Every finding on record at Home Health Services Inc.

Based on interview and record review, the agency failed to maintain the dignity and respect for 1 (#6) of 14 sampled patients. This deficient practice had the potential to affect all patients receiving care by the agency. Findings include: --- During an interview on 9/15/25 at 10:56 a.m., NF1 stated staff member C had referred to patient #6 as, “what’s her nut”, to another staff member at their facility. During an interview on 9/18/25 at 8:40 a.m., staff member C stated she had received training on the different types of abuse including verbal abuse. Staff member C stated verbal abuse could be calling a patient by something other than their name. Staff member C stated she recalled an incident where she referred to another patient by, “what’s her nut”, but recalled saying that to another staff member and not the patient. Staff member C stated she can understand how that could be misinterpreted if overheard by other staff or patients. During an interview on 9/18/25 at 9:04 a.m., staff member A stated she had not been notified of any concerns regarding staff referring to patient’s as, “what’s her nut”, she stated had she been aware she would have followed the agency’s policy and procedures for investigating the incident. Review of the agency’s complaint/abuse/grievance logs, on 9/18/25, did not show the incident was reported to the agency for investigation. A review of the agency’s policy and procedure titled, Program/Service Operations - Abuse, with a revision date of May 2023, showed: “1. Any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. This includes: A. Any knowledge of abuse or neglect…2. The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident, with the addition of the following information…3. If patient is in immediate jeopardy, the proper authorities will be contacted by the clinician immediately as required by state or local law.4. The suspected abuse/neglect investigation report with specific information relating to the occurrence is forwarded to the Clinical Supervisor, who will:- A. Notify the physician and referral source (as appropriate) or direct the clinician to do so- B. Review the documentation for completeness and objectivity- C. Forward the information to the Executive Director/Administrator5. The Executive Director/Administrator will:- A. Review all reports (incident report and follow-up investigation)- B. Conduct any further review if necessary- C. Document additional information- D. Submit reports to the proper authorities6. Reports, reviews, and investigations of suspected abuse/neglect will be held in strictest confidence.7. The organization will maintain a list of private and public community agencies that provide or arrange for assessment of suspected or alleged abuse/neglect victims.”A review of the agency’s policy and procedure, titled Patient Bill of Rights, with a revision date of May 2023, showed: “ …1. The Patient Bill of Rights statement defines the right of the patient to:- A. Exercise and understand his or her rights and responsibilities as a patient of [Agency Name] and not to be subject to discrimination or reprisal for exercising these rights…- C. Have his or her property and person treated with respect, consideration and recognition of patient dignity and individuality.- D. Voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so.- E. Receive an investigation by the organization of complaints made by the patient or the patient's family or guardian regarding treatment or care that is (or fails to be) furnished, or regarding lack of respect for the patient's property by anyone furnishing services on behalf of the organization; the existence of the complaint and the resolution of the complaint must be documented…- I. Be free from mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of an unknown source, and misappropriation of patient property…”

Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of participation for Initial and Comprehensive assessment of the patient. The agency failed to: --- - Complete a comprehensive assessment which included a review of a patient’s skin integrity to include the evaluation, measurement, healing outcomes, and the treatment regimen for a Stage 4 pressure injury to promote the patient’s well-being for 1 patient. This deficient practice had the potential to cause worsening pressure injuries to patients (See L524).- Complete a drug regimen review that included all prescriptions, over-the-counter drugs, herbal remedies and other alternative treatments for 6 patients. This deficiency had the potential to affect all hospice patients’ well-being, comfort, and dignity throughout the dying process (See L530).- Ensure the comprehensive assessment was updated to reflect the changes in a patient’s skin integrity to include the assessment and evaluation of a Stage 4 pressure injury for 1 patient to include progression towards wound healing goals. This deficient practice had the potential to cause worsening pressure injuries (See L533).

