Statement of Deficiencies

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)

G0536

A review of all current medications
CFR(s): 484.55(c)(5)

A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

This ELEMENT is not met as evidenced by:
Based on observation, 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 maintain an accurate, and current medication profiles for three of seven sampled patients (Patient 1, Patient 4, and Patient 5).

This failure had the potential to place Patient 1, Patient 4, and Patient 5 at risk for medication errors and adverse drug reactions.

b. During a record review of Patient 4’s “Patient Profile” (a comprehensive, centralized record containing a person’s demographic data, medical history, medications, allergies, and sometimes lifestyle factors (e.g., occupation, preferences) to support personalized care and improve treatment adherence), undated, “Patient Profile” indicated Patient 4’s start of care was 12/10/2025 with primary diagnosis of Type 2 diabetes mellitus without complications (a diagnosis for individuals with high blood sugar (diabetes) who have not yet developed chronic complications, such as nerve damage, kidney disease, or eye disease).

During a concurrent interview and record review on 3/17/2026 at 10:30 am with RN 1, Patient 4’s Ararat Gardens’ “Order Summary Report” (a concise, organized record of all medical orders), dated 3/17/2026, was reviewed. The Order Summary Report indicated these are some of the medications Patient 4 was currently prescribed:

Carbidopa-Levodopa Oral Tablet 25-100 MG Give 2.5 tablet by mouth four times a day for Parkinson's DiseaseVitamin D3 Oral Capsule 1.25 MG (50000 UT) Give 1 capsule by mouth one time a day every Sat for Supplement on Saturdays for osteoporosis and muscle weaknessRN 1 stated, ALF's “Order Summary Report” lists Patient 4’s current medications.

During an interview on 3/17/26 at 12:30 pm, with Patient 4 in Patient 4’s room, Patient 4 stated he took the meds he was given and didn’t know which medications did what.

During a concurrent interview and record review on 3/17/2026 at 1:10 with RN 1, Patient 4’s HHA's “Patient Medication Profile” (a comprehensive, updated record of a patient's prescription drugs, over-the-counter medications, supplements, allergies, and health conditions, often maintained in electronic health records), for recertification period (60-day timeframe during which a Medicare beneficiary receives ordered home health services under a certified plan of care) 2/8/2026 to 4/8/2026, indicated these were some of the medications Patient 4 was prescribed:

Carbidopa ER 25 mg-levodopa 100 mg tablet, extended release take 2.5 tablets orally, twice daily for Parkinsons DiseaseVitamin D2 1,250 mcg (50,000 unit) capsule take 1 capsule orally, every Saturday, for osteoporosis and muscle weaknessRN 1 stated, Alaunus Home Health’s “Patient Medication Profile” lists Patient 4’s current medications.

During a concurrent interview and record review on 3/17/2026 at 1:10 pm, with RN 1 at Patient 4’s residence, RN 1 reconciled Patient 4’s ALF's “Order Summary Report” with HHA's “Patient Medication Profile”. RN 1 stated the following medication discrepancies for Patient 4:

ALF listed Carbidopa-Levodopa administered “four times a day” while HHA indicated Carbidopa-Levodopa administered “twice daily”ALF listed vitamin “D3” while HHA indicated vitamin “D2”RN 1 stated it appears the medication reconciliation (the formal process of creating the most accurate, up-to-date list of a patient's medications and comparing it against physician orders to prevent errors like omissions, duplications, or dosage mistakes) was not performed, she will let the physician and Alaunus Home Health know of these discrepancies and fix the problem. RN 1 stated these discrepancies could weaken Patient 4’s bones, increase Patient 4’s risk for falls, and cause confusion, agitation, and hallucination.

During an interview on 3/18/2026 at 12:20 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), the DPCS stated it appears LVN 2 did not complete Patient 4’s medication reconciliation, LVN 2 did not contact the DPCS regarding any discrepancies with medication reconciliation, the DPCS will look for the physician’s orders for these medication discrepancies, and LVN 2 should complete medication reconciliations at every patient visit. Discrepancies with medication reconciliations could lead to medication error or the patient receiving the wrong dose or the wrong medication.

During an interview on 3/18/2026 at 1:04 pm with LVN 2, LVN 2 stated medication reconciliations are performed during every patient visit, and Patient 4 had no medication discrepancies. LVN 2 stated a patient could become toxic from receiving double the prescribed dose of Carbidopa-Levodopa and was not aware of any harm to the patient if the patient received vitamin D3, instead of the prescribed vitamin D2.

