Every finding on record at County of Chickasaw

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 9/15/25 through 9/17/25 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 9/15/25 through 9/17/25. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 40 patients at the time of the survey.

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 staff interview, clinical record reviews and agency policy review, the agency failed to complete wound assessments for 1 of 3 sampled patients with wounds (Patient #1). Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of inappropriate treatment. Findings include: According to the agency policy titled Guidelines for Wound Measurement/Documentation/Procedures, dated 5/14/2019, wounds should be measured on the same day every week (when possible) and/or as needed to decrease discrepancies. During an interview on 9/16/25 at 2:30 PM, Staff B, Clinical Manager, reported wounds are to be measured weekly. Measurements include length, width and depth in centimeters and documentation needs to include a description of the wound. Patient #1 had a start of care date of 3/30/23. Clinical record review revealed: a. The Plan of Care (POC), dated 7/17/25 to 9/14/25, included orders for skilled nurse services. b. The recertification visit note, dated 9/12/25, by Staff C, Registered Nurse, included documentation the patient has an open area to the left lateral lower leg that originated as a blister and is decreasing in size. Wound care provided as ordered. The note failed to include documentation of measurements of the open area to the left lateral lower leg. The agency failed to document weekly measurements of the patient's wound to left lateral lower leg. The above findings were reviewed with the Administrator and Clinical Manager.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 3 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patient #3). The agency reported 9 patients who received home health aide services with every 14 day supervision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency's policy titled Home Care Aide Services, dated 8/8/25, if client also receiving skilled nursing service, then supervision will occur no less than every 14 days. The aide does not have to be present. During an interview on 9/16/25 at 2:30 PM the Clinical Manager stated the nurse completes aide supervision every 14 days and documents in the visit section of the patient's chart. Patient #3 had a start of care date of 6/27/25. The Plan of Care (POC), dated 8/26/25 to 10/24/25, included physician orders for skilled nursing and home health aide services and diagnosis of hypertensive chronic kidney disease. Review of the clinical record included the following: a. The skilled nurse visit note, dated 7/8/25, Staff C, Registered Nurse (RN), included documentation of home health aide supervision. b. The skilled nurse visit note, dated 7/23/25, Staff C, RN, included documentation of home health aide supervision 15 days after the previous home health aide supervision (1 day late). c. The skilled nurse visit note, dated 8/5/25, Staff C, RN, included documentation of home health aide supervision. d. The skilled nurse visit note, dated 8/21/25, Staff C, RN, included documentation of home health aide supervision 16 days after the previous home health aide supervision (2 days late). The agency failed to provide home health aide supervision every 14 days. The above findings were reviewed with the Administrator and Clinical Manager.

The recertification survey, conducted from 10/3/22 through 10/6/22, identified the following standard level deficiencies related to emergency preparedness.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on clinical record review, review of the agency's emergency plan and related policies, home visit observation, patient and staff interview, the home health agency failed to: 1) ensure the agency's emergency plan and related policies identified the need for agency staff to review/update the patient's individualized emergency preparedness plan with the comprehensive assessment and each update to the comprehensive assessment; and, 2) ensure the patient received a copy of the patient's individualized emergency plan developed as part of the comprehensive assessment for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation. Failure to ensure the agency provided a copy of the patient's individualized emergency plans and failure to ensure the agency's emergency preparedness policies and procedures addressed the need for agency staff to review/update the patient's individualized emergency preparedness plan with the comprehensive assessment and each update to the comprehensive assessment placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: Review of the agency's emergency preparedness plan and related policies revealed a related policy identified agency staff would develop an emergency preparedness plan with the patient upon admission to the agency and staff would update the plan when changes occurred. The policy failed to identify agency staff needed to review/update the patient's individualized emergency plan with each update to the comprehensive assessment. 1. Patient #1 had a start of care date of 1/21/22 and residing in an assisted living facility. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 1/21/22, and the most recent update to the comprehensive assessment completed at the time of recertification, dated 9/16/22, identified the agency nurse reviewed the patient's emergency preparedness plan during the assessment process. On 10/4/22 at 9:22 AM, during a home visit observation with Staff C, Registered Nurse (RN), the surveyor reviewed the folder provided by the agency to the patient with Staff C. The folder lacked documentation of an individualized written emergency preparedness plan developed by the agency with the patient. The surveyor observed the patient had poor memory recall and was not interviewable. In an interview, during the same home visit observation, Staff C, RN, reported the patient's emergency preparedness plan should be in the folder, and she did not know why it was not there. She thought maybe either the patient's family had it or the assisted living staff had it in their paperwork. On 10/4/22 at 10:20 AM, during an interview, assisted living facility staff reviewed available documentation on the patient with the surveyor and confirmed they did not have a copy of the patient's emergency preparedness plan developed by home health agency staff. 2. Patient #2 had a start of care date of 6/2/22. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 6/2/22, and the most recent update to the comprehensive assessment completed at the time of recertification, dated 9/27/22, identified the agency nurse reviewed the patient's emergency preparedness plan during the assessment process. On 10/4/22 at 11:00 AM, during a home visit observation with Staff D, RN, the surveyor reviewed the folder provided by the agency to the patient. The folder lacked documentation of an individualized written emergency preparedness plan developed by the agency with the patient. In an interview, during the same home visit observation, Staff D, RN, reported while agency nursing staff reviewed the patient's emergency preparedness plan, they did not leave a written copy of the patient's plan in the home. 3. Patient #3 had a start of care date of 9/1/22. Review of the clinical record revealed the following: The comprehensive assessment completed at the start of care, dated 9/1/22, identified the agency nurse reviewed the patient's emergency preparedness plan during the assessment process. On 10/4/22 at 3:15 PM, during a home visit observation with Staff E, Physical Therapist, the surveyor reviewed the folder provided by the agency to the patient. The folder lacked documentation of an individualized written emergency preparedness plan developed by the agency with the patient. In an interview, during the same home visit observation, the patient reported the patient had not received a copy of a written individualized emergency preparedness plan and did not recall reviewing this with agency staff. On 10/5/22 at 3:35 PM, during an interview, the Administrator reported agency staff were taking out copies of the patients' written individualized emergency preparedness plan to each of the patients this week. On 10/6/22 at 10:00 AM, during an interview, the Administrator confirmed an inability to find language in the emergency preparedness plan and related policy which addressed the need for staff to review/update the patient's individualized emergency preparedness plan with each update to the comprehensive assessment. The Administrator and Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the agency emergency preparedness plan and related policies and agency staff interview, the agency failed to complete a written emergency preparedness plan that included procedures to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place for to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency placed agency staff and patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's Emergency Preparedness Plan and related policies identified a lack of procedures to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. On 10/6/22 at 10:00 AM, during an interview, the Administrator verified an inability to find language in the plan or related policies to include procedures to inform State and local officials of on duty staff patients they are unable to contact in the event of an interruption of services related to an emergency. The Administrator received the above findings and staff provided no additional information prior to the end of the survey.

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 10/3/22 through 10/6/22, found the agency operating out of compliance with the following standard level deficient practices. The agency reported a census of 59 patients at the time of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all pertinent components of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring an update to the comprehensive assessment at the time of resumption of care (Patient #6). The agency performed 20 updates to the comprehensive assessment at the time of resumption of care in the last 6 months. Failure to complete updates to the comprehensive assessment at the time of resumption of care in a timely manner increased the potential that patients might not receive services in a timely manner to meet individualized patient needs. Findings include: Review of the agency policy, titled Comprehensive Assessment of Patients, dated 5/14/19, identified agency will complete the update to the comprehensive assessment within 48 hours of knowledge of a patient's return from a hospital stay. Patient #6 had a start of care date of 2/8/2020 and discharged on 