Every finding on record at Salud Integral En La Montana Inc

Based on the record review (RR) and interview with the manager (Employee #2) during the review process on October 16, 2025, which began at 8:30 a.m., it was determined that the facility did not ensure that established nursing services were provided, ensuring the scope and frequency of necessary services established to meet the specific needs of the patient and their family. --- Findings include:1.      RR #1 It was found that the established visit frequency of one visit per week was not offered during the week of 09/28/2025 to 10/04/2025.2.      RR #2 It was found that the established visit frequency of two visits per week was not offered during the week of 09/07/2025 to 09/13/2025, and during the week of 09/28/2025 to 10/04/2025, one of the two established visits was not offered.3.      RR #3 It was evident that the established visit frequency of 1 visit per week was not met with the established visits during the following weeks: 08/31/2025 to 09/06/2025, 09/07/2025 to 09/13/2025 and 09/21/2025.4            4.    RR #4 It was found that the established visit frequency of one visit per week was not offered during the week of 09/07/2025 to 09/13/2025.

Based on interviews with the facility administrator (employee # 1) and document review performed on October 16, 2025, from 10:00 AM to 11:00 AM, it was determined that the facility failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. --- Findings include:1. A review of the Corporate Board of Directors’ regulations manual (October 2024 revision) was done on October 16, 2025, at 10:00 AM.a. The board of director’ s responsibilities section did not include the responsibility to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained.  2.      During an interview with the facility administrator (employee # 1) performed on October 16, 2025, at 11:00 AM, he stated that: a. The board of director’ s responsibilities section document was under revision and that the responsibility to ensure an ongoing program for quality improvement and patient safety was going to be added.b. The facility quality improvement committee has not held any meetings during 2025 because in March 2025 was pending the recruitment of administrative staff, the clinical manager and the clinical supervisor prior to reactivating meetings. Because the staff mentioned was already recruited, he stated that he was going to activate it as soon as possible.    3. The quality improvement committee records file shows no meetings during 2025.

Based on an interview with the agency's Director of Services (Employee No. 1) on 10/ 15/ 2025, it was determined that the facility did not ensure it had occupational therapy, speech therapy, and nutrition professionals on staff to care for hospice patients if they needed services. This condition, according to 42 CFR 418.74, is "Not Met." --- Findings include:During an interview conducted on 10/15/2025 at 10:00 a.m., the agency's Director of Services (Employee No. 1) stated that they have contracts but do not have occupational therapy, speech therapy, and nutritionist staff. A credential review on 10/15/2025 at 11:47 a.m. revealed no evidence and confirmed that the required non-core service professionals are unavailable.

Based on an interview and review of the volunteer manual with the Agency Services Manager (Employee No. 2) on 10/15/2025 at 12:00 PM, it was determined that the center failed to ensure the recruitment and retention of volunteer staff, even though they have strategies to implement as described in the manual. --- Findings include:During an interview conducted on 10/15/2025 at 12:00 AM, the Agency Services Manager (Employee No. 2) stated that they currently do not have volunteer services and that recruitment and retention strategies are in place, but they are finding it difficult to recruit due to the requirements imposed by the Human Resources department.

Based on an interview with the Agency Services Manager (Employee No. 2) on 10/15/2025 at 12:00 PM, it was determined that the center did not ensure a 5% volunteer effectiveness level was demonstrated. --- Findings include:During an interview conducted on 10/15/2025 at 12:00 AM, the Agency Services Manager (Employee No. 2) stated that they do not currently have volunteer services and that they find it difficult to recruit due to human resources demands.

Based on interviews with the facility administrator (employee # 1) and document review performed on October 16, 2025, from 10:00 AM to 11:00 AM, it was determined that the Governing body and administrator failed to assume full authority and responsibility for the continuous quality assessment and performance improvement in the facility. --- Findings include:1.  A review of the Corporate Board of Directors’ regulations manual (October 2024 revision) was done on October 16, 2025, at 10:00 AM.2.The board of director’ s responsibilities section did not include the responsibility for the continuous quality assessment and performance improvement in the facility.3. During an interview with the facility administrator (employee # 1) performed on October 16, 2025, at 11:00 AM, he stated that:a.      The board of director’ s responsibilities section document was under revision and that the full authority and responsibility for the continuous quality assessment and performance improvement in the facility was going to be added.

