Every finding on record at Nursing Placement Home Health Care Services Inc

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the Home Health Agency failed to fully investigate an allegation of sexual abuse regarding Patient ID #1. Findings are as follows: Record review of a community reported complaint reported to the Department of Health on 6/3/2024 alleges that Physical Therapist, Staff A, was engaging in inappropriate sexual behaviors with Patient ID #1. It also alleges that Staff A has nude photographs of the patient on their phone. Additionally, it alleges that Staff A may have drugged Patient ID #1 with a drink he had given him/her. Record review of a Complaint Report provided by the Agency's Human Resources, Staff B, reveals a complaint received by the agency on 6/4/2024 alleging that Physical Therapist, Staff A, had a sexual relationship with Patient ID #1, including oral sex and nude photographs of the patient being taken on the staff member’s phone. During a surveyor interview on 6/6/2024 at approximately 11:55 AM with Staff B, she revealed that she received the complaint regarding Staff A on the evening of 6/4/2024. This surveyor asked for the agency’s investigation of the allegation and was provided one written statement from Staff A dated 6/5/2024. She further revealed that she had not attempted to call Patient ID #1 prior to this surveyor entering the Agency today, nor had she called any of Staff A’s other patients to assure there were no concerns with the care they receive. During a surveyor interview on 6/6/2024 at approximately 1:00 PM with the Director of Operations she could not provide evidence that the agency fully investigated the allegation of sexual abuse.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the Home Health Agency failed to take action to prevent further potential violations while investigating an allegation of a sexual abuse regarding Patient ID #1. Findings are as follows: Record review of a community reported complaint reported to the Department of Health on 6/3/2024 alleges that Physical Therapist, Staff A, was engaging in inappropriate sexual behaviors with Patient ID #1. It also alleges that Staff A has nude photographs of the patient on their phone. Additionally, it alleges that Staff A may have drugged Patient ID #1 with a drink s/he had given him/her. Record review of a Complaint Report provided by the Agency's Human Resources, Staff B, reveals a complaint received by the agency on 6/4/2024 alleging that Physical Therapist, Staff A, had a sexual relationship with Patient ID #1, including oral sex and nude photographs of the patient being taken on the staff member’s phone. During a surveyor interview on 6/6/2024 at approximately 11:55 AM with Staff B, she revealed that she received the complaint regarding Staff A on the evening of 6/4/2024. This surveyor asked for the agency’s investigation of the allegation and was provided one written statement from the alleged perpetrator, Staff A dated 6/5/2024. Staff B further revealed that on 6/5/2024 Staff A was seeing patients at their home, so she was not able to discuss the matter with Staff A until after the Physical Therapy visits were completed on 6/5/2024. She further revealed that she had not attempted to call Patient ID #1 prior to this surveyor entering the Agency, nor had she called any of Staff A’s other patients to assure there were no concerns with the care they receive. Review of the facility provided document titled, “Clinician Weekly Timesheet” for Staff A, revealed that on 6/5/2024 Staff A had seen 5 patients. During a surveyor interview on 6/6/2024 at approximately 1:00 PM with the Director of Operations she could not provide evidence that the HHA removed the staff from patient care while investigating the allegation of sexual misconduct.

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 record review and staff interviews, it has been determined that the Home Health Agency failed to meet the Condition of Participation, relative to ensuring that an individualized plan of care specifies the care and services necessary to meet the patient specific needs and ensuring services are furnished in accordance with accepted standards of practice for 2 of 3 patients receiving wound care, Patient ID #s 1 and 2. Findings are as follows: Record review for Patient ID #’s 1 and 2 revealed failure of the agency to ensure complete wound assessments were completed weekly as per the patients’ plans of care. Record review for Patient ID #2 revealed failure of the agency to ensure all treatment changes related to wound care were recorded as orders in the patient’s plan of care.