Based on interview and record review, the agency failed to complete a comprehensive assessment which included a review of a patient’s skin integrity to include the evaluation, measurement, healing outcomes, and the treatment regimen for a Stage 4 pressure injury to promote the patient’s well-being for 1 (#14) of 14 sampled patients. This deficient practice had the potential to cause worsening pressure injuries to patients. Findings include: --- Patient #14 was admitted to the hospice agency on 5/25/25, with a primary diagnosis o protein-calorie malnutrition, and co-morbidities which included a Stage 4 sacral pressure injury. Review of patient #14’s Initial Comprehensive Assessment, dated 5/28/25, showed, “ …The Stage 4 sacral ulcer reportedly developed due to neglect while she was living alone; it will now be treated twice weekly by a hospice nurse…” The comprehensive assessment did not include an assessment of patient’s skin integrity to include the evaluation, measurement, healing outcomes, and the treatment regimen for the Stage 4 pressure injury.During an interview on 9/22/25 at 3:30 p.m., staff member A stated the initial comprehensive assessment should include a review of the skin integrity of the patient and an assessment of any wounds. The wounds should be documented under wounds in the EMR and measurements and the recommended treatment orders should be documented in the assessment.A review of the agency’s policy and procedure, titled, Wound Management and Assessment – Pressure Ulcer/Wounds, with an effective date of 8/1/25, showed, “ Procedure: 1. Initial Assessment: Conduct comprehensive skin and wound assessment upon admission, at each comprehensive assessment, and with any noted change in wound status. Assess and document the following:- Location, size (length × width × depth in cm), and stage (if pressure ulcer).- Wound bed description (granulation, slough, eschar, necrotic tissue).- Presence and amount of drainage (scant, small, moderate, copious; serous, serosanguinous, purulent).- Odor (none, mild, moderate, strong).- Condition of wound margins and peri wound skin.- Pain related to wound and/or wound care.- Signs/symptoms of infection (erythema, warmth, swelling, drainage changes, fever)…”

Based on interview and record review, the agency failed to complete a drug regimen review that included all prescriptions, over-the-counter drugs, herbal remedies and other alternative treatments for 6 (#s 4, 5, 7, 9, 12, and 14) of 14 sampled patients. This deficient practice had the potential to affect all hospice patients well-being, comfort, and dignity throughout the dying process  Findings include: --- Review of the clinical records for patient #s’ 4, 5, 7, 9, 12, and 14 showed a lack of documentation and evidence that skilled nursing had assessed the potential drug to drug interactions for all the over the counter and prescription medications. The patients' medical records lacked evidence that the use and the potential side effects of all medications were evaluated and discussed with the patients and/or care givers. The patients' medical records lacked evidence that the major and/or moderate drug to drug interactions were sent to the physicians for review and authorization.Review of patient #s 4, 5, 7, 9, 12, and 14’s Initial Comprehensive RN Assessment Notes, showed a lack of documentation and evidence that skilled nursing had assessed the potential drug to drug interactions for all the over the counter and prescription medications.During an interview on 9/16/25 at 11:40 a.m., staff member A stated it was the expectation of the RNs to review all the patient medications at the start of care during the comprehensive assessment. Staff member A stated the medications should be updated in the patient’s EMR.

Based on interview and record review, the agency failed to ensure the comprehensive assessment was updated to reflect the changes in a patient’s skin integrity to include the assessment and evaluation of a Stage 4 pressure injury for 1 (#14) of 14 sampled patients to include progression towards wound healing goals. This deficient practice had the potential to cause worsening pressure injuries. Findings include: --- Patient #14 was admitted to the hospice agency on 5/25/25, with a primary diagnosis of protein-calorie malnutrition, and co-morbidities which included a Stage 4 sacral pressure injury. Review of patient #14’s Initial Comprehensive Assessment, dated 5/28/25, showed, “ …The Stage 4 sacral ulcer reportedly developed due to neglect while she was living alone; it will now be treated twice weekly by a hospice nurse…”Review patient #14’s RN Comprehensive Assessment Nursing Note, dated 6/10/25, showed, “…The Stage 4 sacral ulcer reportedly developed due to neglect while she was living alone; it will now be treated twice weekly by a hospice nurse… Nurse changed dressing on hip and knee…” The comprehensive assessment did not include a review of the patient’s skin integrity or pressure injury.Review of patient #14’s RN Regular Visit Note, dated 6/19/25, showed, “…Wound at hip is healing well, now at a stage 2 with a pink wound bed...”Review of patient #14’s RN Regular Visit Note, dated 6/24/25, showed, “…The nurse