Based on three Home Visit (HV) with records reviewed (RR), fourteen records reviewed (RR) , it was determined that the facility failed to ensure that the clinical record contains current clinical notes for each hospice patient related to physician service and  based on the review of active patient records (RR) and deceased patient records (CRRD) on 10/15/2025 and 10/16/2025, it was determined that the facility did not ensure the nursing professional's clinical notes were included in the patient's record as part of the required content demonstrating the care provided, changes, among others for 6 out of 14 RR (RR-HV 1, #2 , #3, RR #1,# 2, and #3). --- 4.     RR No. 2 does not show clinical notes for visits made on the following days: 08/12, 08/15, 08/19, 08/22, 08/26, 08/28, 09/02, 09/05, 09/16, 09/18, 09/22, 09/24, 09/30, 10/08 (2 notes: regular visit and PRN visit) and 10/10 of 2025.5.     RR No. 3 does not show clinical notes for visits made on the following days: 08/11, 08/15, 08/18, 08/26, 08/28 and 08/29 of 2025.6.     RR No. 4 has clearly not been recertified for the period in which review was from 8/7 to 10/5 2025. Findings include:1. HV # 1 is a 62-year-old female who was admitted on 03/31/2025 with a diagnosis of Alzheimer Disease. The interdisciplinary group determined one visit per month for the Physician (MD). According to the medical record review performed on 10/16/2025 at 9:00 AM, the following was found:a. No evidence of physician’s notes reassessments for the month of September.   2. HV # 2 is a 94-year-old female who was admitted on 06/27/2025 with a diagnosis of Alzheimer Disease with Late Onset. The interdisciplinary group determined one visit per month for the Physician (MD). According to the medical record reviewperformed on 10/16/2025 at 9:00 AM, the following was found: a. No evidence of physician’s notes reassessments for the month of September.   3.  HV # 3 is a 67-year-old male who was admitted on 05/16/2025 with a diagnosis of Bening Neoplasm of Cerebral Meninges. The interdisciplinary group determined one visit per month for the Physician (MD). According to the medical record review performed on 10/16/2025 at 9:00 AM, the following was found:a. No evidence of physician’s notes reassessments for the month of September.   The facility failed to ensure accessible and available physician’s updated comprehensive assessments and clinical notes in the medical record.

Based on the review of active patient records (RR) and deceased patient records (CRRD) on 10/15/2025 and 10/16/2025, it was determined that the facility did not ensure that the physician documented the patient recertification required in 418.22 and 418.25 and described in 418.102(b) and 418.102(c). --- Findings include:During the record review, the following were identified:1. CRRD #1 is evidently not recertified for the period under review (12/06 to 07/08, 2025).2. CRRD #2 is evidently not recertified for the period under review of 10/03, 2025.3. RR #2 is evidently not recertified for the period under review from 03/08 to 04/12, 2025.4. RR #3 is evidently not recertified for the period under review from 06/10 to 10/11, 2025.5. RR #4 is evidently not recertified for the period under review from 07/08 to 05/10, 2025.6. In an interview with the medical director (employee #5) conducted on 10/15/2025 at 3:30 pm, she acknowledged She has visual impairments and is adjusting since purchasing a larger iPad and using dictation to allow for quick and secure documentation. It's evident that she makes the appropriate visits, which she also confirms.

Based on the review of credential files (C. F.) social worker, it was determined that the facility failed to ensure that those who provide services have updated credentials related social worker, as required by State and Local laws. --- Findings include:1. On 10/15/2025 at 10:00 AM during review of the credential file it was identify the following:a. There are no hospice program duties and functions listed in Social Worker file.b. In an interview with the administrator (Employee #1) and the manager (Employee #2), they explain that the social worker is on maternity leave and a social worker from the system has been assigned as a replacement.

