Jojemar Home Health Inc.

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on record review, observation, and interview the agency failed to enforce its written policy addressing infection control including the prevention of the spread of infectious and communicable disease for 1 of 5 active Patients (patient #1) reviewed for infection control in that: Adm (LVN {Licensed Vocational Nurse}) failed to follow proper procedures while conducting a home visit with patient #1: 1.) missed opportunities for glove changes. 2.) missed opportunities to sanitize hands between glove changes This deficient practice could place Patients at risk for increased wound infections, and further deterioration of the patient’s wounds. The findings included: Record review of [Agency Name] Policy and Procedure Compliance Manual titled “IC.1 Infection Control Program” with an revision date of 01/13/18, quoted in part,…Purpose: “Policy: The agency and staff will follow accepted standards of practice…including standard precautions, to prevent the transmission of infections and communicable diseases…G. Home Health Agency policies and procedures address prevention and control activities, as well as strategies to minimize, reduce or eliminate the prioritized risks including…1. Standard precautions 2. Proper use and removal of PPE (equipment worn to minimize exposure to hazards that cause serious injuries and illnesses, such as gloves) …4. Adherence to cleans and sterile procedures 5. CDC (Centers for Disease Control and Prevention) guidelines 6. Communicable Disease prevention and control Act…7. Current federal/state/local laws and regulations 8. OSHA (Occupational Safety and Health Administration) bloodborne pathogens…15. Minimizing potential exposures 16. Procedures to prevent transmission of the pathogen to patients or staff…” Record review of [Agency Name] Policy and Procedure Compliance Manual titled “IC.3 Hand Hygiene” with a revision date of 01/23/22, quoted in part… “Purpose…To ensure patient care staff practice proper hand hygiene techniques… Definitions… A. Alcohol-base hand rubs- and alcohol-containing preparation…Such preparations usually contain 60%--95% ethanol or isopropanol… E. Hand hygiene… Policy…B. All Agency Staff providing care will observe proper hand hygiene at a minimum… 3. Before and after performing an invasive procedure… performing wound care) … 6. Moving from a contaminated-body site to a clean body site during patient care; and …7. After PPE (Personal Protective Equipment) or gloves are removed, changed, become contaminated… 9. Immediately following contact with blood and/or other body fluids…” Record review of [Agency Name] Policy and Procedure Compliance Manual titled “TX.1 Standards of Practice” with a revision date of 05/31/16, quoted in part, “Purpose: To provided patient care with acceptable standards of practice by Agency staff…The agency will provide patient care in accordance with professional employee’s State Practice Act for acceptable standards of practice, acceptable standards of care, and Agency’s policies and procedures…Procedures…C. Staff will be expected to follow all applicable standards of practice…including but not limited to, the following: 1. Federal Regulations for Medicare Home Health Agencies 2. Home Health Conditions of Participation 3. State Licensing for Home Health Agencies…7. Agency Home Health Policy & Procedure Manual; and 8. Clinical Procedural Manual: VNAA 19th Edition…” Review of Patient #1 “Home Health certification and plan of care” documented a 72-year-old male with primary diagnosis of Unspecified open wound, right foot, and other diagnoses of Type 2 Diabetes mellitus(a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), Essential (primary) hypertension(a common condition where the force of blood against the artery walls is consistently too high), Mixed hyperlipidemia (high levels of fat in the blood), Depression (persistent low mood, loss of interest or pleasure in activities). The form also documented a start of care as 04/03/25 and a “current episode” or certification period as 04/03/2025-06/01/2025 with skilled nurse visits for once a week for one week, twice a week for eight weeks and four as needed visits for wound care, hyper/hypoglycemia, hyper/hypotension, chest pain, medication changes and worsening of condition. Safety Measures: Standard precautions/Infection Control. Further review, “wound care orders” dated 05/09/25… Wound #1 Right, Dorsal, Anterior foot (other distal) … cleanse the wound with Vashe (super-oxidized [passes an electrical charge through a solution of salt and