Every finding on record at The Wartburg Home of the Evangelical Lutheran Church

A standard re-certification survey and focused COVID-19 infection control survey of Wartburg Home Care at 1 Wartburg Place Mount Vernon, NY 10550 was initiated on 10/42/21 and exited 10/7/21. Deficient practices were identified within high priority standards in Plan of Care resulting in a partial extended survey. The agency's unduplicated count reported upon arrival on 10/4/21 is 74 and total active census 56. Seven (7) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6 and #7. Three (3) Home Visits (HV) were conducted with Patients #1, #3 and #6. Eleven (11) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11. Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, Covid 19 and Infection Control and Influenza Vaccination policy were reviewed. OBQI Adverse Event Outcome Report was reviewed for the period of 7/1/20 through 6/26/21. The agency's Complaint log was reviewed for the year 2021. Administrative and clinical staff were interviewed. The agency's Quality Improvement meeting minutes were reviewed for 2020 and 2021. The following federal deficiencies are cited: G - Plan of Care Must include the Following; G - 578 - Conformance with Physicians Orders; G - 580 - Only as Ordered by a Physician; The following state deficiencies are cited: J - 1108, 1140, 1156 and 1260 - Governing Authority; J - 1412 – Personnel

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 reviews and interview, the agency failed to develop/revise complete and comprehensive Plans of Care. This was evident for five (5) of seven (7) clinical records reviewed. (Patients #1, #2, #3, #4, #5 and #6) Failure to develop complete and comprehensive Plans of Care places patients at risk for not having needs met and negative patient outcomes. 1. Patient #1 has a start of care date of 8/9/21 with diagnoses of Pressure Ulcer to the Lower Back, Diabetes Mellitus Type Two, Hypothyroid and Anemia as documented on on the Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21. The Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21 documents: Skilled Nursing visits three times a week for eight weeks than two times a week for one week; medications include- Alogliptin Benzoate 25 mg a day, Duloxetine 60 mg a day, Enulose 10 gm/15 ml one teaspoon a day, Nicotine gum 2 mg four times a day as needed, Clozapine 50 mg one tablet every 12 hours, Ranitidine 75 mg two times a day. A home visit was conducted on 10/5/21. During the visit, the Patient's medications were reviewed at the nursing station. The Medication records (MAR) document the following: Duloxetine is 30 mg a day, Enulose 10 gm/15 ml was not being administered as the prescription expired, Nicotine gum 2 mg is five days per week as needed, Clozapine 50 mg is three tablets at bed time, Ranitidine 75 mg is not on the MAR (this medication has been recalled); Alogliptin Benzoate 25 mg is not on MAR, Duloxetine is 60 mg a day and Clozapine 50 mg one tablet is every 12 hours. These medications are not documented on the Plan of Care. The MAR documents the following medications: Advair 250/50 inhalation two times a day, Dorzolamide 2% eye drops one drop in both eyes two times a day, Systane Ultra eye drops one drop to both eyes two times a day, Atenelol 25 mg daily, Lortadine 10 mg daily, Spiriva 18 mcg one inhalation a day, Lactulose 10/gm/15 ml daily, Vitamin D3 1,000 units daily, Sodium Bicarbonate 650 mg three times a day, Ducosate Sodium 100 mg three capsules at bed time, A & D ointment to lower back, Ben Gay Ultra Strength to knees four times a day as needed for pain, Zinc Oxide 20% to left lower back two times a week to open wound. During an interview with the Registered Nurse (RN) on 10/5/21 at 11:00 AM, the RN did not provide an explanation for the above. 