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 record review and staff interview, it has been determined that the Home Health Agency has failed to ensure that the patient receives the home health services that are written in the plan of care for 2 of 3 sample patients with physicians’ orders to measure and assess wounds weekly, Patient ID #s 1 and 2. Findings are as follows: 1) Record review for Patient ID #1 revealed a Plan of Care, certification period dated 5-20-2023 through 7-18-2023. The patient required treatment for a wound to the left outer ankle. The physician’s orders direct the skilled nurse to assess for signs and symptoms of wound infection or deterioration to include wound characteristics such as increased drainage, foul smell, redness, swelling and pain and to measure the wound weekly and as needed for any wound changes. Record review of patient’s wound assessment records and nurse’s notes failed to reveal complete wound assessments for the following weeks: 5-21-23 through 5-27-23 5-28-23 through 6-3-23 6-4-23 through 6-10-23 6-11-23 through 6-17-23 6-18-23 through 6-24-23 2) Record review for Patient ID #2 revealed a Plan of Care, certification period dated 5-26-2023 through 7-24-2023. The patient required treatment for a wound to the outer left foot, a wound to the left heel and a wound to the side of the right foot. The physician’s orders direct the skilled nurse to assess for signs and symptoms of wound infection or deterioration to include change in wound characteristics such as increased drainage, foul smell, redness, swelling and pain and to measure the wound weekly and as needed for any wound changes. Record review of patient’s wound assessment records and nurse’s notes failed to reveal complete wound assessments for the following weeks: 5-28-23 through 6-3-23 6-4-23 through 6-10-23 6-11-23 through 6-17-23 6-18-23 through 6-24-23 During an interview with the Director of Nurses, on 7/5/2023 at approximately 3:15 PM, she was unable to provide evidence of complete wound assessments weekly per the patients' plans of care.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the Home Health Agency failed to ensure that all patient care orders, including verbal orders, must be recorded in the plan of care for 1 of 3 patients, Patient ID #2. Findings are as follows: Record review of a policy titled, “Nursing Placement Home Health Care Services, INC. Service Policies and Procedures Title: Physician Orders” revealed in part, “ Any changes/ additions in physician orders (e.g., change in client condition/status, change in visit frequency, medication changes) must be documented in the EMR [electronic medical record] and signed in a timely manner by a physician…Verbal orders are confirmed in written or electronic form, dated and signed by the professional receiving the verbal order. Orders may also be electronically signed and dated by the physician…Primary care providers (nursing, therapy, social service) are accountable for the presence of current physician orders for the care they render…” Record review for Patient ID #2 revealed the following physician’s orders on the plan of care for certification period 5-26-23 through 7-24-23: - “…Wound care to outer left foot, to be performed daily by client/ RN [Registered Nurse] Cleanse with NSS [normal saline solution], apply/pack with gauze cover and secure with kerlix and tape...” - “… Wound vac: Apply sponge, cover with drape and set vac at 125 mm/Hg [millimeters of mercury] continuous pressure…in emergency…in event of dislodgement/malfunction…remove vac dressing and apply NS wet to dry dressing…” Review of the skilled nursing visit notes revealed the following under the “Today’s Note” Section: 5-31-23- Registered Nurse, Staff A, documented, “Skilled nursing visit for wound care of clients bilateral feet wounds…Wounds washed with normal saline and pat dry. Santyl applied to yellow slough area on right inner foot wound and Silvadine cream to top of both feet…” 6-2-23- Staff A, documented, “Skilled nursing visit for wound care of clients bilateral feet wounds…Wounds washed with normal saline and pat dry. Santyl applied to yellow slough area on right inner foot wound and Silvadine cream to top of both feet…” 6-9-23 Staff A,documented, “Skilled nursing note wound care…wound on heal macerated…Called [Medical Doctor] and he ordered to put collagen and alginate and reassess Sunday. If maceration gone reapply wound vac…” 6-21-23- Licensed Practical Nurse, Staff B, documented, “…Wound care provided to left heel: irrigated with NS [Normal Saline], pat dry. Prisma applied to wound bed f/b gauze, covered with ABD pad and wrapped with kerlix and ace wrap…” 6-25-23- Registered Nurse, Staff C, documented, “…wound care provided as ordered: cleaned with NS [normal saline] granulex, alginate, abd pad, wrapped with kerlix...” 