Every finding on record at Advantage Home Care, Inc Dba Corus Home Health

A Recertification Survey was conducted by Healthcare Management Solutions, LLC, on behalf of the New Mexico Health Care Authority (HCA). An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 05/05/25 to 05/07/25 resulted in no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Health Care Authority (HCA). An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 05/05/25 to 05/07/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review, staff interviews, and policy review, the agency failed to ensure one of five sampled patients (Patient (P) 14) being discharged to a post-acute care provider was assisted in selection by using quality measures data and data on resource use measures, thereby preventing patients from making informed decisions about the performance of other providers. This has the potential to affect all patients being discharged to a post-acute care provider. Findings include: Review of the agency's policy titled, "Discharge Criteria and Planning," revised February 2024, did not include criteria for assisting patients with a list of post-acute providers. Review of the "Plan of Care" tab of the electronic medical record (EMR) indicated P14 was admitted to the agency on 10/27/23 and discharged to another home health agency on 11/10/23. There was no evidence that the agency provided P14 with a list of home health agencies which included quality measures data and data on resource use measures. During an interview on 05/05/25 at 10:00 AM, the Chief Operating Officer (COO) confirmed that patients were not being provided with a list of post-acute providers using quality measures and data on resource use measures. The COO stated that he/she was not aware of that requirement and did not know where to find quality measures for other providers. During an interview on 05/05/25 at 10:30 AM, the Administrator confirmed that patients were not being provided with a list of post-acute providers. The Administrator stated, "I did not know that was a requirement."

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 observation, document review, interview, and policy review, the agency failed to provide a written, individualized, complete, plan of care that identified patient-specific measurable outcomes, goals, and diet for one of seven sampled patients (Patient (P) 5) reviewed for care plans. This deficient practice has the potential to allow different healthcare providers to provide inconsistent or conflicting care and affects all patients. Findings include: Review of the facility's agency policy titled, "Plan of Care-CMS#485 (Centers for Medicare & Medicaid Services (CMS) Form 485) and Physician/Practitioners Orders," revised February 2024, revealed under "PROCEDURE 2," it read "Each patient must receive an individualized written plan of care, including and revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, … and measurable outcomes that the Agency anticipates will occur because of implementation and coordinating the plan of care." During an observation on 05/06/25 at 1:30 PM, a home visit was conducted at P5’s residence while observing Home Health Aide (HHA) 1. Review of P5’s admission packet, provided by the facility, revealed it lacked a complete plan of care which included prognosis, rehabilitation potential, activities permitted, and nutritional requirements. The packet included an agency form titled "Home Health Care Plan" which contained handwritten notes and was not individualized, and complete. Review of the agency form "Home Health Care Plan" provided by the facility, did not include all the information included on P5’s CMS Form 485. It lacked the patient's prognosis, rehabilitation potential, activities permitted, and nutritional requirements. An interview with P5 on 05/06/25 at 1:40 PM revealed that all the paperwork provided by the agency was placed in the admission packet and P5 was not aware of what a plan of care was. During an interview on 05/06/25 at 3:00 PM, the Administrator confirmed that CMS Form 485 was not given to patients. The Administrator stated that the patient was provided with the agency form titled "Home Health Care Plan" as their plan of care. When asked if different patients received different forms, the Administrator replied "No."