2. Patient #4 has a start of care date of 9/24/21 with diagnoses of Diabetes Mellitus Type Two Chronic Kidney Disease and Back Pain as documented on the Home Health Certification and Plan of Care dated 9/24/21 through 11/22/21. The Home Health Certification and Plan of Care dated 9/24/21 through 11/22/21 documents: SN visits for assessment one time one week, two times a week for one week, one time a week for three weeks; report blood glucose reading to physician if outside the range of below 70 or greater than 300; Amlodipine Besylate 10 mg daily (antihypertensive). The SN note dated 9/24/21 documents the Patient is testing the blood glucose three times a day; Patient's blood pressure reading was 210/104 and the physician was called. The Plan of Care does not document the frequency the Patient is to test the blood glucose, parameters for pain, blood pressure and pulse readings for physician notification. During an interview with the Administrator on 10/6/21 at 10:30 AM, the Administrator did not provide an explanation for the above. 3. Patient #5 has a start of care date of 8/26/21 with diagnoses of Cardiac Disease, Diabetes Mellitus Type Two, Lymphedema and Ulcer to the Right Calf as documented on the Home Health Certification and Plan of Care dated 8/26/21 through 10/24/21. The Home Health Certification and Plan of Care dated 8/26/21 through 10/24/21 documents: SN visits two times a week for nine weeks; for assessment and wound care; Acetaminophen 325 mg two tablets two times a day for pain. The Plan of Care lacks documented evidence of parameters for physician notification for pain. During an interview with the Administrator on 10/6/21 at 10:30 AM, the Administrator did not provide an explanation for the above. Patient #6 lives in an assisted living facility, has a start of care date of 7/30/21 with diagnosis Intraarticular Fracture of Lower End of Left Radius documented on the Home Health Certification and Plan of Care for Certification Period dated 7/30/21 to 9/27/21 and renewed 9/28/21 to 11/26/21. The Home Health Certification and Plan of Care for Certification Period dated 7/30/21 to 9/27/21 documents "Medications: Lopressor, Ondansetron, Prilosec, Vitamin D, and Xarelto; PT 1x week x1week; 2x week x5 weeks; instruct patient/caregiver on pain management and appropriate interventions to mitigate pain" A home visit was conducted on 10/6/21 at 9:00 AM " the surveyor observed the following medications on the patient's Medication Administration Record (MAR), Amlodipine, Combigan eye drops, Lasix, Icaps Lutein & Zeaxanthin Cr, Ativan, Hyzaar, Lotemax eye drop, Lumigan eye drop, Potassium Chloride, Rosuvastatin, Vyzulta eye drop, Tylenol, Asperceme, Cyclobenzaprine, Tums, Hyoscyamine, Robitussin Pepto Bismol, and Deep Sea Nasal Spray. The Plan of Care lacks documented evidence of all the medications identified during the home visit on the patient's Medication Administration Record; pain management regimen, pain parameters for pain control and when to notify the physician if control is not met. On 10/6/21 at 10:30 AM. The Administrator was interviewed and did not provide an explanation for the above. 4. Patient #2 has a start of care date of 5/3/21 and a discharge date of 6/4/21 with diagnosis that include" Fracture of Unspecified part of Right Clavicle, Hypertensive Heart disease with Heart Failure Unspecified Atrial Fibrillation" as documented on the "Home Health Certification and Plan Of Care" for the Certification Period of 5/3/21 to 7/1/21. The " Home Health Certification and Plan Of Care" for the Certification Period of 5/3/21 to 7/1/21 document:" Skilled Nurse once a week for three weeks. Physical Therapy once a week for one week, twice a week for four weeks. Medications: Atenolol 25 mg by mouth (PO) one tablet once a day, Furosemide 20 mg tablet one tablet PO once a day, Cefadroxil 500 mg capsule one capsule twice a day PO, Januvia 50 mg tablet one tablet once a day, Atorvastin Calcium 20 mg tablet one tablet once a day, Digoxin 125 mcg tablet, one tablet twice per week Monday and Friday". There is no documented evidence of a diagnosis of Diabetes Mellitus for the use of Januvia on the