water, contains a high concentration of oxygen] solution formulated to combat bacteria and facilitate wound healing), Topical Treatment… Other. Starting Monday (05/12/25) Place small layer of triple antibiotic then apply collagen sheets/powder… Primary Dressing/Apply: Hydrofera blue(a brand of antibacterial, non-cytotoxic wound dressings that use a proprietary PVA[Polyvinyl Acetate: This is a synthetic polymer commonly used as a glue or adhesive] and polyurethane foam technology combined with two naturally occurring organic pigments, methylene blue and gentian violet)… Secondary Dressing/Apply or cover with: Kling/kerlix(a brand of gauze bandage rolls widely used for wound care and first aid)-and fishnet(soft, stretchy, tubular dressings designed to hold wound dressings in place without tape). Review of personnel record for Adm documented a “Conservative Sharp Wound Debridement Certified (CSWD-C” which revealed Adm was provided with training specific to wound care. Adm reviewed and acknowledged that she read, understood, and agreed to comply with the information and literature provided on 01/17/25 for Bloodborne Pathogens and Infection control. An observation was made of Adm performing wound care to Wound #1 Right, Dorsal, Anterior foot (other distal) on 05/14/25 at 01:30 p.m. Surveyor arrived at patient #1’s home at 01:30 p.m. Adm informed Surveyor that Adm arrived at patient #1’s home at 1:00 pm due to a miscommunication with Agency. Adm informed Surveyor that hand hygiene had been done prior to Surveyor’s arrival and all vital signs had been checked by Adm prior to Surveyor’s arrival. Adm informed Surveyor that Adm was waiting for Surveyor to remove wound dressing and perform wound care. Brief introductions were made, and consent for home visit was signed by patient #1. Adm and Surveyor entered home and proceeded into patient #1’s living room. patient #1 observed to be sitting comfortably in couch with legs elevated in couch’s footrest with a blue pad (moisture absorbent pad used for incontinent individuals). Adm sanitized hands, donned (puts on) new gloves, removed soiled dressing to Right, Dorsal, Anterior foot and placed dirty dressing into trash bag. Using same gloves used to remove dirty dressing Adm put Vashe on a 4x4 gauze and cleansed right, dorsal, anterior foot wound. Pat dried with 4x4 gauze. Then proceeded to apply Santyl (brand name for a topical ointment containing the enzyme collagenase. It is a prescription medication used for wound debridement, meaning it helps to remove dead or damaged tissue from wounds, specifically chronic dermal ulcers and severely burned areas) ointment onto wound. Adm proceeded to remove left soiled glove, grabbed a new clean glove from bag, proceeded to Donn (put on) left glove with the help of right hand (right hand was still wearing soiled glove). (missed opportunity to change both gloves and sanitize hands prior to donning a new set of clean gloves). Adm then proceeded to apply Hydrofera blue dressing as per wound care order. Adm proceeded to keep the Hydrofera blue dressing in place by touching it with right contaminated glove, wrapped foot with kerlix, and secured with tape. Adm did not change gloves going from contaminated site to clean site. (Missed opportunity for glove change). Adm rolled up barrier and doffed(removed) gloves and places them in trash bag. In an interview on 05/15/25 at 10:00 a.m., with Adm, surveyor presented the above findings during home visit for patient #1 which included the following: 1.) missed opportunities for glove changes. 2.) missed opportunity for sanitizing hands after left glove change, and 3.) Touching bandage with contaminated right glove prior to covering wound. Adm agreed to these infection control findings concerning the transmission of diseases. Adm confirmed employees are to use infection control precautions at every home visit. Adm further confirmed Adm was trained upon hire and yearly for standard and infection control precautions by the agency. Surveyor asked Adm why infection control policy was not followed regarding changing gloves when going from contaminated area to clean area. Adm responded “I absolutely accept that one, I was holding the spray bottle in my right hand but changed my left glove but not the right hand. I did wrong and I accept that, it was a split of the moment decision, I messed up.” Surveyor asked also why Adm had not sanitized hands when the left glove was changed, Adm responded “I have it there, the sanitizer, but then I did not do it. In my mind I thought was my hand was sweaty, and I don’t know what happened, I totally