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 a request for documents and staff interview, the agency failed to develop a policy addressing the pneumococcal vaccine administration for patients, thereby increasing the risk of transmitting preventable diseases. This deficient practice potentially affects all patients. Findings include: During a request submitted to the Administrator for a policy outlining the administration of the pneumococcal vaccine for the patients on 05/07/25 at 10:00 AM, the Administrator was unable to provide the requested policy. During an interview on 05/07/25 at 10:15 AM, the Administrator revealed that the agency had not established a policy regarding the administration of the pneumococcal vaccine for patients. The Administrator stated that all patients were asked about the vaccine upon admission, and if they chose to receive it, the agency coordinated with their physician to facilitate its administration.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, document review, interviews, and policy review, the agency failed to promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes were not being achieved and/or that the plan of care should be altered for one of seven sampled home visit patients (Patient (P) 4). This lack of communication led to delays in necessary interventions and adjustments to the care plan. Findings include: Review of the agency's policy titled, "Coordination of Patient Care" revised February 2024, revealed under "Procedure 1. The Agency must: 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." Review of the "Plan of Care" tab of the electronic medical record (EMR), with the certification period from 11/11/24 to 01/09/25 listed a medical diagnosis of right total knee replacement, following a hospital stay from 10/30/24 to 11/06/24. Review of the undated "Disciplines to see patient" section of the EMR, noted a "Physical Therapy (PT) evaluation," with no documented evidence that skilled nursing services were ordered. Review of the hospital’s "Discharge Summary," provided by the facility, indicated P4 was admitted from 12/13/24 to 12/16/24 for generalized edema (fluid retention) and shortness of breath, due to volume overload with pleural effusion (excessive fluid between the lungs and chest wall). Additional diagnoses include hypothyroidism, chronic atrial fibrillation, hypertension, lupus, and end-stage kidney disease with in-center dialysis. Review of the "Plan of Care" under "Medical Diagnosis for Continued Home Health" for the certification period from 03/11/25 to 05/09/25 and provided by the facility, listed congestive heart failure, characterized by weakened heart function leading to fluid buildup in the body. The ordered service for this period remained physical therapy. There was no evidence that skilled nursing services were ordered, nor was there evidence that interventions for congestive heart failure were prescribed or communicated to the patient’s physician. During an observation on 05/06/25 at 9:00 AM, a home visit was conducted at P4’s residence to observe Physical Therapist (PT) 2 provide strength and gait training. P4 was seen sitting at the kitchen table, eating breakfast, and appeared frail. With assistance from PT2 and the use of a gait belt, P4 attempted to stand but was only able to do so for approximately 15 seconds. During an interview on 05/06/25 at 9:15 AM, P4 shared that P4 previously underwent peritoneal dialysis at home but experienced an infection in the port (a small, surgically implanted reservoir used to withdraw excess fluid). P4 stated as a result, dialysis treatments were delayed, leading to fluid buildup in the lungs. P4 stated now had a fistula/graft in the right arm and received dialysis treatments at an in-center facility three days a week for four hours per session. P4 remarked, "I’ve lost almost 20 pounds since going to the in-center dialysis center." During an interview on 05/06/25 at 9:45 AM, when questioned if there had been any communication or coordination with nursing services, PT2 stated, "No." When asked if the patient’s physician was notified about the diagnosis of congestive heart failure, PT2 replied, "No." During an interview on 05/07/25 at 10:00 AM, the Administrator reviewed the electronic medical record of P4 and stated, "I agree, there should have been skilled nursing services ordered, and the physical therapist should have contacted the patient’s physician."

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure initial competency evaluations supervised by a Registered Nurse (RN) were conducted prior to providing patient care, thereby potentially allowing aids to perform essential tasks incorrectly, and/or inadequate patient care for seven of eight Home Health Aides (HHA) 1, HHA2, HHA3, HHA4, HHA5, HHA7, and HHA8. This has the potential to affect all patients receiving HHA services. Findings include: Review of the agency's policy titled, "Staff Competency Program," revised February 2024, revealed under "PROCEDURE 4." It read "Examples of qualified individuals to perform competency assessment may include: Home Health Aide; competency assessed by a RN." Review of the "Training Records," provided by the facility, for HHA1, HHA2, HHA3, HHA4, HHA5, HHA7, and HHA8 revealed the records did not contain documentation verifying that the agency had performed initial competency testing under the supervision of a registered nurse before allowing them to provide patient care. The records did indicate that yearly competency testing was being conducted. During an interview on 05/07/25, at 9:00 AM, the Administrator confirmed that aide competency evaluations were not being conducted by an RN before patient care was provided. The Administrator explained that HHAs participated in a home visit, during which they observed another HHA performing personal hygiene and grooming tasks for a patient. The Administrator stated after a single observation, the HHA was deemed competent and permitted to conduct these functions independently. The Administrator stated, "We do not conduct initial competency training. We have them observe another home health aide to ensure they are performing correctly, but they are not assessed by a registered nurse."

G0000 On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at Advantage Home Care, Inc Dba Corus Home Health, Home Health Agency (HHA) on May 20, 2022, resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

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: G572 Based on record review and interview, the facility failed to obtain attending physician’s signature on the Plan of Care (POC) for 7 (Patient (P)1, P2, P3, P4, P5, P6 and P7) of 7 patients (P1, P2, P3, P4, P5, P6 and P7) sampled. This deficient practice is likely to delay treatment and can cause harm to patients. Findings include: A. Review of the POC in the Electronic Medical Record (EMR) for P1, P2, P3, P4, P5, P6 and P7 revealed the POC was not signed by the attending physician. B. During an interview on 05/20/22 at 04:20 PM, the Home Health Director confirmed the agency's POC should contain the attending physician’s signature.