7/20/22. Review of the clinical record revealed the following: a. An update to the comprehensive assessment, dated 2/16/22, included documentation which identified agency staff received notification of the patient's discharge from an inpatient hospital stay and the need to resume agency services on 2/15/22. The nurse who completed the update to the comprehensive assessment, documented she completed the assessment on 2/18/22 (1 day late). b. An update to the comprehensive assessment, dated 4/21/22, included documentation which identified agency staff received notification of the patient's discharge from an inpatient hospital stay and the need to resume agency services on 4/19/22. The nurse who completed the update to the comprehensive assessment, documented she completed the assessment on 4/22/22 (1 day late). On 10/5/22 at 3:35 PM, during an interview, the Administrator reported she thought agency nursing staff had 48 hours from the date the visit occurred to complete the update to the comprehensive assessment at the time of resumption of care. The Administrator and Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the Plan of Care included wound care orders for 1 of 4 sampled patients (Patient #5) with a wound. Failure to maintain complete and accurate Plans of Care with current wound care orders placed the patients at risk to not receive wound care treatments according to physician orders. Findings include: Review of the agency policy, titled Home Health Certification and Plan of Care, dated 5/14/19, revealed agency nursing staff develop the Plan of Care (POC) at the time of admission and includes orders for all disciplines and treatments. Patient #5 had a start of care date of 9/2/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 9/2/22, identified the patient had a surgical incision on the middle toe of the right foot. The nurse documented the patient had a wet to dry Betadine soaked gauze dressing, covered with dry gauze then Kling Wrap and an Ace Wrap. The nurse documented a family member of the patient was performing the wound care dressing changes. b. The Plan of Care (POC), dated 9/2/22 to 10/31/22, identified diagnoses of aftercare following surgical amputation and right toe(s) amputation, identified the patient used wound care supplies and included orders for the nurse to assess the patient's surgical wound status every visit, measure the surgical wound weekly, instruct the patient on signs and symptoms of wound infection and on disposal of contaminated wound dressings. c. Skilled nursing visits, dated 9/14 and 9/21/22, included documentation the nurse observed the family member assist the patient with the wound dressing change for the right middle toe amputation. She documented the family member and patient did well with the dressing change. The POC failed to identify the specific location of the patient's wound and lacked documentation of wound care orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure staff assessed wounds and provided wound care treatments only as ordered by the physician and per the Plan of Care for 3 of 4 sampled patients (Patients #1, #5 and #7) with a wound. Failure to ensure staff assessed wounds and provided wound care treatments only as ordered by the physician and per the Plan of Care placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency policy, titled Home Health Certification and Plan of Care (POC), dated 5/14/19, revealed staff implement all clinical services in accordance with the Plan of Care established by physician written orders. The nurse ensures staff carry out all orders for disciplines and treatments on the POC at each visit. 1. Patient #1 had a start of care date of 1/21/22 and received services while residing at an assisted living facility. Review of the clinical record revealed the following: a. The Plans of Care, 7/20/22 to 9/17/22 and 9/18/22 to 11/16/22, included the following wound care orders: cleanse with wound cleanser, apply moisture barrier around the ankle wound, apply Aloe Vista Ointment to the rest of the leg and foot; apply Aquacel sheet (type of wound dressing), 3 layers over medial ankle and one layer over all other open ulcers; cover the ankle wound with 2 layers of ABD (abdominal wound dressing); secure with Surepress bandage, paper tape and Tubigrip. b. The skilled nursing visits, dated 8/9, 8/12, 8/23 and 8/26/22, identified the patient had 3 wounds including a left medial ankle wound, left lateral leg wound and left lower leg lateral upper and lower medial wound. The nurse documented she used barrier cream around the edges of all 3 wounds instead of just the left medial ankle wound. The nurse documented she applied only 2 layers of Aquacel instead of 3 layers on the left medial ankle wound and none to the left lateral upper and lower medial wound. c. The skilled nursing visits, dated 9/6, 9/9, 9/16, 9/20 and 9/23/22, identified the patient had 2 lower left leg wounds, including one on the left medial ankle and one on the left lower lateral leg. The nurse documented she applied barrier cream to both wounds and only 2 layers of the Aquacel dressing to the left medial ankle wound. d. Interim physician orders, dated 9/26/22, included orders for wound care to the left medial ankle as follows: cleanse the wound with wound cleanser, pat dry, apply a thin layer of Sensicare Protective Barrier around the wound, apply Prisma cut to the size of the wound bed, apply