6-27-23- Staff B, documented, “…Wound care provided to left heel: irrigated with NS, pat dry, Regranex gel applied to wound bed f/b Prisma, f/b [followed by] Prisma, f/b gauze. ABD pad and wrapped with kerlix and ace wrap…” During a surveyor interview on 7-5-23 at 1:29 PM with Staff A he revealed that the physician did change the wound treatments often and acknowledged that he failed to put the new orders into the electronic record. During a surveyor interview on 7-5-23 at 2:13 PM with Staff B she revealed that the patient would text the physician pictures of the wounds and the physician would send back what treatment the resident should do. She acknowledged that these treatments failed to be added as orders into the plan of care.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and staff interview it has been determined that the Home Health Agency failed to ensure that all drugs, services and treatments are administered only as ordered by a physician for 1 of 3 patients, Patient ID #2. Findings are as follows: Record review for Patient ID #2 revealed the following physician’s orders on the plan of care for certification period 5-26-23 through 7-24-23: - “…Wound care to outer left foot, to be performed daily by client/ RN [Registered Nurse] Cleanse with NSS [normal saline solution], apply/pack with gauze cover and secure with kerlix and tape...” - “… Wound vac: Apply sponge, cover with drape and set vac at 125 mm/Hg [millimeters of mercury] continuous pressure…in emergency…in event of dislodgement/malfunction…remove vac dressing and apply NS wet to dry dressing…” Review of the skilled nursing visit notes revealed the following treatments provided without documented physician's orders under the “Today’s Note” Section: 5-31-23- Registered Nurse, Staff A, documented, “Skilled nursing visit for wound care of clients bilateral feet wounds…Wounds washed with normal saline and pat dry. Santyl applied to yellow slough area on right inner foot wound and Silvadine cream to top of both feet…” 6-2-23- Staff A, documented, “Skilled nursing visit for wound care of clients bilateral feet wounds…Wounds washed with normal saline and pat dry. Santyl applied to yellow slough area on right inner foot wound and Silvadine cream to top of both feet…” 6-9-23 Staff A, documented, “Skilled nursing note wound care…wound on heal macerated…Called [Medical Doctor] and he ordered to put collagen and alginate and reassess Sunday. If maceration gone reapply wound vac…” 6-21-23- Licensed Practical Nurse, Staff B, documented, “…Wound care provided to left heel: irrigated with NS [Normal Saline], pat dry. Prisma applied to wound bed f/b gauze, covered with ABD pad and wrapped with kerlix and ace wrap…” 6-25-23- Registered Nurse, Staff C, documented, “…wound care provided as ordered: cleaned with NS [normal saline] granulex, alginate, abd pad, wrapped with kerlix...” 6-27-23- Staff B, documented, “…Wound care provided to left heel: irrigated with NS, pat dry, Regranex gel applied to wound bed f/b [followed by] Prisma, f/b gauze. ABD pad and wrapped with kerlix and ace wrap…” During a surveyor interview on 7-5-23 at approximately 3:15 PM with the Director of Clinical Services she was unable to provide evidence of orders for the above treatment changes.

A Federal Recertification, State Licensure, and Federal Vaccination Mandate survey, was completed at this agency. Federal deficiencies were identified.

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 clinical record review and staff interview it has been determined that the agency failed to assure that the patient’s clinical record identifies all medication the patient is currently taking for 6 of 7 sample patients, Client ID #’s 1, 2, 4, 5, 6, and 7. Findings are as follows: 1. Review of the medications during a home visit with the nurse, Staff A, on 3/24/2022 at 8:30 AM revealed that Patient ID # 1’s plan of care certification dated 2/9/2022-4/9/2022, failed to include the following medication the client is currently taking: Jardiance 10 mg (milligrams) one tablet every day Additionally, the plan of care stated Metoprolol succinate 100 mg tablet one daily During surveyor interview on 8/24/2022 at approximately 9:15 AM with Client ID # 1, the Patient stated s/he is taking Jardiance once a day since s/he saw the doctor approximately a month ago. The Patient also stated s/he has been taking 2 tablets of Metoprolol 100 mg, since it was changed by the doctor about 2 weeks ago. During an interview with nurse, Staff A, at the end of the home visit, she stated she was unaware of the medication changes noted above and could not provide evidence that the medication profile had been updated and verified on an ongoing basis. During a surveyor interview with the Director of Nurses (DON) on 3/28/2022 at approximately 9:40 AM, she stated that the medications should be reviewed on each visit and that the nurse should have been aware of the medications changes and contacted the physician to update the orders and reconcile the medication list. 2. Review of the medications during a home visit with the nurse, Staff B, on 3/24/2022 at 10:20 AM revealed that Patient ID # 2’s plan of care certification dated 2/26/2022-4/26/2022, revealed the following. Metoprolol tartrate 25 mg tablet take 2 times a day via g-tube Oxycodone 10 mg take one tablet every 8 hours as needed via g-tube Senna 8.8 mg/5ml take 5 ml