The following deficiencies were cited during a complaint investigation completed on 01/14/2021 for the requirements of 42 CFR 484 for Home Health Agencies. Complaint #48889 was substantiated. A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Division of Health Improvement on 01/14/2021. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record reviews the facility failed to meet the Condition of Participation (CoP) for Care planning, coordination of services, and quality of care by failing to ensure that significant medical information exists in the plan of care, that orders are only executed as prescribed as evidenced by the following and medical doctors are notified of changes: A. The facility failed to obtain and/or document Advance Directive (AD) information and documents. See tag 574 B. The facility failed to adhere to the prescribed medication regiment. See tag 580 C. The facility failed to keep the plan of care current based on significant changes and promptly notify physician regarding changes in status that require a care plan modification. See tag 590

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 may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review of 5 patient charts (P#1-P#5) the facility failed to obtain and/or document Advance Directive (AD) information and documents for 3 (P#2,3,4) of 5 patient charts reviewed. Advance Directives (which include "Do Not Resuscitate" (DNR) documents) are important medical/legal documents which guide patient care and treatment. This deficient practice is likely to lead to patient care and treatment being administered incorrectly with possible catastrophic consequences (such as providing life-saving care for a patient who is a DNR) for the patients and their families. The Findings are: A. Record review of patient (pt.) P#2's chart (EMR- Electronic Medical Record) revealed that the "Admissions Agreement" (a pt. consent form) dated 09/01/2020 had a box checked "I Do" in regards to having an AD. The corresponding boxes "I Will" or "I Will Not" "provide a copy" (of the Advance Directive documents) are not checked, indicating that the facility did not request a copy of the pts. AD's and did not have clear guidance from the pt./family as to what the pt's. wishes are regarding Advance Directives. Advanced Directives include the following: DNR's (states a pt. does not wish to have life-saving interventions such CPR (Cardio-Pulmonary Resuscitation)), Living Will's (written instructions regarding pts. right to live/die wishes) and Durable Health Care Power of Attorney (designates a living personal representative to make healthcare decisions should the pt. become incapacitated). 1. Record review of patient (pt.) P#2's chart (EMR- Electronic Medical Record) revealed that the chart's document "Plan of Care (POC)", page #3, under "Advance Directives [MD orders]: DNR Start Effective Date: 09/01/2020". No corresponding actual AD or DNR's documents confirming the POC order were in this pt's. EMR, even though these forms were documented as existing in the POC. B. Record review of patient P#3's EMR revealed that the "Admissions Agreement" dated 09/04/2020 had a box checked "I Do" in regards to having an AD. The corresponding boxes "I Will" or "I Will Not" "provide a copy" (of the Advance Directive documents) are not checked. This indicates that the facility did not request a copy of the pt's. AD's and therefore did not have clear guidance from the pt./family as to what the pts. wishes are regarding Advance Directives. No AD documents confirming the POC order were in this pt's. EMR. C. Record review of patient P#4's EMR revealed that the "Admissions Agreement" dated 12/05/2020 had a box checked "I Do" in regards to having an AD. The corresponding boxes "I Will" or "I Will Not" "provide a copy" (of the Advance Directive documents) are not checked, indicating that the facility did not request a copy of the pts. AD's and therefore did not have clear guidance from the pt./family as to what the pt's. wishes are regarding Advance Directives. No AD documents confirming the POC order were in this pt's. EMR. 1. Record review of patient (pt.) P#4's chart (EMR- Electronic Medical Record) revealed that the "Plan of Care (POC)", page #3, under "Advance Directives [MD orders]: DNR Start Effective Date: 12/05/2020". No AD or DNR's documents confirming the POC order were in this pt's. EMR. D. On 12/14/2021 at 1:55 pm during interview S#2 (Director of Business Operations) confirmed that the "Admissions Agreement" form was not clearly and completely filled out properly regarding Advance Directives. Again, all of the 4 boxes: "I Do" or "I Do Not" have and AD, and "I Will" or "I Will Not" "provide a copy" (of the Advance Directive documents) are left blank/unchecked. E. On 12/14/2021 at 2:00 pm during interview S#3 (Chief Innovation Officer) acknowledged that the "Admissions Agreement" form should have had either the "I Will" or "I Will Not" box checked regarding whether the patient was willing to provide a copy