take responsibility for that mistake. Since there was no drainage in my mind my focus was to change the dressing, in my mind it was not too contaminated since it was one wound, but yeah, I apologize. Surveyor asked Adm to explain what was meant about looking at a wound and knowing it was infected, Adm responded “No, I did not mean that, I am sorry I don’t mean you can see infection, I know better, I was just being defensive”. Surveyor asked Adm what negative outcome could happen to a wound if proper infection control technique is not utilized, Adm answered “We introduce infection on the patient and the wound could get infected and it may be worse, like sepsis (the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body) and the patient could go to the hospital and yeah anything can happen, but always in my mind looks no sign of infection so the infection control did not pop on my mind, but yes, I did wrong.” Further interview with Alt Adm/DON on 05/15/25 at 11:30 a.m., the surveyor presented the findings of infection control for home visit with patient #1. Alt Adm/DON confirmed the agency provided trainings to their nurses for standard and infection control precautions upon hire and annually. Alt Adm/DON confirmed the agency’s infection control policy should be used at every home visit and agreed that the findings were an infection control issue concerning transmission of diseases. Surveyor asked considering the patient’s age, diagnosis, comorbidities (medical conditions that you have in addition to a primary diagnosis. You may have one or more comorbidities. Morbidity is a medical term that refers to the state of having a specific disease or condition. So, adding “co” in front of this word means two or more conditions occur together), and wounds how can these infection control findings concerning transmission of disease affect the agency clients. Alt Adm/DON stated, “Well this could have a catastrophic effect on our patient’s health as well as many infections caused by our staff, which could range from hospitalization to wounds becoming septic or worse.” Review of OSHA (Occupational Safety and Health Administration) 29 CFR 1910.1030 with a date of 11/03/23, contains the following in part: “Personal protective equipment… Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin…and when handling or touching contaminated items or surfaces… (A) Disposable (single use) gloves such as surgical or examination gloves, shall be replaced as soon as practical when contaminated…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 05/16/25.”

“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 record review, observation, and interview, the agency’s Supervising Nurse failed to ensure that treatments were performed only as ordered for 1 of 5 active patients (patient #1) receiving licensed and certified services and whose clinical records were reviewed, in that: Patient #1 did not receive proper wound care treatment by Adm as ordered by a physician. Patient #1 received Santyl (brand name for a topical ointment containing the enzyme collagenase. It is a prescription medication used for wound debridement, meaning it helps to remove dead or damaged tissue from wounds, specifically chronic dermal ulcers and severely burned areas) instead of the ordered “triple antibiotic”. This failure could place the clients at risk of worsening of patient #1’s wound. If Santyl is applied to healthy skin, it will likely cause harm or damage, primarily because it is designed to target damaged collagen (a structural protein that makes up a significant portion of the body’s connective tissue, including skin, bones, tendons, and ligaments). The findings included: Review of patient #1 “Home Health certification and plan of care” documented a 72-year-old male with primary diagnosis of Unspecified open wound, right foot, and other diagnoses of Type 2 Diabetes mellitus(a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), Essential (primary) hypertension(a common condition where the force of blood against the artery walls is consistently too high), Mixed hyperlipidemia (high levels of fat in the blood), Depression (persistent low mood, loss of interest or pleasure in activities). The form also documented a start of care as 04/03/25 and a “current episode” or certification period as 04/03/2025-06/01/2025 with skilled nurse visits for once a week for one week, twice a week for eight weeks and four as needed visits for wound care, hyper/hypoglycemia, hyper/hypotension, chest pain, medication changes and worsening of condition. Safety Measures: Standard precautions/Infection