Based on the review of  credential files (C. F.) of the  register nurse, it was determined that the facility failed to ensure that those who provide services have updated credentials as required by State and Local laws. --- Findings include:1.      On 10/15/2025 at 10:00 AM during review of the credential file it was identify the following:a.        a. The manager (employee #2) and the nursing supervisor (employee #3) do not demonstrate CPR as required by federal and state law, CPR is demonstrated taken online.

Based on a follow up survey and interview, it was determined that the facility failed to ensure that core services, are provided directly by hospice employee related to the facility no provide the social worker services. --- Findings include: 1.During the interview on 03/20/2023 from 9:00 AM with the Clinical Manager employee #1 stated that the social worker quit the job on 02/28/2023 and did not have any social worker to cover patient need. On 02/15/2023 the facility posts an announcement related to employee opportunity for the social worker position. The clinical manager stated that on 03/23/2023 they are beginning to interview candidates for the social worker position. However, the facility continues to accept new admission of patients since 03/01/2023. They have 2 new admissions performed on 03/11/2023 and 03/16/2023 and they do not have the social worker services. 2. The facility failed to provide core service Social Worker directly by hospice employees.

Based on an unannounced Recertification Survey , three (3) Home Visit (H.V.), and eight record review (R.R) performed on 12/20/2022 through 12/22/2022, with the Clinical Manager (employee #1), and interview, it was determined that the facility failed to ensure that the plan of care include a detailed statement of the scope and frequency visits of Register Nurse, Home Health Aide, Physician, Social Worker, Counseling services necessary to meet the specific patient and family needs, for 2 out of 11 records reviewed ( R.R. #4 and #5). --- Findings include: 1.R.R #4 is an 87-year-old female who was admitted on 06/11/2021 with a diagnosis of Alzheimer. During the record review on 12/22/2022 at 11:30 AM, with the Clinical Manager employee #1, provide the following: The Interdisciplinary Group (IDG) performed the initial plan of care on 06/17/2022, the review the Plan of Care on 10/08/2022, do not establish the frequency to the services Registered Nurse Services (RN), Physician Services, Social Worker Services, and Counseling Services. 2. R.R #5 is a 58-year-old female who was admitted on 08/19/2021 with a diagnosis of Cerebral Aneurism. During the record review on 12/22/2022 at 10:30 AM, it was identified that Interdisciplinary Group (IDG) plan of care performed on 10/28/2022, On 11/11/2022 and 12/09/2022 do not establish the frequency of the services for Registered Nurse Services (RN), Physician Services, Social Worker Services, and Counseling Services. The record was review on 12/22/2022 at 10:30 AM with the Clinical Manager employee #3, provide the following: a. On 10/11/2022 the Recertification Registered Nurse (RN) note specified that the RN services have a frequency of 1 visit per week (wk) for 1 wk and 2 visit per wk for 8 weeks (wks) and 4 visit as necessary (PRN). b. On 10/11/2022 the Recertification Registered Nurse (RN) note specified that the Physician Services have a frequency of 1 visit per month (MO) for 3 MO and 2 visit PRN c. No evidence was found related to the frequency of visit of the other Core services. 3. During interview with the Clinical manger employee #1 on 12/20/2022 at 11:00 AM state that the Plan of Care was discuss with the patient verbally and not provide a written plan of care discussion to the patient and the nurse writes the frequency of visit on the nurses note.