every night as needed via g-tube Additionally, the patient has Gabapentin 300 mg take 3 times a day. During surveyor interview on 8/24/2022 at approximately 11:05 AM with Client ID # 2, the Patient stated s/he is not taking the Metoprolol tartrate 25 mg, the Oxycodone 10 mg, or the Senna 8.8 mg/5 ml as they have all been discontinued by the doctor. The Patient is taking the Gabapentin which is not on the medication list. During an interview with nurse, Staff B, at the end of the home visit, she stated she was unaware of the medication changes noted above and could not provide evidence that the medication profile had been updated and verified on an ongoing basis. Additionally, she acknowledged that the patient’s g-tube had been removed on 3/16/2022 per her nursing visit note, however the medications were still ordered as being administered via the g-tube. During surveyor interview with the DON on 3/28/2022 at approximately 9:55 AM, she stated that the medications should have been reconciled upon each visit and that the orders should have been changed when the patient’s g-tube was removed. 3. Review of the medications during a home visit with the physical therapist, Staff D, on 3/24/2022 at 1:15 PM revealed that Patient ID # 4’s plan of care certification dated 2/20/2022-4/20/2022, failed to reveal the following medications that the patient was taking. During surveyor interview on 3/24/2022 at approximately 1:30 PM with Patient ID # 4 and his/her caretaker, the surveyor was given the medications that the patient is using for pain. Oxycodone 5mg tablets take one every 8 hours as needed Tramadol 30 mg 3 times a day as needed for pain The caregiver and patient both stated that the patient has had the prescriptions for pain for a long time prior to the start of care on 2/20/2022. The surveyor interviewed staff D, during the visit who stated that she was unaware that the patient had Oxycodone or Tramadol that he/she was taking for pain. She was unable to produce evidence that the medication profile was reconciled with the medications the patient was taking in the home. During surveyor interview with the DON on 3/30/2022 at approximately 11:45 AM, she stated that the medications should have been reconciled upon the admission visit on 2/20/2022 and on the following visits and that the orders should have been clarified with the physician and orders obtain for the pain medications. 4. Review of the medications during a home visit with the occupational therapist, Staff E, on 3/24/2022 at 2:45 PM revealed that Client ID # 5’s plan of care certification dated 2/12/2022-4/12/2022, revealed the following. Oxygen 1-2 liters as needed via nasal cannula Calcium-vitamin D 3 200 units one tablet twice a day by mouth The surveyor interviewed the patient during the home visit, who informed the surveyor that he does not have any oxygen, and that he has not taken the Calcium Vitamin D3, since he returned home. The surveyor interviewed Staff E, during the home visit who was unaware the patient did not have the oxygen that was ordered and was not taking the Calcium Vitamin D3. The surveyor interviewed the patient’s nurse case manager, Staff A, on 3/30/2022 at approximately 10:45 AM, who was not aware that the patient did not have the oxygen as ordered, nor that he was not taking the Calcium-Vitamin D. She was unable to produce evidence that the medications had been reconciled upon admission or on-going on following visits. 5. Review of the medications during a home visit with the nurse, Staff F, on 3/28/2022 at 11:30 AM revealed that Patient ID # 6’s plan of care certification dated 2/2/2022- 4/2/2022, revealed the following: Amlodipine 5mg oral tablet one daily The surveyor interviewed the patient ID # 6 during the home visit, s/he stated that the Amlodipine had been put on hold by the doctor on 3/17/2022. During an interview with the nurse, Staff F during the visit, stated she was unaware that the Amlodipine had been put on hold, and could not produce evidence that the medications are reconciled during the nursing visits, which are currently scheduled for three times a week. 6. Review of the medications during a home visit with the health aide, Staff G, on 3/28/2022 at 2:30 PM revealed that Client ID # 7’s plan of care certification dated 3/18/2022 - 5/16/2022, revealed the following. Albuterol 2.5mg/3ml (milliliter) inhalation solution every 6 hours Docusate sodium 100 mg oral tablet take 2 daily Loratadine 10 mg oral tablet take 1 daily Omeprazole 40 mg oral capsule take 1 daily Pulmicort Respules 0.5me/2ml inhalation suspension 2 times a day The surveyor interviewed the patient and caregiver during the home visit, who stated that the Albuterol, Docusate sodium, Loratadine and Omeprazole had all been discontinued and that the patient was not taking these medications since return home. Additionally, the Pulmicort is once a day not twice a day as noted on the plan of care. The surveyor interviewed the DON of 3/302022 at approximately 11:10 AM, who was unable to provide evidence that the medications had been reconciled and or the physician contacted for clarification.