Control. Further review, “wound care orders” dated 05/09/25… Wound #1 Right, Dorsal, Anterior foot (other distal) … cleanse the wound with Vashe (super-oxidized [passes an electrical charge through a solution of salt and water, contains a high concentration of oxygen] solution formulated to combat bacteria and facilitate wound healing), Topical Treatment… Other. Starting Monday (05/12/25) Place small layer of triple antibiotic then apply collagen sheets/powder… Primary Dressing/Apply: Hydrofera blue(a brand of antibacterial, non-cytotoxic wound dressings that use a proprietary PVA[Polyvinyl Acetate: This is a synthetic polymer commonly used as a glue or adhesive] and polyurethane foam technology combined with two naturally occurring organic pigments, methylene blue and gentian violet)… Secondary Dressing/Apply or cover with: Kling/kerlix(a brand of gauze bandage rolls widely used for wound care and first aid)-and fishnet(soft, stretchy, tubular dressings designed to hold wound dressings in place without tape). An observation was made of Adm performing wound care to Wound #1 Right, Dorsal, Anterior foot (other distal) on 05/14/25 at 01:30 p.m. Surveyor arrived at patient #1’s home at 01:30 p.m. Adm informed Surveyor that Adm arrived at patient #1’s home at 1:00 pm due to a miscommunication with Agency. Adm informed Surveyor that hand hygiene had been done prior to Surveyor’s arrival and all vital signs had been checked by Adm prior to Surveyor’s arrival. Adm informed Surveyor that Adm was waiting for Surveyor to remove wound dressing and perform wound care. Brief introductions were made, and consent for home visit was signed by patient #1. Adm and Surveyor entered home and proceeded into patient #1’s living room. patient #1 observed to be sitting comfortably in couch with legs elevated in couch’s footrest with a blue pad (moisture absorbent pad used for incontinent individuals). Adm sanitized hands, donned (puts on) new gloves, removed soiled dressing to Right, Dorsal, Anterior foot and placed dirty dressing into trash bag. Adm put Vashe on a 4x4 gauze and cleansed right, dorsal, anterior foot wound. Pat dried with 4x4 gauze. Then proceeded to apply Santyl (brand name for a topical ointment containing the enzyme collagenase. It is a prescription medication used for wound debridement, meaning it helps to remove dead or damaged tissue from wounds, specifically chronic dermal ulcers and severely burned areas) ointment onto wound (Missed opportunity, Adm used Santyl ointment instead of ordered triple antibiotic ointment). Adm then proceeded to apply Hydrofera blue dressing as per wound care order. Adm rolled up barrier and doffed(removed) gloves and places them in trash bag. In an interview on 05/15/25 at 10:00 a.m., with Adm, surveyor presented the above finding during home visit for patient #1 which included the following: Using Santyl ointment instead of ordered triple antibiotic. Adm agreed to this finding regarding not following the most current physician order was not followed. Adm responded “I saw yellow slough (a layer of dead tissue that separates from the underlying healthy tissue. It is typically a yellow, gray, or brown mass that can be moist or dry), I did not see any new medication, that was the only available medication, I did not see the new order, that was on me, I trusted that whoever received the new order to communicate it to me and it was not. But I should know better, it was my mistake.” Surveyor asked Adm to clarify regarding the decision to use Santyl instead of ordered triple antibiotic, Surveyor asked Adm of credentials and possible prescription rights, Adm responded “No not at all, that is not what I mean, the Santyl was there with his name and it means it is for him, however I should have known better, I do not have prescription rights, I did not mean that I could prescribe, I was out of my scope, I made a big mistake because I know what Santyl does to a wound and I should have known better.” Surveyor asked Adm what negative outcome could happen to a wound if the wrong medication (in this case Santyl) is utilized, Adm answered “So far, I did not see it getting worse, but yes I made the mistake, using Santyl by mistake may delay the granulation of the tissue, that is all I can imagine that could happen since I did see the yellow slough.” Further interview with Alt Adm/DON on 05/15/25 at 11:30 a.m., the surveyor presented the findings of not following physician orders for home visit with patient #1. Alt Adm/DON confirmed the agency provided trainings to their nurses to make sure to only provide services ordered by