Aquacel sheet dressing starting with 2 layers to accommodate drainage, cover with ABD, secure with Suripress bandage, paper tape and Tubigrip. On 10/4/22 at 9:22 AM, during a home visit observation, Staff C, Registered Nurse (RN), performed wound care to 3 separate lower leg wounds. Staff C, RN, set up a clean field under the patient's lower left leg, obtained would care supplies and sanitized a pair of scissors. Staff C, RN, changed gloves, applied wound cleanser to a 4 by 4 gauze and cleansed the left medial ankle wound first, then the left lateral lower leg wound and a left mid anterior shin wound. Staff C, RN, stated all 3 wounds were open and the left lateral lower leg wound had become larger. Staff C, RN, measured all 3 wounds using a disposable tape measure. Staff C, RN, applied a topical barrier cream around the edges of each of the 3 open wounds, instead of just the medial ankle wound. She then applied a Prisma and Aquacel dressing to the left medial ankle wound and Aquacel to the left lateral lower leg wound. She did not apply Aquacel to the shin wound. She applied an ABD pad over all 3 wounds, one layer, Surepress (a soft wrap dressing), cloth tape to hold in place and Tubigrip over the top. Staff C, RN, applied barrier cream to the left lateral lower leg wound and left shin wound without an order. She failed to apply Aquacel to the left shin wound. She applied an ABD pad over the left lateral lower leg wound and left shin wound without an order. 2. Patient #5 had a start of care date of 9/2/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 9/2/22, identified the patient had a surgical incision on the middle toe of the right foot. The nurse documented the patient had a wet to dry Betadine soaked gauze dressing, covered with dry gauze then Kling Wrap and an Ace Wrap. The nurse documented a family member of the patient was performing the wound care dressing changes. b. The Plan of Care (POC), dated 9/2/22 to 10/31/22, identified diagnoses of aftercare following surgical amputation and right toe(s) amputation, identified the patient used wound care supplies and included orders for the nurse to assess the patient's surgical wound status every visit, measure the surgical wound weekly, instruct the patient on signs and symptoms of wound infection and on disposal of contaminated wound dressings. c. The week of 9/11/22, included documentation of one skilled nursing visit, dated 9/14, and the week of 9/18/22, included documentation of one skilled nursing visit, dated 9/21/22. Both visits included documentation the nurse observed the family member assist the patient with the wound dressing change for the right middle toe amputation. She documented the family member and patient did well with the dressing change. The visit notes lacked documentation of an assessment of the wound including measurements per physician orders. 3. Patient #7 had a start of care date of 4/6/22 and discharged from agency services on 5/10/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed at the start of care, dated 4/6/22, identified the patient had 2 wounds, a pressure ulcer on the right bunion of the foot and on the right heel. b. The Plan of Care, dated 4/6/22 to 6/4/22, included orders for to cleanse the foot wounds with Normal Saline, apply Iodosorb and gauze, wrap with Kerlix. c. The skilled nursing visit, dated 4/7/22, included documentation the nurse assessed and treated the right bunion foot wound, but lacked any documentation of assessment or treatment of the right heel wound. The Administrator and Assistant Administrator received the above findings and staff provided no further information prior to the end of the survey.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and staff interview, the agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice observed during a home visit for 1 of 3 sampled patients with a home visit observation (Patient #1). Failure to follow agency expectations and accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: Review of the agency policy, titled Guidelines For Wound Measurement/Documentation/Procedures, dated 1/11/21, identified lesions separated by health intact tissue indicates these are separate wounds and could have different bacteria in them. A separate 4 by 4 gauze must be used to the clean each wound. The first step of wound care is for the nurse to wash his/her hands. After setting up a clean field, the nurse should apply non-sterile gloves, get out/set up needed wound supplies and clean the scissors with an alcohol wipe. Remove gloves, don non-sterile gloves, cleanse the wound with wound cleanser and a 4 by 4 gauze, discard the gauze and change gloves. Apply a skin sealant or moisture barrier around the wound margins as ordered, and then change gloves. Apply primary dressing as ordered, and then change gloves. Change gloves after each dressing layer. When done, change gloves, apply tape and/or wrap (such as Tubifast or Surepress) to secure as ordered. Change gloves, put away unused supplies, and discard any used supplies and gloves. The policy directed staff to wash hands after completing the dressing change. Patient #1 had a start of care date of 1/21/22 and received services while residing at an assisted living facility. Review of the clinical record revealed the following: a. The update to the comprehensive assessment completed at the time of recertification, dated 9/16/22, identified the patient