Based on an unannounced Recertification survey, three (3) Home Visit (H.V.), and eight record review (R.R) performed on 12/20/2022 through 12/22/2022, with the Clinical Manager (employee #1), it was determined that the facility failed to ensure that the Interdisciplinary group (IDG) review, revises and documented the plan of care at less than every 15 days 2 out of 11 records reviewed ( R.R. #4 and #5). --- Findings include: 1.R.R #4 is an 87-year-old female who was admitted on 06/11/2021 with a diagnosis of Alzheimer. During the record review on 12/22/2022 at 11:30 AM, with the Clinical Manager employee #1, provide the following: No evidence was found that the IDG performed the review of the plan of care every 15 days due to lack of evidence of the plan of care for 07/01/2022, 09/02/2022, 09/16/2022, and on 10/17/2022. 2. R.R #5 is a 58-year-old female who was admitted on 08/19/2021 with a diagnosis of Cerebral Aneurism. During the record review on 12/22/2022 at 10:30 AM, it was identified that Interdisciplinary Group (IDG) plan of care performed on 10/28/2022, On 11/11/2022 and 12/09/2022 do not establish the frequency of the services for Registered Nurse (RN), Physician Services, Social Worker Services, and Counseling Services. The record was review on 12/22/2022 at 10:30 AM with the Clinical Manager employee #3, provide the following: No evidence was found that the IDG performed the review of the plan of care every 15 days on 10/14/2022, on 11/25/2022 and on 12/9/2022. 3. During interview with the Clinical Manager employee #1 on 12/20/2022 at 11:30 AM state that they are having problem with the electronic medical record, that they performed the meeting, however the electronic record does not permit writing the IDG plan of care, and the facility corporation did not authorize to document in hard copy due to confidentially of the medical record. When the surveyor ask if the facility have policy and procedure (P&P) respect to what to do when the electronic medical record is not available, she states that they do not have P&P.

Based on an unannounced recertification survey, the home visit (HV) with records reviewed (RR), interview with the clinical manager (Employee #1) it was determinate the facility failed to maintain responsibility for coordinating and supervising the plan of care and services from the Home Health Aide (HHA) to the patient for 1 out of 3 HV (HV #1). --- Findings include: 1. HV #1 female of 99 years old who was admitted on 10/20/2022 with diagnosis of Alzheimer disease with las onset. According to the medical record reviewed on 12/21/2022 at 1:00 PM the HHA do not provide evidence the patients' visit. a) Observed on the medical record review, a physician ordered two visits from the HHA a week. On the weekends of 20-26 November 2022 the HHA failed to provide two visit, and 27 November-3 December 2022 also failed to provide two visit. b) During the interviewed the clinical manager (Employee #1) 12/21/2022 at 1:48 PM refer the HHA was on vacation. The facility failed in maintaining the coordination the two visits a week with another HHA according to the plan of care of the patient.

Based on an unannounced recertification survey, observation during the home visit (HV) with record reviewed it was determined the facility failed in ensure that care and services of the Home Health Aide (HHA) was provided in accordance with the plan of care for 2 our 3 HV. (HV #1 and HV #2). --- Findings include: 1. HV #1 female 89 years old admitted 1/27/2022 with diagnosis of Cerebral Vascular Accident (CVA) and Congestion Heart Disease (CHF). The patient was visited 12/20/2022 at 12:15 PM, it was observed bedridden and totally depend on activities of daily living (ADL) with nasal canula 0.3 litters (lt), foley catheter and nasogastric tube. a) No evidence was found in the record reviewed that an assessment was performed from the Registered Nurse (RN) about the HHA in the last two certification periods (9/19/2022- 11/17/2022) – (11/18/2022- 1/16/2023) accordance of the plan of care. 2. HV #2 female 99 years old admitted 10/20/2022 with diagnosis of Alzheimer Disease with late onset and Diabetic mellitus (DM). The patient was visited 12.20/2022 at 10:45AM observed bedridden and is totally dependent on activities of the daily living (ADL) with foley catheter and gastrostomy receiving Diabetic at 50ml/hrs. a). Review of the medical record 12/21/2022 at 1:48 PM revealed that the patient did not receive two visits of the HHA in the week 11/20/2022 – 11/26/2022 and two visits of the week 11/27/2022 – 12/3/2022. b) . During interview with the clinical manager (Employee #1) states that the HHA was on vacation. It was also asked by the surveyor if there was another staff member included like an RN, she said the RN could not do it because the law say the RN could not do bed bath. c). The facility failed provide the patients, frequency and services of the HHA according to the needs and plan of care.