physician upon hire and annually. Alt Adm/DON confirmed the clinicians should review client’s clinical records for any updates or new orders prior to every home visit and agreed that the findings were valid. Surveyor asked considering the client’s age, diagnosis, comorbidities (medical conditions that you have in addition to a primary diagnosis. You may have one or more comorbidities. Morbidity is a medical term that refers to the state of having a specific disease or condition. So, adding “co” in front of this word means two or more conditions occur together), and wounds how can this finding concerning following orders can affect Agency clients. Alt Adm/DON stated, “Well what happened since it wasn’t communicated timely, old orders and incorrect medications will be applied to the wound, which could range from hospitalization to wound becoming septic (the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body) or worse.” Review of the agency’s policy titles, “TX.5 Physician Orders”, dated 09/17/18 revealed in part, “Purpose…to ensure patient care is provided in accordance with physician’s orders and federal and state laws and regulations…Policy A. Agency will obtain orders and provide care in accordance with physician’s orders…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 05/16/25.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on record review, observation, and interview, the Agency failed to enforce its written policy to make sure client care was coordinated among all service providers for 1 of 5 active patients (patient #1) receiving licensed and certified services and whose clinical records were reviewed, in that: Patient #1 did not receive proper wound care treatment by Adm as ordered by a physician. Patient #1 received Santyl (brand name for a topical ointment containing the enzyme collagenase. It is a prescription medication used for wound debridement, meaning it helps to remove dead or damaged tissue from wounds, specifically chronic dermal ulcers and severely burned areas) instead of the ordered “triple antibiotic”. This deficient practice could place Patients at risk of receiving subpar care due to Agency’s employees not coordinating care appropriately. The findings included: Record review of [Agency Name] Policy and Procedure Compliance Manual titled “TX.8 Coordination of Care” with an revision date of 09/24/18, quoted in part,…”Purpose: To ensure the effective exchange of information, reporting and coordination of patient care and services… Coordination of care will occur to ensure that patient needs are continually assessed, addressed in the plan of care, that care is delivered in a timely and effective manner, and that goals of care are achieved… Policy: A. The Agency will use an interdisciplinary approach to coordinate services with all healthcare providers, disciplines… B. Agency will exchange information, report to and coordinate services among: … 1. All Agency personnel providing care and services…E. The clinical managers are responsible for the coordination of services. The clinical manager’s oversight will include the following: 2. Coordinating patient care and assignments; and … 3. Assuring the development, implementation, and updates of the individualized plan of care.” Review of patient #1 “Home Health certification and plan of care” documented a 72-year-old male with primary diagnosis of Unspecified open wound, right foot, and other diagnoses of Type 2 Diabetes mellitus(a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), Essential (primary) hypertension(a common condition where the force of blood against the artery walls is consistently too high), Mixed hyperlipidemia (high levels of fat in the blood), Depression (persistent low mood, loss of interest or pleasure in activities). The form also documented a start of care as 04/03/25 and a “current episode” or certification period as 04/03/2025-06/01/2025 with skilled nurse visits for once a week for one week, twice a week for eight weeks and four as needed visits for wound care, hyper/hypoglycemia, hyper/hypotension, chest pain, medication changes and worsening of condition. Safety Measures: Standard precautions/Infection Control. Further review, “wound care orders” dated 05/09/25… Wound #1 Right, Dorsal, Anterior foot (other distal) … cleanse the wound with Vashe (super-oxidized [passes an electrical charge through a solution of salt and water, contains a high concentration of oxygen] solution formulated to combat bacteria and facilitate wound healing), Topical Treatment… Other. Starting Monday (05/12/25) Place small layer of triple antibiotic