During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile, Policy No. 4-024.1,” dated November 2017, the P&P indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record.”

c. During a record review of Patient 5’s “Patient Profile” undated, “Patient Profile” indicated start of care was 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 interview and record review on 3/17/2026 at 10:30 am with RN 1, Patient 5’s ALF's “Order Summary Report,” dated 3/17/2026, was reviewed. The “Order Summary Report” indicated these are some of the medications Patient 5 was currently prescribed:

Aspirin Oral Capsule 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CHF with an order status of “On-Hold” to reduce risk for heart attacks and strokesCholecalciferol Oral Capsule (Cholecalciferol) Give 50 mcg by mouth one time a day for SUPPLEMENT with an order status of “On-Hold” for healthy bones and musclesCyanocobalamin Oral Tablet (Cyanocobalamin) Give 1000 mcg by mouth one time a day for Supplement with an order status of “On-Hold” to reduce risk of anemiaPreserVision AREDS 2 Oral Capsule (Multiple vitamins w/ Minerals) Give 1 capsule by mouth two times a day for MACULAR DEGENERATION with an order status of “On-Hold” to slow progression of macular degenerationPriolia Subcutaneous Solution Prefilled Syringe (Denosumab) Inject 1 ml subcutaneously one time only for OSTEOPOROSIS for 168 daysRN 1 stated, ALF's “Order Summary Report” lists Patient 5’s current medications.

During an interview on 3/17/26 at 11:14 am, with Patient 5 in Patient 5’s room, Patient 5 stated she took whatever meds she was given.

During a concurrent interview and record review on 3/17/2026 at 12:00 with RN 1, Patient 5’s HHA's “Patient Medication Profile” for recertification period 1/20/2026 to 3/20/2026, indicated these were some of the medications Patient 4 was prescribed:

Aspirin 81 mg tablet, delayed release take 1 tablet orally, once dailyCholecalciferol (vitamin D3) 50 mcg (2,000 unit) capsule take one capsule orally, once dailyCyanocobalamin (vit B-12) 1,000 mcg tablet take one tablet orally, once dailyPreserVision AREDS 2 Oral Capsule (Multiple vitamins with minerals) Take 1 capsule orally, twice dailyPriolia 60 mg/ml subcutaneous syringe Inject 1 ml subcutaneously, once daily every Monday until 5/24/2026. Injection performed by LVNRN 1 stated, HHA's “Patient Medication Profile” lists Patient 5’s current medications.

During a concurrent interview and record review on 3/17/2026 at 12:00 pm, with RN 1 at Patient 5’s residence, RN 1 reconciled Patient 5’s ALF's “Order Summary Report” with HHA's “Patient Medication Profile”. RN 1 stated the following medication discrepancies for Patient 5:

ALF listed Aspirin “On-Hold” while HHA indicated Aspirin administered “once daily”ALF listed Cholecalciferol “On-Hold” while HHA indicated Cholecalciferol “once daily”ALF listed Cyanocobalamin “On-Hold” while HHA indicated “once daily”ALF listed PreserVision AREDS 2 “On-Hold” while HHA indicated “twice daily”ALF listed Priolia Subcutaneous Solution Prefilled Syringe (Denosumab) Inject 1 ml subcutaneously “one time only” for OSTEOPOROSIS while HHA indicated “once daily every Monday until 5/24/2026”RN 1 stated it appears the medication reconciliation was not performed; she will let the physician and HHA know of the discrepancies and fix the problem. RN 1 stated these discrepancies could lead to stroke, weakened immune system and falls.

During an interview on 3/18/2026 at 12:20 pm with DPCS, the DPCS stated it appears LVN 2 did not complete Patient 5’s medication reconciliation, LVN 2 did not contact the DPCS regarding any discrepancies with medication reconciliation, the DPCS will look for the physician’s orders for these medication discrepancies, and LVN 2 should complete medication reconciliations at every patient visit. Discrepancies with medication reconciliations could lead to medication error or the patient receiving the wrong dose or the wrong medication.

During an interview on 3/18/2026 at 1:04 pm with LVN 2, LVN 2 stated medication reconciliations are performed during every patient visit, and Patient 5 had no medication discrepancies. LVN 2 stated if a patient did not receive Aspirin, Cholecalciferol, Cyanocobalamin, AREDS 2 or Priolia, they could experience a stroke, weakened immune system, anemia, poor eyesight, and falls.

During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile, Policy No. 4-024.1,” dated November 2017, the P&P indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record.”

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.

During a review of Patient 1’s current medications on 3/17/2026 at 11:20 a.m. with LVN 3, the following medications were available at Patient 1’s residence but not listed in Patient 1’s medication profile or POC provided by the HHA:
- Simethicone (a medication used to relieve symptoms of excess gas, such as painful pressure, bloating, and fullness) 500 milligrams (mg, a unit of measurement)
- Calcium carbonate (a medication used to relieve heartburn, acid indigestion, and upset stomach) 1000 mg

During an interview on 3/17/2026 at 11:24 a.m. with LVN 3, LVN 3 stated she was the visiting nurse for Patient 1. LVN 3 stated simethicone and calcium carbonate were medications that should have been included in Patient 1’s medication profile. LVN 3 stated she did not thoroughly complete medication reconciliation (a process of comparing the physician ordered medication to all the medications the patient is taking) during past visits.

During an interview on 3/18/2026 at 2:38 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation should be completed by the visiting nurses during every visit. The DPCS stated completing medication reconciliation at each visit is important to ensure medications are being taken as prescribed, the medication profile remains current and accurate, and potential medication interactions are identified. The DPCS stated not doing medication reconciliation at each visit could result in medications being administered incorrectly.

During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” revised 11/2017, the P&P indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.”

b.

c.