Based on an unannounced recertification survey, review of quality assurance activities, documents and interview, it was determined that the facility failed to implement, and maintain an effective, ongoing, hospice-wide data-driven Quality Assessment and Performance Improvement (QAPI) program. --- Findings include: 1.During survey procedures on 12/22/2020 thought 12/23/2020 the following was identified during the revision of agency QAPI program activities: a. Documentation provided as evidence of the activities performed by the QAPI program does not demonstrate how facility improve outcomes in patient/family care and other hospice clinical related operations. b. Evidence provided as quality indicators results does not represent a comprehensive framework of the assessment and monitoring of hospice's non-clinically relevant operations. c. Information included as part of the quality assurance committee meetings discussions and indicators selected as part of the performance improvement plan does not demonstrate the interaction and connection between data collection and performance improvement activities. d. As part of the QAPI program, the facility did not include statistical tools (graphs, cause and effect diagrams and flow charts) to relate processes from which improvement activities are performed and results identified in data collected. e. Systematic analysis and actions performed after data collection, or a mechanism to identify and correct processes from which a deviation from standards or facility procedures are established was not evidenced, not included as part of the QAPI program activities.

Based on an unannounced recertification survey, Quality Assessment Performance Improvement (QAPI) program review, interview with the QAPI program officer (employee #1), performed on 12/20/2022 through 12/22/2022, the Clinical Manager (employee #1), it was determined that the facility failed to include as part of the QAPI program quality indicators and other relevant data related with services and activities that may impact patient and family care. --- Findings include: 1.No evidence was found that facility establish plans of activities to ensure all patient services and all activities that may impact patient family care was performed, accordingly with the following findings identified during QAPI survey performed on 12/22/2022 at 11:30 AM: a. No facility QAPI plan and activities was provided during the survey. Accordance to the QAPI coordinator employee #1 state on 12/22/2022 at 11:30 AM that they performed surveillance of the following indicator during 2021 and 2022, Pain Management, Constipation in patient using opioid and Dyspnea that was the only indicator that demand hospice regulation. They surveillance Ulcer and wound Management, Physician visit at the moment of death and medication review. b. There are no evidence that the hospice collect data related with patient rights, administrative services, volunteers and Hospice Item Set (HIS) as part of QAPI program activities in order to use the data collected to identify opportunities for improvement.

Based on an unannounced recertification survey, the review of quality assurance activities and interview with the Quality coordinator employee #1, it was determined that the facility failed to ensure that one or more specific quality improvement projects are undertaken each year. --- Findings include: 1.The facility failed to provide evidence on 12/22/2022 at 12:00 PM of performance improvements projects currently underway, as well as those completed in the prior year. 2. The agency failed to comply with the requirement established on February 2, 2009, for all hospices on 418.58 (d) where they must develop, implement and evaluate performance improvement projects every year. During interview on 12/22/2022 at 12:00 PM with the Quality coordinator employee #1, stated that the Quality committee initiate a new indicator related to Interdisciplinary group visit in the last 72 hour of life. However, no evidence was found of Performance improvement project are being conducted, the reason for conducting the project, and documentation that include outlined in the standard that reflect the scope, complexity and past perform.

Based on an unannounced recertification survey, the review of quality assurance activities and interview with the administrator (employee #3), it was determined that the facility failed to conduct performance improvement projects annually, based on the needs of the hospice's population and internal organizational needs that reflects the scope, complexity, and past performance of the hospice's services and operations. --- Findings include: 1. The facility failed to provide evidence on 12/22/2022 at 12:00 PM of performance improvements projects currently underway, as well as those completed in the prior year. 2. The agency failed to comply with the requirement established on February 2, 2009, for all hospices on 418.58 (d) where they must develop, implement and evaluate performance improvement projects every year. During interview on 12/22/2022 at 12:00 PM with the Quality coordinator employee #1, stated that the Quality committee initiated a new indicator related to Interdisciplinary group visit in the last 72 hour of life. However, no evidence was found of Performance improvement project are being conducted, the reason for conducting the project, and documentation that include outlined in the standard that reflect the scope, complexity and past perform.