Plan Of Care. There is no documented evidence of glucose parameters for physician notification. The Initial Nursing OASIS assessment dated 5/3/21document: " Pain evaluation: Current pain regimen, no current pain. Pain well controlled with current Plan Of Care." The Physical Therapy (PT) note dated 5/6/21 document: " Pain well controlled with current plan of care. Shoulder weakness due to pain/ injury". The Skilled Nurse note dated 5/11/21 document:" Current pain regimen, no current pain. The (PT) Clinical notes dated 5/11/21document:" Upon arrival patient reports pain during visit, reports taking pain medication as prescribed prior to initial visit". The PT note dated 5/12/21 document:" Complains of pain to buttocks aspects". The PT note dated 5/14/21 document" Complains of pain to buttocks aspects". The Skilled Nurse note dated 5/18/21 document:" Patient reports feeling fatigued and tired states today is a bad day. patient reports pain while ambulating, taking pain medication as prescribed". There is no documented evidence the PT informed the Skilled Nurse about the Patient' s pain. There is no documented evidence the Physician was about the patient's pain by the Skilled Nurse and the Physical Therapist There is no documented evidence of an order for pain medication in the Plan Of Care. 5. Patient #3 has a start of care date of 8/25/21 with diagnosis that include Pressure Ulcer Sacral Region Stage 3, Malignant Neoplasm Of Prostate, Other Obstructive and Reflux Uropathy, Retention Of Urine as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 8/25/21 to 10/23/21. The "Home Health Certification and Plan Of Care" for the Certification Period of 8/25/21 to 10/23/21 document:" Skilled Nurse once a week for one week, twice a week for eight weeks, AID ( aide) twice a week for four weeks, four hours duration. Physical Therapy (PT) twice a week for four weeks, Occupational Therapy (OT) once a day for one day, twice a week for two weeks". Wound care : Cleanse wound to sacrum, pat dry, apply Silvadene to wound bed and cover with foam dressing. Medications: Fish Oil 1000 mg one tablet (tab) once a day (QD) via mouth (PO), Furosemide 20 mg tab QD PO, Sodium Bicarbonate 650 mg tab one tab three times a day PO, Tamsulosin HCL 0.4 mg capsule one capsule QD PO, Vitamin D3 10 mcg capsule one capsule QD PO, Xarelto 15 mg one tab QD PO, Rosuvastatin Calcium 5 mg one tab QD PO,Occuvite Adult 50+ one tab QD PO, Vitamin B 12 Extended Release 1000 mcg one tab QD PO Xtandi 40 mg one tab QD PO". On 10/ 6/21 at 11:45 AM, during an observational home visit, a review of the medications identified the following: Tamsulosin was not found among the medications the patient is currently taking, The Patient's caregiver presented the surveyor with a prescription to be filled prior to the patient next urology appointment. A bottle labeled Xtandi with a filled date of 8/9/21 40 mg four capsules via mouth daily." There is no documented evidence of all the medications the patient is currently taking. The Skilled Nurse Note on 8/25/21 document:" patient seen for admission for Homecare services following discharge from hospital and rehabilitation. Wife states patient complained of lower abdomen pain, seen by urologist, sonogram revealed empty bladder with directions to properly hydrate. Still in pain taken to emergency room for further evaluation now has a Foley, diagnosis prostate cancer". On 10/6/21 at 12:50 AM, during the observational home visit the Patient's wife stated she did not receive instruction how to care for the Foley catheter. The Skilled Nurse visited on 8/25/21 to 9/24/2021. There was no order for a Foley Catheter. There is no documented evidence the Physician was notified that Patient had a Foley Catheter There is no documented evidence of an order for Foley catheter care on the Plan Of Care . There is no documented evidence the Plan Of Care is complete. On 10/6/21 at 2:25 PM, the Administrator was interviewed and did not provide an explanation.