changed the dressing on the hip and left knee wound open to air…”Review of patient #14’s RN Comprehensive Assessment Nursing Note, dated 7/3/25, showed, “…The nurse changed the dressing on the hip and left knee wound open to air Skin [clean, dry, intact] other than wounds being treated…” The comprehensive assessment failed to include the evaluation and assessment of patient #14’s pressure injury to include the change in pressure injury staging.Review of patient #14’s RN Comprehensive Assessment Nursing Note, dated 7/15/25, showed, “Pressure wound on hip healing well… Skin [clean, dry, intact] other than wounds being treated…” The comprehensive assessment failed to include the evaluation and assessment of the patient’s pressure injury.Review of patient #14’s RN Comprehensive Assessment Nursing Note, dated 7/16/25, showed, “Skin Assessment for [Bilateral Lower Extremity] trace edema… ITop of Formntegumentary: Pallor. Dry and fragile. Pt has a pressure injury on her [left]. hip. 2x2 Mepilex applied. No drainage observed. Education provided [related to] skin breakdown prevention…” The comprehensive assessment failed to include the evaluation and assessment of the patient’s pressure injury.Review of patient #14’s RN Comprehensive Nursing Note, dated 7/29/25, showed, “…Wound to left hip is open to air…” The comprehensive assessment failed to include the evaluation and assessment of the patient’s pressure injury.Review of patient #14’s RN Regular Visit Nursing Note, dated 8/12/25, showed, …”Wound to left hip has healed and is [open to air] no sign of redness of infection visualized…"Review of patient #14’s Skilled Nurse Visit, dated 8/15/25, showed, “… Skin remains pale, dry, and fragile. The left hip pressure area was cleansed and redressed with a clean 3x3 Mepilex during the visit; no drainage noted. Wound nearly healed. No new breakdown identified...”Review of patient #14’s Skilled Nurse Visit, dated, 8/22/25, showed, “…The left hip pressure area is nearly healed. Dressing changed during visit with a clean 3x3 Mepilex applied to protect skin from friction; no drainage or signs of infection noted. Remaining skin is fragile, pale, and dry, but without new breakdown…”Review of patient #14’s RN Comprehensive Assessment Nursing Note, dated 8/27/25, failed to address the continued care provided for patient #14’s pressure injury.Review of patient #14’s skilled Nurse Visit, dated 8/29/25, showed, “…the pressure area on the left hip have both healed and remain open to air without dressings. No drainage or skin breakdown was identified. Her skin overall remains pale, fragile, and dry, though intact…”Review of patient #14’s RN Comprehensive Assessment Nursing Note, dated 9/3/25, failed to address the continued care provided for patient #14’s pressure injury.During an interview on 9/18/25 at 8:40 a.m., staff member C stated the plan of care should be updated when new treatment orders are provided or if changes occur to the plan of care for the patient during the IDG meetings.During an interview on 9/22/25 at 3:30 p.m., staff member A stated the nurses should complete a comprehensive assessment on patient’s which includes a review of the skin integrity of the patient and an assessment of any wounds. The wounds should be documented under wounds in the EMR and measurements and the recommended treatment orders should be documented. Any changes in the wound condition should be communicated at the IDG meetings.A review of the agency’s policy and procedure, titled, Wound Management and Assessment – Pressure Ulcer/Wounds, with an effective date of 8/1/25, showed, “… 3. Ongoing Monitoring:- Reassess and document wound status at each skilled nursing visit.- Report any change in wound condition, signs of infection, or uncontrolled pain to physician/NP promptly.- Revise plan of care as needed in coordination with IDG…”

Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of participation for Interdisciplinary group, care planning, and coordination of services. The agency failed to: --- - Ensure the frequency of visits for services necessary to meet specific patient and family needs was documented on the plan of care for 4 patients. This deficient practice had the potential to affect the palliation and management of patient care needs for all hospice patients (See L547).- Ensure the individualized plan of care addressed interventions, treatments, and goals for a Stage 4 pressure injury for 1 patient; and failed to ensure all medications were addressed on the plan of care for 3 patients. This deficiency has the potential to affect the care and wound healing for patients with pressure injuries and all patients medication therapy (See L549).- Coordinate services with the agency’s Interdisciplinary Group (IDG) in collaboration with the attending physician failed to ensure the individualized plan of care was updated and new treatment orders were obtained for a change in wound care management for a sacral pressure injury that progressed from a Stage 4 to a Stage 2, then to healed, for 1 patient. This deficient practice had the potential to affect the patients’ palliation, well-being, and comfort regarding the management of pressure injuries (See L552).

