due to metastatic cancer to breast and bone, as well as the need to assess bowel function. The skilling nursing (SN) visit note on 11/30/2022 does not evidence an assessment of pain or bowel status. The SN visit note includes vital signs and a narrative note that reads, "Patient doing well since admission. No need "to" concerns from patient or family at this time. Encourage going to call hospital with any questions, concerns or changes and patient condition." There is no evidence or reference to following the care plan. Clinical Record 6: The patient was admitted on 11/19/2022. The initial RN assessment on 11/19/2022 documented that the patient had a stroke and was hospitalized prior to admission to hospice. The initial assessment further documented that the patient requires assist with all ADL's, is incontinent of bowel and bladder and is bed-bound. During Home visit #2, it was noted that the patient was in a crooked position in the bed with the head of bed and feet elevated. The patient verbally answered questions but did not open eyes. The RN took vital signs including use of the pulse oximeter then begin wiping down equipment. The RN was asked if he was done with his visit and he reported, "I am done with my assessment, I am just going to go check and make sure he has all the medications he needs". The RN did not assess the patient's skin, did not assess for a wet incontinence brief, and did not reposition the patient in a more aligned manner. 2 of 13 (15%) of records reviewed reveal that the agency did not ensure continuous assessment and ensure the implementation of the interdisciplinary care plan at every visit.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records reviewed revealed that the agency did not ensure that the hospice aide care plan included all necessary items to allow the aide to function within scope of practice. Clinical Record 1: The physician order on 5/28/2022 reads, " Oxygen via nasal cannula at 2 to 4 L per minute as needed for shortness of breath and comfort." The aide care plan dated 5/28/2022, and updated 6/6/2022, does not include mention of oxygen use or oxygen precautions. 1 of 13 (7%) of clinical records reviewed revealed that the agency did not ensure that the aide care plan included all necessary items to allow the aide to function within scope of practice.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (7%) clinical records reviewed, the agency did not ensure that the hospice aide provided services as ordered on the plan of care. Clinical Record 9: The plan of care dated 11/11/2022 reads, "Aide; 5 wk 10 wk; Beginning during week of 11/11/2022 -Ending 1/9/2023". The patient was seen by the aide on Friday, 11/11/2022, however, no other visits were documented after 11/11/2022 through the end of the week, 11/12/2022. In 1 of 13 (7%) of clinical records reviewed the agency did not ensure that the aide provided services as ordered on the plan of care.

Based on record review and interview, the agency failed to ensure services were provided as written in the plan of care for one of three patients (Patient #1) whose clinical records were reviewed. This deficient practice could place the agency's hospice patients at risk of a decline in health. The findings included: A. Closed record review of Patient #1's plan of care for certification period 02/10/22 through 04/10/22 revealed a start of care date of 12/17/2020 with a terminal diagnosis of Chronic diastolic (congestive) heart failure and orders for the nurse to visit twice a week for nine weeks. Review of the nursing notes revealed one visit dated 04/01/22 the week of 03/27/22 through 04/02/22. During an interview and record review on 04/20/22 at 9:33 a.m., the findings above were reviewed and discussed with the Alternate Administrator. The Alternate Administrator was unable to find a second nurse visit the week of 03/27/22 through 04/02/22 and stated she would follow up. During a second interview on 04/20/22 at 12:21 p.m., the Alternate Administrator stated a second nursing visit was not conducted because the nurse missed the visit. The Alternate Administrator stated the potential patient negative outcome would be that there may be a potential missed opportunity to order medication refills and provided additional support and teaching. B. Review of the agency's undated policy titled "Interdisciplinary Group Coordination of Care" revealed in part, "...The type and scope of services provided...will be based upon...the comprehensive plan of care..."

Based on record review and interview, the agency failed to ensure ongoing sharing of information for one of three patients (Patient #1) whose records were reviewed. This failure could place the agency's hospice patients at risk of harm from a delay in service. The findings included: A. Closed record review of Patient #1's plan of care for certification period 02/10/22 through 04/10/22 revealed a start of care date of 12/17/2020 with a terminal diagnosis of Chronic diastolic (congestive) heart failure and orders for the nurse to visit twice a week for nine weeks. Review of the nurse's notes revealed in part: 1. 04/05/22 - 5:45 am RN Routine Visit by RN B. Visit 0545 call for rectal bleeding...Patient had no rectal bleeding and had stopped. 2. 04/06/22 - 1:30 pm RN routine Visit by RN/CM A...he (Patient #1) said he just doesn't feel well and he has some pain in his head...the facility nurse also said he had an episode of blood in his stool... Further review of the nurse's notes revealed no documentation that the physician was notified of the rectal bleeding or blood in the patient's stool. During a telephone interview on 04/19/22 at 2:38 p.m., RN B stated she was on-call on 04/05/22, received the call regarding rectal bleeding, and there was no active bleeding at the time of her assessment. RN B stated that she did not notify the physician because there was no immediate harm or anything unusual, that it was 5:45 am, and that the Case Manager would notify the physician during normal business hours. During a telephone interview on 04/20/22 at 9:46 a.m., RN/CM A stated he did not remember notifying the physician of Patient #1's blood in the stool. During a telephone interview on 04/20/22 at 11:36 a.m., the physician stated she did not remember being told about Patient #1's rectal bleeding or blood in the stool and that if she would have, it would be documented. During an interview on 04/20/22 at 12:23 p.m., the Alternate Administrator stated she did not anticipate the staff notifying the physician because the nurse's assessments were within normal limits. She stated she did not anticipate a potential client negative outcome from the staff not notifying the physician of the bleeding or blood in stool because there was no active bleeding at the time of the nurses' assessments. B. Review of the agency's undated policy titled "Interdisciplinary Group Coordination of Care" revealed in part, "...3. It will be the responsibility of the Care Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician..."