of the Advance Directive documents to the facility. Again, the facility's "Admissions Agreement" form was not clearly and completely filled out properly regarding Advance Directives, which are critical documents regarding direction for patient care and treatment. It is standard practice for the facility to obtain, or attempt to obtain a copy of these AD documents from the patient for the facility's patient EMR. There was no documentation or evidence that the facility did any of these tasks or had scanned copies of the AD's in the pt's EMR. F. On 12/14/2021 at 2:05 pm during interview S#1 (Director of Home Health) confirmed that the facility had no scanned copies of any type of Advance Directive (AD) form in any of 3 patient charts (P#2, P#3, P#4). These 3 pt. charts had documention on the facility's "Admissions Agreement" form and/or also on their "POC" form indicating that these patient did have some type of AD.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on record review and interviews, the facility failed to adhere to the prescribed medication regiment for 1(p# 1) of 5 sampled patients selected for needing similar wound care needs or having communication-based grievances filed against the facility. This failed practice is likely to lead to inconsistent administration of high risk medications (medications that require timely administration to achieve wanted effect) and increase risk of exacerbating conditions that are being treated. The findings are: A.On 01/13/2021 at 2:00 pm, record review of facility's Medication Administration Policy revealed: 1. Drugs and treatments are administered by Agency staff only as ordered 2. Staff will use information from medication monitoring to assess the medication's continued administration and will communicate medication findings to patient's physician and other appropriate staff. B.On 01/14/2021 at 1:00pm, record review of P#1's initial referral from the hospital on 11/20/2020 prior to discharge home with home care services revealed: 1. Patient prescribed to receive intravenous ceftriaxone (antibiotic medication) once a day every day starting 11/21/2020 with end of treatment date of 11/30/2020. C. On 01/14/2021 at 1:30pm, record review of P#1's form CMS-485 (plan of care and certification form dictating all prescribed treatments the patient is to receive) from 11/21/2020 revealed that: 1. Medical doctor's (MD's) initial medication order for ceftriaxone does not include a completion date. D. On 01/14/2021 at 1:45pm, record review of P#1's skilled nursing notes from 11/21/2020-01/17/2020 revealed: 1. From 11/23/2020-11/26/2020 patient had documented missed visits with no mention of ensuring that intravenous antibiotics were being administered or if the patient had access to the medication. No documentation for ordering provider if there was an interruption in antibiotic administration. 2. On 11/27/2020 Registered Nurse's (RN's) assessment note does not indicate if intravenous antibiotics were administered during visit. 3. On 12/01/2020 (date beyond expected discontinue date for antibiotic) nurse's note indicates antibiotic infused during visit. Nurse notes that they contacted contracted infusion service provider regarding picking up more of the medication, but the infusion service provider indicated they believed that the antibiotic course has been completed. No documentation of notifying ordering provider about this discrepancy. 4. On 12/04/2020 (date beyond expected discontinue date for antibiotic) nurse's note indicates antibiotics infused during visit. 5. On 12/05/2020 nurse's note creates further inconsistency as it indicates that the patient has not received antibiotic for 1 week. This would place the discontinue date for antibiotic therapy at 11/28/2020, earlier than the original order. No documentation of physician notified promptly of discrepancy in medication monitoring. Nurse does describe patient's existing wound as worsening with right heel being foul smelling and containing wet necrotic (dead) tissue. E. On 1/14/2021 at 1:45pm interview with (Name of Facility Director) acknowledged discrepancy in medication administration in P#1's skilled nursing notes and indicated that it would be expected to have an end date for antibiotic administration. (Facility Director) also confirmed that case conference messages are not sent to patient's ordering providers, rather they stay intradepartmental to core facility staff. F.On 1/14/2021 at 2:00pm, record review of P#1's case conference communication log revealed: 1. On 12/05/2020, nurse indicates that patient has not had antibiotics for a week. No indication that MD is notified of this discrepancy