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 observations, record reviews and interviews, the agency failed to ensure that services are provided in accordance with the Plans of Care (POC). This was evident for five (5) of seven (7) clinical records reviewed. (Patients #1, #3, #4, #5 and #6) Failure to ensure that patient care is provided in accordance with the Plans of Care has the potential for patients to receive poor care and health care needs to go unmet. Patient #6 lives in an assisted living facility, has a start of care date of 7/30/21 with diagnosis Intra-articular Fracture of Lower End of Left Radius documented on the Home Health Certification and Plan of Care for Certification Period dated 7/30/21 to 9/27/21 and renewed 9/28/21 to 11/26/21. The Home Health Certification and Plan of Care for Certification Period dated 7/30/21 to 9/27/21 documents "Medications: Lopressor, Ondansetron, Prilosec, Vitamin D, and Xarelto; PT 1 x week x 1 week; 2x week x 5 weeks; instruct patient/caregiver on pain management and appropriate interventions to mitigate pain" The Orthopedic Consult dated 9/22/21 documents "Edema control, modalities as indicated; treatment procedures/modalities: hot/cold pack" The Plan of Care lacks documented evidence of hot/cold treatment modalities. There is no documented evidence of the services including the treatments being provided in conformance with the with physician orders. During an interview with the Administrator on 10/7/21 at 10:30 AM, the Administrator did not provide an explanation. 1. Patient #1 has a start of care date of 8/9/21 with diagnoses of Pressure Ulcer to the Lower Back, Diabetes Mellitus Type Two Hypothyroid and Anemia as documented on the Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21. The Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21 documents: Skilled Nursing (SN) visits three times a week for eight weeks than two times a week for one week; assess wound location, size, stage, drainage, and wound bed, assess vital signs. The SN notes document the nurse went to the home for seven weeks. There is no documented evidence of wound measurements for the weeks of 8/23/21, 8/30/21, 9/6/21, 9/13/21, 9/20/21 and 9/27/21. The SN notes dated 8/27/21, 9/24/21 and 10/1/21 lack documented evidence of vital signs. During an interview with the Administrator on 10/7/21 at 10:30 AM, the Administrator did not provide an explanation for the above. 2. Patient #4 has a start of care date of 9/24/21 with diagnoses of Diabetes Mellitus Type Two Chronic Kidney Disease and Back Pain as documented on the Home Health Certification and Plan of Care dated 9/24/21 through 11/22/21. The Home Health Certification and Plan of Care dated 9/24/21 through 11/22/21 documents: SN visits for assessment one time one week, two times a week for one week, one time a week for three weeks; report blood glucose reading to physician if outside the range of below 70 or greater than 300; Tramadol HCL 50 mg every 12 hours as needed for pain; Acetaminophen 325 mg two tablets every 6 hours as needed for pain. The SN notes dated 9/24/21 and 9/30/21 document the Patient has back pain and the pain is rated a 5 on a scale of 0 to 10. The SN note dated 9/27/21 documents the Patient has pain to the left hip and it is rated a 6. The notes lack documented evidence as to whether the Patient is using the Tramadol and/or Acetaminophen and if so, the amount, frequency and effectiveness. The SN notes dated 9/24/21 and 9/27/21 lack documented evidence as to whether the Patient is monitoring the blood glucose, and if so, what the readings are. During an interview with the Administrator on 10/7/21 at 10:30 AM, the Administrator did not provide an explanation for the above. 3. Patient #5 has a start of care date of 8/26/21 with diagnoses of Cardiac Disease, Diabetes Mellitus Type Two, Lymphedema and Ulcer to the Right Calf as documented on the Home Health Certification and Plan of Care dated 8?26/21 through 10/24/21. The Home Health Certification and Plan of Care dated 8/26/21 through 10/24/21 documents: SN visits two times a week for nine weeks; for assessment and wound care; Acetaminophen 325 mg two tablets two times a day for pain. The SN note dated 8/26/21 documents the Patient has edema to the lower extremities. The SN notes dated 8/26/21 and 8/30/21 lacks documented evidence of measurements and type of edema (pitting/non-pitting). The SN note dated 9/7/21 documents the edema is pitting but no measurements are documented. The SN note dated 9/13/21 9/23/21 documents the Patient has edema to the lower extremities. The note lacks documented evidence of the type and measurements. The SN note dated 9/20/21 documents the edema is a plus 4. There is no documentation as to whether this measurement is new or if it has been a plus 4 since the start of care. The SN notes dated 9/23/21, and 9/30/21 do not document the edema to the lower extremities was measurement and the type of edema. During an interview with the Administrator on 10/7/21 at 10:30 AM, the Administrator did not provide an explanation for the above. 