Based on interview an record review, the agency failed to enforce a written policy to control infections and communicable diseases that included requirements to document infections that the patient acquires while receiving services from the agency for one of three active patients (Patients #3) and for two of two inactive patients (Patients #4 and #5) whose records were reviewed, in that: 1. Patients #3 and #4 were prescribed antibiotics (kills infections) and it was not recorded in the infection control log; and 2. Patient #5 had COVID-19 (worldwide infection) and it was not documented in the infection control log. This deficient practice could place the active patients at risk of receiving adequate care when the agency does not track and trend antibiotic use and surveillance of infections occurring at the agency. The findings included: 1. Review of the agency's policy titled "Evaluating and Maintaining Records of Infections Among Patients" dated 4/2019 revealed in part "...All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery...1. The Infection Identification Patient Report form is completed when any of the following occur: A. A new, actual, or suspected infection is clinically observed by personnel, C. a new antibiotic is ordered, D. A patient is admitted to a hospital due to an actual or suspected infection...2. The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection..." 2. Review of the agency's "Infection Report Log" (white binder) dated 2021 revealed no documented evidence that a patient infection report form was completed for Patients #3, #4, and #5. 3. Review of Patient #3's clinical record revealed a POC with a SOC date of 3/26/21 for a certification period from 9/22/21 through 11/20/21 with a diagnosis of Unspecified Arteriosclerosis Native Arteries (the build-up of fats, cholesterol, and other substances in and on the artery walls), and Neurogenic bladder (problems with the nervous system affecting the bladder and urination) and the Patient had an indwelling urinary catheter (a hollow tube that is inserted into the bladder to drain urine into a bag found outside the body). Further review revealed to provide catheter care once a week and to change the urinary catheter every 30 days and as needed. Additional record review revealed SN frequency: 1-2 times per week for 8 weeks and HHA visit frequency: two times a week. Moreover, the POC revealed in section titled "Brief narrative statement: This benefit period the patient was given antibiotics for a UTI when she was confused..." Review of "Medication List" (undated) revealed the Patient #3 received "Ciprofoxacin HCL (antibiotic) 500 mg tab take one tablet by mouth two times a day with a start date on 8/31/21." During an interview on 10/5/21 at 2:30 p.m., with RN A she stated Patient #3 was confused so the Medical Director put her on an antibiotic for a suspected UTI. 4. Review of Patient #4's "Discharge Summary" dated 5/9/21 revealed a SOC on 8/25/20 and was discharged on 5/9/21 with a diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and Hypertension heart disease (heart problems that occur because of high blood pressure that is present over a long time). Further review revealed the Patient's FM wanted the Patient transferred to the hospital due to BLE swelling...Patient was transferred/admitted to the hospital with a diagnosis of cellulitis (swelling an inflammation of the tissues)." Review of Client #4's clinical record revealed a SOC on 5/11/21 for a POC certification period from 5/11/21 to 7/9/21 with a diagnosis of Heart Failure and the client was being admitted from the hospital for hospice services. Further review revealed the client was receiving Augmentin (antibiotic) 875-125 mg oral tablet, take 1-tab po every 12 hours for infection (start date 5/11/21). Review of the "Hospice Initial Assessment" dated 5/11/21 revealed in part "Patient returned from hospital due to an exacerbation to include peripheral and pulmonary edema. Patient was suspected to have cellulitis to BLE and sepsis (infection of the blood)..." 5. Review of an e-mail (hospice case manager to the Alternate Administrator) dated 8/8/21 revealed in part "Client #5 is COVID 19 positive and is being isolated in the facility (assisted living) at this time, pharmacy to deliver meds this evening." Review of the Client #5's clinical record revealed a "Discharge Summary" dated 8/18/21 revealed a SOC on 7/23/21 and the client's last day of service was on 8/17/21 with a diagnosis of heart failure (inability of the heart to pump blood throughout the body) and was discharged to the hospital per family request..." 6. During an interview on 10/5/21 at 1:10 p.m., with the Alternate Administrator she stated that she will continue to look for the patient infection report for Clients #3, #4, and #5. During a second interview on 10/5/21 at 2:50 p.m. with the Supervising Nurse and the Alternate Administrator, the Alternate Administrator stated that the nurse or the case manager that identified the infection and/or ordered the antibiotic therapy should have completed a client infection report. The Supervising Nurse stated that she did not complete a client infection report for Client #5, and she should have. They further stated that it was an oversight and that they did not have a process to track clients who were prescribed antibiotics.