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interviews, the facility failed to keep the plan of care current based on significant changes for 2 (p 1 & 2) of 5 patients sampled with similar wound care needs or had grievances based on communication filed, promptly notify physician regarding changes in status that require a care plan modification. This deficient practice is likely to lead to fragmented care, ineffective treatments, and increased risk of poor outcomes. The findings are: A. On 01/13/2021 at 1:30pm, record review of facility's Reassessments/Update of the Comprehensive Assessment policy revealed: 1. Each patient will be reassessed when: a. A significant change in condition, status, diagnosis, care, environment or support system occurs. b.Physician orders more frequent reassessments. c.Response to care needs to be reassessed. B. On 01/13/2021 at 1:45pm, record review of facility's Plan of Care and CMS 485 (plan of care and certification form dictating all prescribed treatments the patient is to receive) Policy revealed: 1. The total Plan of Care will be reviewed and signed by the attending physician and Agency personnel involved in the patient's care as often as the severity of the patient's condition requires 2. The Agency professional staff will promptly alert the physician to any changes that suggest a need to alter the Plan of Care. 3. The Plan of Care will be reviewed more frequently if a significant change in condition occurs. C.On 01/14/2021 at 1:30pm, record review of P#1's form CMS-485/Plan of Care from 11/21/2020 revealed: 1.Patient's active diagnosis is osteomyelitis (bone infection) of right amputated (surgically removed) foot, open draining wound requiring daily wound care and intravenous antibiotics (medication). D. On 01/14/2021 at 1:45pm record review of P#1's skilled nursing notes from 11/21/2020-01/17/2020 revealed: 1. Start of care skilled nursing note from 11/21/2020 indicates that patient has a right foot diabetic ulcer (break down in skin complicated by diabetes.) and a right heel pressure ulcer (break down in skin due to a pressure). 2. From 11/23/2020-11/26/2020 patient had documented missed visits with no mention of ensuring that intravenous antibiotics or wound care being administered or if the patient had access to the medication or supplies. No documentation for ordering provider if there was an interruption in antibiotic administration or if wound care was performed. 3. On 11/27/2020 nursing assessment only done for right heel pressure ulcer, not for right foot diabetic ulcer. Nursing note included photographic documentation that captured both ulcers clearly. 4. On 11/28/2020 nursing assessment note documents for both wounds, but that the right heel pressure ulcer is worsening with increased drainage and there is concern for debridement (surgical procedure to remove damaged or infected tissue from a wound to promote healing). Nurse instructs family to call on 11/30/2020 about this change but does not immediately notify the physician about concern. 5. On 12/01/2020 nursing assessment for wound care states "See Swift App (application facility uses for wound assessment and tracking)." No entry for 12/01/2020 attached into patient's electronic medical record. 6. On 12/04/2020 nursing assessment for wound care states "See Swift App" but no entry found for 12/04/2020. Note further reports that nurse describes wound as worsening with "wound to heel appears to boggy (wet or saturated with underlining potentially infectious material) and foul (unpleasant) smelling. Nurse instructs family to keep doctor appointment on Monday 12/07/2020, but doesn't notify doctor immediately of change in wound status. 7. On 12/05/2020 nursing assessment note states that right heel wound has wet necrosis (area of dead tissue in wound). Nurse instructs family to keep doctor appointment on Monday 12/07/2020 and that a paper report will be sent with patient, but no documentation that nurse notified doctor of change to wound's status. 8. On 12/16/2020 nursing assessment note done using "Swift App" indicates both wounds as having improved to stage 2 (pressure ulcer marked by a small opening and partial loss of underlying tissue.) pressure ulcer. No indication to change plan of care or wound care. 9. On 01/08/2020 nursing assessment note done using "Swift App" indicates that patient's wound on right heel is now a stage 4 (pressure ulcer marked by full tissue loss with exposed bone and muscle) pressure ulcer. No entry for right foot diabetic ulcer. 10. On 01/13/2021 nursing assessment note reports that patient had a debridement (bed soar) done on 01/06/2020 by a podiatrist (medical doctor that specializes in feet). No documentation in chart found on if the ordering provider is aware or if there is a need to change the wound care regiment after a surgical intervention. 11. On 01/14/2021 communication note from ordering provider to increase the frequency of wound care visits. E. On 01/14/2021 at 2:30pm, record review of P#2's form CMS-485/Plan of Care from 09/01/2020 and 10/13/2020 revealed: 1. On 09/01/2020 integumentary (relating to skin) interventions: clean sacrum (tailbone) wound. 