Based an unannounced recertification survey, observation during the home visit (HV) on 12/20/2022 at 10:45AM review of police and procedure, it was determinate that the hospice failed to ensure that appropriate standards of prevention of the infection transmission and including the use of standard precaution for infection control are followed related to hand wash for 2 out of 3 HV. (HV#2 and HV#3). --- Findings include: 1. HV#2 female of 99 years old who was admitted on 10/20/2022 with diagnosis of Alzheimer disease with late onset. During the home visit 12/20/2022 at 10:45AM the patient was observed bedridden totally dependent on activities of daily living (ADL), disoriented, Foley catheter and receiving enteral nutrition by gastrostomy (Diabetic at 50ml/hrs). The Registered Nurse (RN) (Employee #4) proceed to perform the care of ulcer: a) The RN (Employee #4) was organizing gauzes, wound cleansing, and scissor, to proceed to clean the ulcer. The scissor dropped on the floor, the RN (Employee #4) pick up of the floor, clean the scissor with alcohol and then puts on a non-sterile glove. b) During the procedure the RN (Employee #4) failed to follow polices and procedures related to appropriate standard of infection control relate to ulcer procedure. c) The RN (Employee #4) failed after picking up the scissor to wash the hands before putting the gloves. 2. H.V. #3 its a 91-year-old female admitted on 10/11/2022 with a diagnosis of Alzheimer and Skin Cancer During the Home visit performed on 12/20/2022 at 10:15 AM for Foley change with the Clinical Supervisor employee #2, it was observed the RN #6 performed a skin lesion care, gastrostomy care and change of the Foley catheter #18, with the clinical supervisor employee #2 and it was observed the following: a. During the three-procedure performed by the RN employee #6, she has 15 opportunities for hand wash. The RN employee #6 fail to wash her hand in 2 out of 15 opportunities to wash her hand, at glove change.

Based on unannounced recertification survey, the home visit (HV) with records reviewed (RR), interview with the clinical manager (Employee #1) it was determinate the facility failed to supervise hospice aides no less frequently than every fourteen days and documented for 2 out of 3 HV. (HV #1 and HV #2) --- Findings include: 1. HV #1 female 89 years old admitted 1/27/2022 with diagnosis of Cerebral Vascular Accident (CVA) and Congestion Heart Disease (CHF). According to the medical record reviewed on 12/22/2022 at 9:31 AM, the RN failed to assess the adequacy of the aide services in relationship to the needs of the patient and family. a) The RN (Employee #4) failed to comply with the required documentation of HHA supervision for the periods of certification 9/24/2022-11/22/2022 and 11/23/2022-01/21/2023. 2. HV #2 female 99 years old admitted 10/20/2022 with diagnosis of Alzheimer Disease with late onset and Diabetic mellitus (DM). According to the medical record reviewed on 12/21/2022 at 1:00 PM, the RN failed to assess the adequacy of the aide services in relationship to the needs of the patient and family. a) The RN (employee #6) failed to comply with the required documentation of HHA supervision for the period of certification 10/20/22-1/17/2023. Review on 12/22/22 at 8:30 AM of the facilitys policies and procedures of the Registered Nurse ";Duties and Responsibilities on page 2 of 3 item #27 states Coordina y supervise los servicios de la enfermera practica catorce (14) dias, Coordinates and supervise the license practical nurse services fourteen (14) days.