4. Patient #3 has a start of care date of 8/25/21 with diagnosis that include Pressure Ulcer Sacral Region Stage 3, Malignant Neoplasm Of Prostate, Other Obstructive and Reflux Uropathy, Retention Of Urine as documented on the " Home Health Certification and Plan Of Care" for the certification period of 8/25/21 to 10/23/21. The "Home Health Certification and Plan Of Care" for the certification period of 8/25/21 to 10/23/21 document:" Skilled Nurse once a week for one week, twice a week for eight weeks, AID ( aide) twice a week for four weeks". On 10/6/21 during the survey, a request was made for the aides activity sheets from 8/25/21 to the day of the survey. This information was not received. A " clinical notes" dated 9/20/21 document: Wife questioned re patient Home Health Aide (hha)service. Informed agency is currently having a hard time staffing due to limited hha availability. Occupational Therapy (OT) notified and he will provide teaching to patient and caregiver on methods for transferring in and out of the shower safely. Wife states she will wait for hha to become available in the meantime". On 10/6/21 at 11:45 AM, during the observational home visit , the patient's wife stated the agency called and stated a Spanish speaking hha will providing aide services, the person never came and the agency has not gotten back to the patient as to the reason the hha did not provide services. There is no documented evidence the services were provided in conformance with the Plan Of Care. On 10/6/21 at 2:25 PM, the Administrator was interviewed and did not provide an explanation for the above findings.

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, clinical record reviews and interview, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care. This was evident for two (2) of seven (7) clinical records reviewed. (Patients #1 and #6) Failure to notify the physician of the patient's status has the potential for patients to not receive interventions which may result in negative outcomes. The findings are: 4. Patient #6 lives in an assisted living facility, has a start of care date of 7/30/21 with diagnosis Intraarticular Fracture of Lower End of Left Radius documented on the Home Health Certification and Plan of Care for certification period dated 7/30/21 to 9/27/21 and renewed 9/28/21 to 11/26/21. The Home Health Certification and Plan of Care for Certification Period dated 7/30/21 to 9/27/21 documents "PT 1x week x1week; 2x week x5 weeks; instruct patient/caregiver on pain management and appropriate interventions to mitigate pain" A home visit was conducted on 10/6/21 at 9:00 AM. The patient states "the stretching exercises are very painful, I go back to my room/chair in tears after the sessions" The following Physical Therapy visit notes documents pain evaluation: 8/18/21 Left wrist forearm 6/10; 8/23/21 left forearm and shoulder, 4/10; 8/25/21 Left wrist/forearm, 5/10; 8/30/21 Left forearm wrist, 7/10; 9/8/2021 Left wrist, 5/10; 9/15/21 Left wrist hand 5/10; and 10/4/21 Left wrist 5/10. There is no documented evidence the Physical Therapist notifying the RN and or physician about the patient pain. During an interview with the Administrator on 10/5/21 at 2:30 PM, the Administrator did not provide an explanation. 1. Patient #1 has a start of care date of 8/9/21 with diagnoses of Pressure Ulcer to the Lower Back, Diabetes Mellitus Type Two Hypothyroid and Anemia as documented on on the Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21. The Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21 documents: Skilled Nursing (SN) visits three times a week for eight weeks than two times a week for one week; "PT (Physical Therapy) eval (evaluation) needed gait training". There is no documented evidence of communication with the PT or physician regarding a PT evaluation/treatment. During an interview with the Administrator on 10/5/21 at 2:30 PM, the Administrator did not provide an explanation for the above.