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 record review and staff interview it has been determined the agency failed to develop an individual plan of care for 1 of 1 insulin dependent patient, ID #10 relative to monitoring blood sugars. Findings are as follows: Record review for patient ID # 10 reveals the patient was admitted to service on 3/10/2022 and has a certification and plan of care dated 3/10/2022-5/8/2022. The patient has a diagnosis of Type 2 Diabetes and is on the following medications. Basagler Kwik Pen 100 units/ml (milliliter) subcutaneous 54 units at HS (hour of sleep) Insulin Lispro Junior Kwik Pen 100 units/ml injectable solution 5 units three times a day. Review of the plan of care lacks any orders for blood sugar monitoring, and or parameters or goals for the patients’ blood sugars and or education relative to the blood sugars. Additional review of the record reveals that in some of the nurse visit notes, there are blood sugars noted. The surveyor interviewed the Director of Nurses (DON), on 3/29/2022 at 12:16 PM, relative to the plan of care lacking any orders relative to the monitoring of this insulin dependent patient’s blood sugars and or goals or education. The DON stated that she would expect the plan of care to include orders relative to the monitoring and frequency of the blood sugars, as well as a scale with parameters, interventions, and goals.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure that all physician orders in the Plan of Care are complete for 1 of 1 patient , ID #12 with an order for Santyl (used to remove dead tissue from wounds). Findings are as follows: Record review for patient ID # 12, revealed a start of care date of 12/2/2021, and a current certification and plan of care dated 1/31/2022-3/31/2022. Review of the medications on the plan of care, includes an order for “Santyl 250 units/g topical ointments apply once daily”. The surveyor interviewed the Director of Nurses (DON) on 3/29/2022 at 1:06 PM, relative to the Santyl, that lacked instructions as to where to apply the ointment. The DON stated that the physician’s order lacked the information as to where to apply the Santyl, which should have been included in the order as Santyl is used to remove dead tissue from wounds. The agency failed ensure that the plan of care contained complete medication orders, relative to the application of Santyl for patient ID #12.

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 surveyor observation record review and staff interview, it has been determined that the agency failed administer treatments as ordered by the physician for 1 of 2 patients observed for wound care, Patient ID # 1. Findings are as follows: Record review for Patient ID # 1, during a home visit with the nurse, Staff A, on 3/24/2022 at 8:30 AM revealed that Patient ID #1’s plan of care certification dated 2/9/2022-4/9/2022, stated the following. "Wound care to right foot plantar aspect, LLE [left lower extremity] stasis ulcer, to be performed 2 times a week by RN, cleanse with normal saline, apply/pack with Xeroform cover with gauze and secure with cling." During surveyor observation of the wound care on 3/242022 by Staff Nurse A, she removed the dressing, cleansed the wound with Dura Phor and applied Calcium Alginate, followed by cling. The surveyor interviewed the nurse at the time of the dressing change and she acknowledged that she had not followed the physicians order to apply xeroform gauze to the wound, and had applied Calcium Alginate. The Surveyor interviewed the Director of Nurses on 3/28/2022 at approximately 10:15 AM, who acknowledged that the staff need to obtain a physician's order prior to any changes in treatments for wound care.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to provide infection control education to a patient and patient's caregiver for 1 of 1 patients with a C-Diff ( clostridium difficile colitis) infection, patient ID #8. Findings are as follows: Record review for Patient ID #8, reveals the patient was admitted to service on 2/14/2022, with a primary diagnoses of clostridium difficile colitis, diarrhea, which is noted on the plan of care dated 2/14/2022-4/14/2022. The admission assessment on 2/14/2022 notes that the patient resides with spouse and family. The record also reveals that the patient is currently on a 10-day course of antibiotics which will end on 2/18/2022. Review of the plan of care reveals that the patient is receiving, skilled nursing services, physical therapy, occupational therapy, and health aide for personal care. The patient needs assistance with ADLs (activities of daily living), ambulation and is noted to be forgetful. Review of the initial nursing assessment and visit note fail to reveal any documentation of any education relative to infection control practices was given to the patient and or the caregivers for the care and management of C-Diff. Additional review of the record lacks evidence that any of the health care providers, discussed or educated the patient or caregivers relative to the need to wash hands with soap and water and or how to clean surfaces as the D-Diff bacteria can live for up to 70 days on surfaces and cause infections. The surveyor interviewed the Director of Nurses on 3/29/2022 at 3:15 PM, who stated that the nurse in her admission note or assessment, should have addressed the C-Diff infection and provided educated to the patient and caregivers relative to handwashing and cleaning of the environment to prevent spread of the infection.