Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 757737 (X3) Date Survey Completed 03/19/2026
Name of Provider or Supplier Alaunus Home Health, Inc Street Address, City, State 110 S Rosemead Blvd. Suite R4, Pasadena, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0528 Health, psychosocial, functional, cognition
CFR(s): 484.55(c)(1)

Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status;


This ELEMENT is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure to complete wound assessments and timely for three of seven sampled patients (Patient 1, Patient 5, and Patient 6).

 

This failure had the potential to place Patient 1, Patient 5, and Patient 6 at risk for complications of wound infection, delayed wound healing, amputation (a surgical procedure where a limb or body part is removed due to injury, disease, or congenital defect), hospitalization.  


a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/21/2026 to 3/21/2026, the POC indicated Patient 1 was admitted to the HHA on 1/21/2026 with a primary diagnosis of stage 3 pressure ulcer of the sacral region (full-thickness skin loss over the tailbone).

 

During a joint home visit on 3/17/2026 at 10:20 a.m. in Patient 1’s residence, with Licensed Vocational Nurse 3 (LVN 3), Patient 1 was observed lying in bed watching television. Patient 1 was observed with a sacral wound dressed with a foam dressing. Patient 1 stated he did not want LVN 3 to remove the foam dressing and assess the sacral wound.

 

During an interview on 3/17/2026 at 11:04 a.m. with LVN 3, LVN 3 stated she was the visiting nurse for Patient 1. LVN 3 stated she changes Patient 1’s wound dressing once a week. LVN 3 stated her process for changing Patient 1’s wound was to cleanse with saline and pat dry, apply collagen powder (a wound dressing used to accelerate healing in chronic and acute wounds), xeroform (a sterile gauze designed to create a moist, antimicrobial environment for healing wounds), Calmoseptine (a moisture barrier designed to treat and prevent skin irritations), and cover with a foam dressing. LVN 3 stated she follows the Wound Specialist Nurse Practitioner (WSNP) order from 1/26/2026.

 

During an interview on 3/17/2026 at 1:26 p.m. with LVN 3, LVN 3 stated she does not assess Patient 1’s sacral wound when she visits Patient 1 because it is the WSNP’s responsibility. LVN 3 stated she does not take Patient 1’s wound measurements or assess for signs of infection, including odor, color, drainage. LVN 3 stated she does not document any wound assessments for Patient 1 in the electronic medical record.

 

During a concurrent interview and record review on 3/17/2026 at 3:20 p.m. with the WSNP, Patient 1’s “Wound Specialist Progress Note,” dated 3/9/2026 was reviewed. The Wound Specialist Progress Note indicated the treatment plan for Patient 1’s sacral wound was to cleanse the sacral wound with normal saline rinse at each dressing change and pat dry, apply MediHoney (a medical-grade, sterilized Manuka honey used to treat wounds and burns by maintaining a moist environment, reducing infection risk, and aiding debridement) to areas of slough (stringy necrotic tissue that covers the wound bed), apply collagen powder evenly to the wound bed, cover the wound with calcium alginate (a highly absorbent, biodegradable dressing used to treat moderate to heavily exudating wounds) and foam pad, and apply Calmoseptine to the peri wound (area of skin surrounding a wound). The WSNP stated she wrote the order for the wound treatment process. The WSNP stated LVN 3 should have been following her most recent order from 3/9/2026, not from 1/26/2026. The WSNP stated she expected LVN 3 to follow each treatment step to change Patient 1’s wound dressing. The WSNP stated LVN 3 should not have used xeroform when treating Patient 1’s wound, and that MediHoney should be applied before collagen powder.

 

During an interview on 3/17/2026 at 3:41 p.m. with the WSNP, the WSNP stated she visits Patient 1 weekly to assess and treat Patient 1’s sacral wound. The WSNP stated LVN 3 should have been assessing Patient 1’s sacral wound during each visit and notify her (WSNP) if there were any changes in the wound. The WSNP stated it was LVN 3’s responsibility to assess Patient 1’s wound measurements, color, odor, peri wound, and drainage. The WSNP stated LVN 3’s lack of assessment could have resulted in Patient 1’s wound becoming infected, which could lead to delayed wound healing.

 

During an interview on 3/18/2026 at 2:27 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated LVN 3 should have followed the most recent orders written by WSNP. The DPCS stated not following wound treatment order as written could result in Patient 1’s wound worsening. The DPCS stated it was also LVN 3’s responsibility to assess Patient 1’s sacral wound during each visit, including wound size and measurement, pain level, drainage, odor, color, and signs of infection. The DPCS stated not assessing Patient 1’s wound could have resulted in the wound developing an infection, which could lead to hospitalization. 