2. On 10/13/2020 resumption of home health services after discharge from hospital. Integumentary interventions: clean pressure ulcer to back, buttocks, tops of both feet, and left arm. F.On 01/14/2021 at 2:45pm, record review of P#2's skilled nursing notes: 1.On 09/03/2020 nursing assessment done for pressure ulcer on sacrum. Neurologically (pertaining to patient's mental capacity, ability, and level of consciousness), patient assessed as alert and oriented to person and place. 2. On 09/09/2020 nursing assessment note indicates 2 new wounds, abrasions (scrape or scratch) formed on top of each foot. Nurse's note continues by stating "Patient's bilateral (both sides) feet abrasions not healing. Cleansed with Dakins (brand) wound cleanser, xeroform (brand of petroleum based gauze) applied, gauze to cover. Intervention section of nurse's note does not have this wound or wound treatment listed. No documentation of physician being made aware of new wounds. Neurologically, patient assessed as alert and oriented to person and place. 3.On 09/16/2020 nursing assessment again indicates presence of abrasions to the top of P2's feet. Wound care to feet documented with no order of how to perform it. Neurologically, patient assessed as alert and oriented to person and place. No documentation that physician was made aware. 4.On 9/18/2020, nursing assessment indicates that abrasion wounds have worsen and are classified as Stage 2 pressure ulcers. Intervention section only has steps for wound care to be done to sacrum. Nurse indicates that wound care is complete, but there is no documentation that the physician is notified of change in wounds to feet. Neurologically, patient assessed as alert and oriented to person, place, and time. 5.On 09/21/2020 nursing assessment generates inconsistency as foot ulcers are documented as abrasions. Nurse documents that wound care is provided to the abrasions, but there is no order in intervention section of how to do so. Neurologically, patient assessed as alert and oriented to person and place. 6.On 09/25/2020 nursing assessment note indicates that foot wounds are stage 3 (pressure ulcer marked by deep tissue loss) pressure ulcer. Wound care documented on the ulcers, but no order in intervention section. No documentation of physician aware of worsening of wounds. Neurologically, patient assessed as alert and oriented to person and place. 7.On 09/28/2020 nursing assessment note generates inconsistency as top of foot ulcers are classified as abrasions. A new wound is recorded as a stage 1 (pressure ulcer marked by intact skin with discoloration that does not change) pressure ulcer to the right scapula (shoulder blade.) Nurse continues in narrative note by stating "patient has new area of breakdown right scapula, exuderm (wound dressing) put in place" No orders in intervention for how to dress feet or scapula. No documentation that physician made aware of new wounds. Neurologically, patient assessed as alert and oriented to person and place. 8.On 10/02/2020 nursing assessment note indicates that right scapula wound has gotten worse and progressed to a stage 2 pressure ulcer. Wound care documented on feet and scapula with no order. No documentation that physician made aware of worsening wound. Neurologically, patient assessed as alert and oriented to person, place, and time. 9.On 10/07/2020 transfer note indicates that patient was sent to the hospital for COVID-19 infection. G.On 01/14/2021 at 3:30 record review of P#2's Chat Communication Notes from 10/11/2020-11/18/2020 revealed: 1.On 9/23/2020 occupational therapist communication note stated that P#2 has "reduced alertness" no documentation that physician was made aware of neuro status change. This created inconsistency when compared to neurological assessments in skilled nursing notes. 2.On 09/30/2020 occupational therapist communication note stated that patient had limited alertness and ability to participate in treatment. No documentation of physician notified of pertinent change. 3.On 10/15/2020 Occupational Therapist communication note concerned about patient's functional status and how they may be a hospice candidate. No documentation of physician notified of pertinent change to status. H.On 1/14/2021 at 1:45pm interview with S2 (Executive Director) confirmed that case conference messages are not sent to patient's ordering providers, rather they stay intradepartmental to core facility staff. I.On 01/14/2021 at 3:45 pm, interview with S3 (Chief Innovation Officer) indicated that the facility relies on the wound care knowledge that staff attain from their formal college or trade-based education. S3 continued by stating that the facility "does not have a wound care skills check list" to determine competency in wound care, assessment, or recognition. S3 stated that education in wound care solely encompasses an orientation on using the "Swift App" but not on specifics of each kind of wound staff may encounter. When going through inconsistencies in charting of wound care, S3 acknowledged the difficulty in determining if plan of care was working for the patient and that the physician must be notified and plan of care changed when there's a change in patient status.