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on Clinical Record review, policy and procedure review, current practice guidelines, and staff interview, the Agency failed to ensure services are provided in accordance with current clinical practice guidelines, accepted professional standards of practice and the Agency's policy and procedure. This was evident in two (2) of two (2) Clinical Records with wounds (Patient # and #6). Failure to ensure that the Agency follows accepted professional standards of practice has the potential for negative patient outcomes through delayed wound healing. The findings are: 2. Patient #3 has a start of care date of 8/25/21 with diagnosis that include Pressure Ulcer Sacral Region Stage 3, Malignant Neoplasm Of Prostate, Other Obstructive and Reflux Uropathy, Retention Of Urine as documented on the " Home Health Certification and Plan Of Care" for the certification period of 8/25/21 to 10/23/21. The "Home Health Certification and Plan Of Care" for the certification period of 8/25/21 to 10/23/21 document:" Skilled Nurse once a week for one week, twice a week for eight weeks, AID ( aide) twice a week for four weeks, four hours duration. Physical Therapy (PT) twice a week for four weeks, Occupational Therapy (OT) once a day for one day, twice a week for two weeks". Wound care : Cleanse wound to sacrum, pat dry, apply Silvadene to wound bed and cover with foam dressing. A review of the Skilled Nurse visit document the following wound documentation: 8/25/21 - Stage 3 Pressure Ulcer measured 2 x 2; 8/30/21- Stage 3 Pressure Ulcer measured 2 x 2; 9/7/21 - Stage 2- not measured; 9/10/21- not measured; 9/14/21- Stage 2- not measured 9/16/21 Stage 2- not measured; 9/20/21- Stage 2- not measured; 9/23/21- Stage 2 healed. 9/24/21 "Sacral wound is progressing well, since drainage is minimal. Skilled Nurse provided wound care and left wound open to the air". There is no documented evidence of an assessment and measurement of the wound. There is no documented evidence the services provided followed professional standards of practice for wound assessment and monitoring. On 10/6/21, the Administrator was interviewed and did not provide an explanation for the above findings. An article titled Wound Wise: Measuring Wounds to Improve Outcomes published in the AJN, American Journal of Nursing August 2013, Volume :113 Number 8, page 60 - 61 the documents "Wounds must be assessed and monitored to detect important changes, quantify progress, and guide treatment decisions. Assessment covers a variety of variables, such as the amounts of exudate, necrotic tissue, fibrin slough, and granulation tissue; the presence of undermining, tunneling, and epithelium; and the size of the wound." and "Improvement in any of these variables is encouraging and important to document and consider when making decisions about the type of wound-treatment product to choose (which dressing, for instance).1 But merely assessing and documenting these wound variables and tweaking protocols of care over many weeks (or months), hoping a pressure ulcer, venous ulcer, or foot ulcer is going to heal doesn't suffice. Only one of these variables-wound size, as measured over time-provides quantifiable data that can be used to help predict wound outcome. The healing trajectory, evidenced by changes in wound size, of every type of chronic wound can help in the prediction of whether or not that wound is going to heal within a reasonable period of time." A request was made on 10/5/21 at 1:00 PM for the agency's policy regarding wound care. The agency did not provide a policy for wound care. 1. Patient #1 has a start of care date of 8/9/21 with diagnoses of Pressure Ulcer to the Lower Back, Diabetes Mellitus Type Two Hypothyroid and Anemia as documented on on the Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21. The Home Health Certification and Plan of Care dated 8/9/21 through 10/7/21 documents: Skilled Nursing visits three times a week for eight weeks than two times a week for one week;assess wound location, size, stage, drainage, and wound bed. A review of the Skilled Nursing notes documents the nurse went to the home for seven weeks. The notes document wound measurements were done 8/9/21 8/18/21 and 10/5/21. No other measurements ware documented. During a home visit on 10/5/21, the nurse was asked how frequently the wound is being measured. The nurse stated "once a week, I try to do it on Wednesdays". During an interview with the Administrator on 10/6/21 at 10:30 AM, the Administrator did not provide an explanation for the above.