 

During an interview on 3/18/2026 at 2:45 p.m., the DPCS stated the HHA does not have a policy for wound assessments. 

 

During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process,” revised 11/2017, the P&P indicated, “The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.”

 

b. During a record review of Patient 5’s “Patient Profile,” undated, indicated start of care date 11/21/2025 with primary diagnosis of pressure ulcer of sacral region, stage 2 (a partial-thickness loss of skin over the tailbone/sacrum, presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister).

 

During a concurrent observation and interview on 3/17/2026 at 10:15 am with Registered Nurse (RN, a nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 1 and Patient 5 in Patient 5’s room, Patient 5’s sacral region was faintly discolored, intact with light pressure, and showed no signs of skin breakdown.  RN 1 stated the pressure ulcer appears to have healed.  Patient 5 stated that the pressure ulcer healed about 2 weeks ago.

 

During a concurrent interview and record review on 3/172026 at 12:00 pm with RN 1, Patient 5’s “Nursing Progress Notes” (legal, chronological records within a patient's medical chart that detail the patient’s clinical status, nursing assessments, interventions, and their response to care) dated 3/10/2026, 3/3/2026, 2/24/2026, 2/10/2026, 1/24/2026, 1/10/2026, and 12/1/2025 were reviewed.  All seven “Nursing Progress Notes” indicated, “Sacral region: SN cleared the wound with normal saline, patted dry, closed sacrum bordered dressing.  PRESSURE ULCER of SACRAL REGION, STAGE 2.”  RN 1 stated, these are not my nursing notes, Patient 5’s pressure ulcer appears to have healed, and these nursing notes are inconsistent with Patient 5’s current physical condition.

 

During an interview on 3/18/26 at 1:04 pm with LVN 2, LVN 2 stated Patient 5’s sacral wound healed at the end of February, no more care was provided after it healed, and LVN 2 cannot comment on why LVN 2’s "Nursing Progress Notes" for Patient 5 indicate that Patient 5 received wound care after the wound healed.  LVN 2 stated LVN 2 called the office and let Intake know that the wound was healed.

 

During a concurrent interview and record review on 1/18/2026 at 1:47 pm with Director of Patient Care Services (DPCS, senior nursing leadership role responsible for overseeing clinical staff, quality assurance, and patient care standards), Patient 5’s “Nursing Progress Notes” dated 3/10/2026, 3/3/2026, 2/24/2026, 2/10/2026, 1/24/2026, 1/10/2026, and 12/1/2025  were reviewed.  All seven “Nursing Progress Notes “indicated, “Sacral region: SN cleared the wound with normal saline, patted dry, closed sacrum bordered dressing.  PRESSURE ULCER of SACRAL REGION, STAGE 2.” DPCS stated this would indicate falsification of records and lead to unnecessary treatment for Patient 5.

 

During a concurrent interview and record review on 1/18/2026 at 1:47 pm with DPCS, the facility’s policy and procedure (P&P) titled, “Reassessments/Recertification Policy No. 4-020.1,” revised November 2017 was reviewed.  The P&P indicated, “4. Each patient will be reassessed … when A. There is a significant change in the patient’s condition…”  The DPCS stated Patient 5's condition changed, but the LVN 2 did not update and falsified Patient 5's medical records when “Nursing Progress Notes” indicated treatment for a healed wound. DPCS stated falsifying medical records could lead to unnecessary treatment.

 

c. During a record review of Patient 6’s “Patient Profile,” undated, indicated start of care date 12/20/2025 with primary diagnosis of pressure ulcer of sacral region, unstageable (a full-thickness wound over the tailbone where dead tissue covers the wound base).

 

During a concurrent interview and record review on 3/18/2026 at 1:47 pm with Director of Patient Care Services (DPCS, a senior healthcare leader responsible for overseeing clinical operations, ensuring regulatory compliance, and maintaining high standards of patient care), Patient 6’s "Nursing Progress Notes" dated 2/1/2026, 1/31/2026, 1/28/2026, and 1/25/2026 were reviewed.  DPCS stated Patient 6's "Nursing Progress Notes" do not contain wound assessments, and the Skilled Nurse (SN, a licensed professional nurse who provides high-level medical care, such as wound management) is responsible for assessing the patients’ wounds during every patient visit by including, but not limiting to, wound size, pain level, drainage, color, signs of infection. The DPCS stated there is no wound care or wound assessment policy.  The DPCS stated not assessing Patient 6’s wound could have resulted in a wound infection and hospitalization. 

 

During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process, Policy No. 4-001.1,” revised November 2017, the P&P indicated, “The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.”