had 2 left lower leg wounds, one located on the left medial (inner) ankle area and one on the left lateral (outside) lower leg. b. The Plan of Care, dated 9/18/22 to 11/16/22, included the following wound care orders: cleanse with wound cleanser, apply moisture barrier around the ankle wound, apply Aloe Vista Ointment to the rest of the leg and foot; apply Aquacel sheet (type of wound dressing), 3 layers over medial ankle and one layer over all other open ulcers; cover the ankle wound with 2 layers of ABD (abdominal wound dressing); secure with Surepress bandage, paper tape and Tubigrip. c. Interim physician orders, dated 9/26/22, included orders for wound care to the left medial ankle as follows: cleanse the wound with wound cleanser, pat dry, apply a thin layer of Sensicare Protective Barrier around the wound, apply Prisma cut to the size of the wound bed, apply Aquacel sheet dressing starting with 2 layers to accommodate drainage, cover with ABD, secure with Suripress bandage, paper tape and Tubigrip. On 10/4/22 at 9:22 AM, during a home visit observation, Staff C, Registered Nurse (RN), performed wound care to 3 separate lower leg wounds. Upon arrival to the patient's home, Staff C, RN, used an alcohol based hand sanitizer, set up a clean field and got out equipment to measure the patient's vital signs. After completing an assessment of the patient's vital signs, Staff C, RN, sanitized her hands, gloved and went to the bathroom to assess the wound dressings removed by the assisted living staff prior to the RN's arrival. Staff C, RN, returned to the patient, removed her gloves, sanitized her hands and gloved again. Staff C, RN, set up a clean field under the patient's lower left leg, obtained would care supplies and sanitized a pair of scissors. Staff C, RN, changed gloves, applied wound cleanser to a 4 by 4 gauze and cleansed the left medial ankle wound first, then the left lateral lower leg wound and a left mid anterior shin wound. She used a separate 4 by 4 gauze to clean each wound, but kept the same gloves on. Staff C, RN, stated all 3 wounds were open and the left lateral lower leg wound had become larger. Staff C, RN, measured all 3 wounds using a disposable tape measure. Staff C, RN, removed her gloves, sanitized her hands and gloved again. She applied a topical barrier cream around the edges of each of the 3 open wounds using the same gloves and same fingers from her left hand to apply the cream. She changed gloves, sanitizing in between. She then applied a Prisma and Aquacel dressing to the left medial ankle wound and Aquacel to the left lateral lower leg wound using the same gloves. She applied an ABD pad over all 3 wounds, one layer, Surepress (a soft wrap dressing), cloth tape to hold in place and Tubigrip over the top. Staff C, RN, then removed the same gloves she had been wearing since applying the first dressing layer of Prisma to the left medial ankle wound. The nurse failed to follow wound infection control procedures established by the agency including handwashing prior to wound care, changing gloves between each wound and each layer of a dressing change in order to prevent the possibility of cross-contamination of bacteria between separate wounds. On 10/5/22 at 9:07 AM, during an interview, the Administrator reported the expectation that the nurse should treat each wound separately and change gloves between the treatment of each wound.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure registered nurses provided individualized and specific written patient care instructions to agency home health aides for 1 of 2 sampled patients receiving home health aide services (Patient #5). The agency reported 20 out of 59 patients received home health aide services at the time of the survey. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: Review of the agency policy, titled Home Care Aide Service, dated 9/14/22, revealed the admitting registered nurse (RN) will perform a comprehensive assessment to determine the needs of the patient. The RN will develop an individualized home care aide plan during the initial visit based on the patient's needs. On 10/4/22 at 8:22 AM, during an interview, the Administrator reported the admitting nurse was responsible for creating the home health aide care plan. Patient #5 had a start of care date of 9/2/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 9/2/22 to 10/31/22, included orders for skilled nursing one time per week and home health aide services three times per week. The POC included an order for Zeasorb medicated powder, apply to rash in skin folds twice daily as needed. b. The home health aide care plan, dated 9/9/22, included RN directions to the home health aide to apply medicated powder/cream as requested every visit. The home health aide care plan failed to identify a specific medicated powder or cream and failed to specify application instructions and location of application. c. The home health aide visit notes, dated 9/7, 9/9, 9/12, 9/14, 9/16, 9/19, 9/21, 9/23, 9/26, 9/28, 9/30, 10/3 and 10/5/22, included documentation the home health applied a medicated powder or cream on the patient, but failed to identify what the home health aide applied and where the home health aide applied the medication on the patient's body. The Administrator and Assistant Administrator received the above findings and agency staff provided no further information prior to the end of the survey.