Based on interview and record review, the agency failed to ensure the frequency of visits for services necessary to meet specific patient and family needs was documented on the plan of care for 4 (#s 4, 5, 12, and 14) of 14 sampled patients. This deficient practice had the potential to affect the palliation and management of patient care needs for all hospice patients. Findings include: --- 1. Patient #4 had a start of care date of 8/12/25, with primary diagnosis of Alzheimer’s disease. Review of patient #4’s Plan of Care, with visit frequency effective date of 8/12/25, showed skilled services ordered for RN services for four visits monthly, with 10 PRN visits every 30-days.Review of patient #4’s EMR, from 8/12/25 to 9/18/25, showed the patient received chaplain services, and social work services which were not ordered on the plan of care.2. Patient #5 had a start of care date of 5/14/24, with primary diagnosis of Alzheimer’s disease.Review of patient #5’s EMR, from 6/18/25 to 9/18/25, showed the patient received chaplain services.Review of patient #5’s Plan of Care, with visit frequency effective 12/9/24, did not include an order frequency for chaplain services.  3. Patient #12 had a start of care date of 4/11/25, with a diagnosis of Parkinson’s disease.Review of patient #12’s EMR, from 5/12/25 to 9/18/25, showed the patient received volunteer services.Review of patient #12’s Plan of Care, with an assignment effective date of 7/9/25, did not include ordered frequency visits for volunteer services.4. Review of patient #14’s Plan of Care, with an effective date of 6/4/25, showed the skilled services ordered for Hospice Aide, one visit weekly. There were no other skilled service frequencies ordered on the plan of care.A review of patient #14’s EMR, from 5/28/25 to 9/18/25, showed the patient received LPN and RN services, chaplain services, and social work services not ordered on the plan of care.During an interview on 9/18/24 at 9:04 a.m., staff member A stated the frequency of clinician visits should be reflected on the patient’s plan of care.A review of the agency’s policy and procedure titled, Plan of Care, with a revision date of May 2023, showed, “… Procedure… M. Frequency/Amount/Duration of services…”

Based on interview and record review, the agency failed to ensure the individualized plan of care addressed interventions, treatments, and goals for a Stage 4 pressure injury for 1 (#14); and failed to ensure all medications were addressed on the plan of care for 3 (#s 4, 5, and 6) of 14 sampled patients. This deficiency has the potential to affect the care and wound healing for patients with pressure injuries and all patients medication therapy. Findings include: --- 1. Wound Care TreatmentPatient #14 was admitted to the hospice agency on 5/25/25, with a primary diagnosis of protein-calorie malnutrition, and co-morbidities which included a Stage 4 sacral pressure injury.Review of patient #14’s Initial Comprehensive Assessment, dated 5/28/25, showed, “ …The Stage 4 sacral ulcer reportedly developed due to neglect while she was living alone; it will now be treated twice weekly by a hospice nurse…”Review of patient #14’s Plan of Care, dated 5/28/25, Showed, “Physical Comfort Alteration due to wounds on hip and knee, with an effective date of 6/3/25. The interventions did not include treatments or goals for wound management of the Stage 4 pressure injury.Review of patient #14’s Provider Orders did not include orders for wound management or treatment of the Stage 4 pressure injury.During an interview on 9/22/25 at 3:30 p.m., staff member A stated the plan of care should include the physician orders for treatment of wounds and interventions and goals should be included in the plan of care. Staff member A stated the plan of care for patient #14 did not include treatment orders, interventions, or goals necessary to treat and manage patient #14’s pressure injury.A review of the agency’s policy and procedure titled, Plan of Care, with a revision date of May 2023, showed, “Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.