Based on an unannounced recertification survey, three Home Visit (H.V) and eight Records Reviewed (R.R), it was determined that the facility failed to ensure that all medical record contain past and current findings, no evidence of the ulcer measure accordance to facility policy and procedure for 2 out of 11 records reviewed (R.R #4 and #5). --- Findings include: 1.R.R #4 is an 87-year-old female who was admitted on 06/11/2021 with a diagnosis of Alzheimer. During the record review on 12/22/2022 at 11:30 AM, with the Clinical Manager employee #1, provide the following: The Interdisciplinary Group (IDG) performed the initial plan of care on 06/17/2022, the review the Plan of Care on 10/08/2022, do not establish the frequency of the services for Registered Nurse (RN), Physician Services, Social Worker Services, and Counseling Services. No evidence was found that the IDG performed the review of the plan of care every 15 days due to lack of evidence of the plan of care for 07/01/2022, 09/02/2022, 09/16/2022, and on 10/17/2022. The RN performed visits: On 11/28/2022, the nurse progress note was not performed. On 11/30/2022 the nurses did not complete the progress note and did not sign the note. On 12/13/2022, the nurse progress note was not performed. On 12/15/2022, the nurses did not complete the progress note and did not sign the note. 2. R.R #5 is a 58-year-old female who was admitted on 08/19/2021 with a diagnosis of Cerebral Aneurism. During the record review on 12/22/2022 at 10:30 AM, it was identified that patient have a Stage IV Sacral Ulcer that measure on 06/23/2022 2.5-centimeter (cm) Length per 2.0 cm Width per 0.5 cm depth. The record was review on 12/22/2022 at 10:30 AM with the Clinical Manager employee #1, provide the following: No evidence was found that the Interdisciplinary Group (IDG) plan of care performed on 10/28/2022, on 11/11/2022 and 12/09/2022 establish the frequency of the Registered Nurse Services (RN), Physician Services, Social Worker Services, and Counseling Services. No evidence was found that the IDG performed the review of the plan of care every 15 days on 10/14/2022, on 11/25/2022 and on 12/9/2022. The RN performed visit: On 10/11/2022, the nurses did not complete the progress note and did not provide evidence of the sacral ulcer measure and the nurses did not sign the note. On 10/13/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 10/17/2022, the nurses progress note did not complete the note and do not provide evidence of the sacral ulcer measure. On 10/21/2022, the nurses did not complete the progress note and the nurses did not sign the note. On 10/24/2022, the did not complete the nurses progress note and do not provide evidence of the sacral ulcer measure and the nurses did not sign the note. On 10/28/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 10/31/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/4/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/09/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/14/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/15/2022, the on-call nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/18/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/19/2022, the on-call nurses did not complete the progress note and do not provide evidence of the sacral ulcer measure and the nurses did not sign the note. On 11/22/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/25/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. On 11/29/2022 and on 12/01/2022, the nurse progress notes do not provide evidence of the sacral ulcer measure. On 12/06/2022, no provide evidence of the sacral ulcer measure. On 12/09/2022, the nurses did not complete the progress note and do not provide evidence of the sacral ulcer measure and the nurses did not sign the note. On 12/13/2022, the nurses progress notes do not provide evidence of the sacral ulcer measure. On 12/15/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure. on 12/20/2022, the nurse progress note was not performed and do not provide evidence of the sacral ulcer measure.

Based on an unannounced recertification survey, observations during the tour on 12/21/2022 at 2:21PM of the medical equipment area and medical surgical supply, it was determinate that the facility failed to document temperature in the equipment and supply rooms. --- Findings: 1. The temperature list did not provide evidence of the initials of the person who evaluates the temperature every day since January – December 2022. a) 1/1/2022-1/31/2022 b) 2/1/2022-2/28/2022 c) 3/1/2022-3/31/2022 d) 4/1/2022-4/30/2022 e) 5/1/2022-5/31/2022 f) 6/1/2022-6/30/2022 g) 7/1/2022-7/31/2022 h) 8/1/2022-8/31/2022 i) 9/1/2022-9/30/2022 j) 10/1/2022-10/31/2022 k) 11/1/2022-11/30/2022 l) 12/1/2022-12/20/2022 2. List of temperatures that have no been taken and written. a) 2/11/2022 b) 2/16/2022 c) 2/21/2022 d) 3/17/2022 e) 3/22/2022 f) 4/7/2022 g) 4/12/2022-4/15/2022 h) 4/19/2022-4/20/2022 i) 5/24/2022-5/27/2022 j) 6/01/2022-6/3/2022 k) 6/06/2022-6/09/2022 l) 7/04/2022 m) 7/06/2022 n) 7/08/2022 o) 7/19/2022 p) 7/25/2022-7/29/2022 q) 8/15/2022-8/29/2022 r) 9/01/2022-9/30/2022 s) 10/01/2022-10/31/2022 t) 11/01/2022-11/0/2022