- Procedure… 12. The written plan of care will contain, but will not be limited to, the following: Q. Statement of treatment goalsT. Drugs and treatments (including allergies)V. Physician (or other authorized licensed independent practitioner) ordersW. Measurable outcomes anticipated from implementing and coordinating the plan of care…”A review of the agency’s policy and procedure, titled, Wound Management and Assessment – Pressure Ulcer/Wounds, with an effective date of 8/1/25, showed,” … 2. Care Planning: Collaborate with interdisciplinary team (IDG), physician/NP, patient, and family to develop individualized wound care plan. Interventions… Wound care orders must be signed by physician/NP and updated as condition changes…”2. Medications on Plan of CarePatient #4 had a start of care date of 8/12/25, with primary diagnosis of Alzheimer’s disease.Review of patient #4’s Plan of Care dated 8/22/25, did not include the patient’s current medications.Review of patient #4’s Medication List in the agency’s EMR, did not show any medications listed.Patient #5 had a start of care date of 5/14/25, with a primary diagnosis of Alzheimer's disease with late onset.Review of patient #5’s medication list in the agency’s EMR, showed the following medications:- Acetaminophen 325 mg one tablet three times daily- Alprazolam 0.5mg three times daily- amlodipine besylate 10 mg once daily- duloxetine HCL 30 mg once daily- Lasix 40 mg once daily- Haloperidol Lactate 2mg/ml 0.25 - 1 ml- Hydrocodone-Acetaminophen 5-325MG one tablet two times daily.- Levothyroxine Sodium 100 MCG once daily- Lidocaine Pad 5 % 1 Patch TOPICAL 1 times a day- Olanzapine 5 mg once daily- potassium chloride 20 mEq once daily- risperidone 0.25 mg tablet two times daily, as needed- MiraLAX 17 gm once daily- Voltaren 1 % 1 gm topically as needed for pain- Seroquel 25mg once daily- lorazepam 2 mg/ml 0.25/2 ml as needed- Morphine Sulfate(Concentrate) 20 mg/ml give 5 - 20 mg orally every 1 hour as needed.Review of patient #5’s Medication List provided by the Assisted Living Facility, on 9/18/25, showed:- Acetaminophen 500 mg one tablet three times daily- amlodipine 10 mg once daily- diclofenac 1% gel, 2-4 gm once daily for pain- duloxetine HCL 60 mg once daily- duloxetine HCL DR 30mg once daily with 60mg dose- Lasix 20mg take two tablets every morning- hydrocodone/APAP 5/325 take one tablet twice daily- levothyroxine 100 mcg once daily- lidocaine 5% patch- lorazepam 2 mg/ml, give 0.5 mg (1mg) under the tongue at 6 p.m.- olanzapine 5 mg once daily- oxybutynin 5 mg twice daily- pantoprazole 40 mg once daily- MiraLAX 17 gm once daily- potassium chloride ER 20 mEq once daily- quetiapine 25 mg one tablet twice daily- Bisacodyl 10 mg suppository as needed- haloperidol 2 mg/ml, give 0.25 ml every eight hours as needed- loperamide HCL 2 mg, take two tablets after loose stool- lorazepam 0.5 mg tablet once daily as needed- morphine 20 mg/ml, take 5 mg to 20 mg by mouth every 1 to 2 hours as needed for pain/dyspnea- nasal spray saline 0.65%, instill two sprays each nostril every hour as needed- ondansetron 8 mg orally disintegrating tablet, dissolve one tablet by mouth every six hours as neededPatient #6 had a start of care date of 5/18/25, with a primary diagnosis of respiratory failure.Review of patient #6’s plan of care, with medications listed as ordered on 5/19/25, showed the following medications listed on the plan of care:- Colace, one capsule two times daily as needed- lorazepam 0.25 – 2 ml every hour as needed for agitation- morphine sulfate 5 – 20 mg every hour as needed for dyspnea and pain- Zofran one tablet every 4 hours as needed for nausea.Review of patient #6’s Medication List provided by the Assisted Living Facility, on 9/18/25, showed:- acetaminophen 500 mg take two tablets twice daily- citalopram 10 mg take one half tablet every night at bedtime- divalproex DR 125 mg capsule, take one capsule by mouth three times daily- gabapentin 100 mg once daily at bedtime- morphine sulfate 20 mg/ml, take 0.25 ml by mouth at bedtime- multivitamin gummy once daily- Myrbetriq ER 50 mg tablet once daily- olanzapine 2.5 mg tablet twice daily- omeprazole DR 40 mg once daily- quetiapine 50 mg one tablet every night- scopolamine 1 mg, apply one to two patches every 72 hours- SF 1.1 % Fluoride gel, brush pea size amount daily- Xiidra 5% solution, instill one drop each eye twice daily- acetaminophen 650 mg tablet, one tablet every four hours as needed- calcium 500 mg chew, chew two tablets every four hours- guaifenesin/codeine 100/10 mg/5 ml, take 5 ml by mouth every hour as needed- loperamide HCL  2 mg capsule, take two capsules by mouth as needed or diarrhea- lorazepam 2 mg/ml, give 0.25 ml under the tongue every four hours as needed- MiraLAX 17 gm once daily as needed- morphine 20 mg/ml, give 0.25 ml under tongue every one to two hours as needed for pain and dyspnea.During an interview on 9/18/25 at 9:04 a.m., staff member A stated it was the expectation all medications were updated on the patient’s plan of care.A review of the agency’s policy and procedure titled, Plan of Care, with a revision date of May 2023, showed, “… Procedure… 12. The written plan of care will contain, but will not be limited to, the following… T. Drugs and treatments (including allergies)…”

Based on interview and record review, the agency’s Interdisciplinary Group (IDG) in collaboration with the attending physician, failed to ensure the individualized plan of care was updated and new treatment orders were obtained for a change in wound care management for a sacral pressure injury that progressed from a Stage 4 to a Stage 2, then to healed, for 1 (#14) of 14 sampled patients. This deficient practice had the potential to affect all patients’ palliation, well-being, and comfort regarding the management of pressure injuries. Findings include: --- Patient #14 was admitted to the hospice agency on 5/25/25, with a primary diagnosis of protein-calorie malnutrition, and co-morbidities which included a Stage 4 sacral pressure injury.Review of patient #14’s Plan of Care, dated 5/28/25, Showed, “Physical Comfort Alteration due to wounds on hip and knee, with an effective date of 6/3/25. The interventions did not include wound care management for the sacral pressure injury or treatment orders. The plan of care was not updated with new orders for treatment or management of the patient’s sacral pressure injury.Review of patient #14’s Initial Comprehensive Assessment, dated 5/28/25, showed, “ …The Stage 4 sacral ulcer reportedly developed due to neglect while she was living alone; it will now be treated twice weekly by a hospice nurse…”Review of patient #14’s RN Regular Visit Note, dated 6/19/25, showed, “…Wound at hip is healing well, now at a stage 2 with a pink wound bed...” The plan of care did not show new treatment orders were obtained for a change in wound care management and did not reflect the change in the pressure injury from Stage 4 to Stage 2 was updated on the plan of care.Review of patient #14’s RN Comprehensive Nursing Note, dated 7/29/25, showed, “…Wound to left hip is open to air…” The plan of care did not show new treatment orders were obtained for a change in wound care management and did not reflect the change in the pressure injury.Review of patient #14’s RN Regular Visit Nursing Note, dated 8/12/25, showed, …”Wound to left hip has healed and is [open to air] no sign of redness of infection visualized…" The plan of care did not show new treatment orders were obtained for the change in wound care management and did not reflect the change in the pressure injury to healed.Review of patient #14’s Skilled Nurse Visits from 8/15/25 to 8/29/25, showed the skilled nurse continued to provide wound care and dressing changes to the sacral pressure injury, after the RN noted it was healed on 8/12/25. The plan of care was not updated to reflect the healed pressure ulcer and the discontinuation of wound care to the pressure injury.  During an interview on 9/18/25 at 8:40 a.m., staff member C stated the plan of care should be updated when new treatment orders are provided or if changes occur to the plan of care for the patient during the IDG meetings.During an interview on 9/18/25 at 9:04 p.m., staff member A stated the care plan should be updated to show changes in wound care orders and wound assessments. She stated these updates would occur at the IDG meetings, if not sooner.A request for documentation was made for patient #14 on 9/22/25 at 3:30 p.m., for physician orders for change in treatment for wound care, updated plan of care to show the change in wound treatment and change in the pressure injury, and IDG notes regarding the sacral pressure injury. Nothing was provided by the end of the survey.During an interview on 9/22/25 at 4:00 p.m., staff member A stated the agency did not have wound care orders for patient #14, the plan of care was not updated to reflect the changes in patient #14’s sacral pressure injury, and there was no documented notes from IDG meetings which showed the communication with the provider and the nursing staff on the change in wound management for patient #14’s sacral pressure injury.  A review of the agency’s policy and procedure, titled, Wound Management and Assessment – Pressure Ulcer/Wounds, with an effective date of 8/1/25, showed, “… 3. Ongoing Monitoring:- Reassess and document wound status at each skilled nursing visit.- Report any change in wound condition, signs of infection, or uncontrolled pain to physician/NP promptly.- Revise plan of care as needed in coordination with IDG…”