then apply collagen sheets/powder… Primary Dressing/Apply: Hydrofera blue(a brand of antibacterial, non-cytotoxic wound dressings that use a proprietary PVA[Polyvinyl Acetate: This is a synthetic polymer commonly used as a glue or adhesive] and polyurethane foam technology combined with two naturally occurring organic pigments, methylene blue and gentian violet)… Secondary Dressing/Apply or cover with: Kling/kerlix(a brand of gauze bandage rolls widely used for wound care and first aid)-and fishnet(soft, stretchy, tubular dressings designed to hold wound dressings in place without tape). An observation was made of Adm performing wound care to Wound #1 Right, Dorsal, Anterior foot (other distal) on 05/14/25 at 01:30 p.m. Surveyor arrived at patient #1’s home at 01:30 p.m. Adm informed Surveyor that Adm arrived at patient #1’s home at 1:00 pm due to a miscommunication with Agency. Adm informed Surveyor that hand hygiene had been done prior to Surveyor’s arrival and all vital signs had been checked by Adm prior to Surveyor’s arrival. Adm informed Surveyor that Adm was waiting for Surveyor to remove wound dressing and perform wound care. Brief introductions were made, and consent for home visit was signed by patient #1. Adm and Surveyor entered home and proceeded into client #1’s living room. patient #1 observed to be sitting comfortably in couch with legs elevated in couch’s footrest with a blue pad (moisture absorbent pad used for incontinent individuals). Adm sanitized hands, donned (puts on) new gloves, removed soiled dressing to Right, Dorsal, Anterior foot and placed dirty dressing into trash bag. Adm put Vashe on a 4x4 gauze and cleansed right, dorsal, anterior foot wound. Pat dried with 4x4 gauze. Then proceeded to apply Santyl (brand name for a topical ointment containing the enzyme collagenase. It is a prescription medication used for wound debridement, meaning it helps to remove dead or damaged tissue from wounds, specifically chronic dermal ulcers and severely burned areas) ointment onto wound (Missed opportunity, Adm used Santyl ointment instead of ordered triple antibiotic ointment). Adm then proceeded to apply Hydrofera blue dressing as per wound care order. Adm rolled up barrier and doffed(removed) gloves and places them in trash bag. In an interview on 05/15/25 at 10:00 a.m., with Adm, surveyor presented the above finding during home visit for patient #1 which included the following: Using Santyl ointment instead of ordered triple antibiotic. Adm agreed to this finding regarding not following the most current physician order was not followed. Adm responded “I saw yellow slough (a layer of dead tissue that separates from the underlying healthy tissue. It is typically a yellow, gray, or brown mass that can be moist or dry), I did not see any new medication, that was the only available medication, I did not see the new order, that was on me, I trusted that whoever received the new order to communicate it to me and it was not. But I should know better, it was my mistake.” Surveyor asked Adm to clarify regarding the decision to use Santyl instead of ordered triple antibiotic, Surveyor asked Adm of credentials and possible prescription rights, Adm responded “No not at all, that is not what I mean, the Santyl was there with his name and it means it is for him, however I should have known better, I do not have prescription rights, I did not mean that I could prescribe, I was out of my scope, I made a big mistake because I know what Santyl does to a wound and I should have known better.” Surveyor asked Adm what negative outcome could happen to a wound if the wrong medication (in this case Santyl) is utilized, Adm answered “So far, I did not see it getting worse, but yes I made the mistake, using Santyl by mistake may delay the granulation of the tissue, that is all I can imagine that could happen since I did see the yellow slough.” Further interview with Alt Adm/DON on 05/15/25 at 11:30 a.m., the surveyor presented the findings of not following physician orders for home visit with patient #1. Alt Adm/DON stated, “So we got the new order just on Monday on 05/12/25 and I did fail to tell him {Adm} about the new order of medication for this patient, it was a failure on my part, this will not happen again.” Surveyor asked Alt Adm/DON why Adm was not notified of the new order, Alt Adm/DON responded, “I forgot to tell him, not an excuse, I should have but I don’t know why I did not.” Surveyor asked Alt Adm/DON what current process exists for coordinating care, Alt Adm/DON responded, “So what is supposed to happen was we received the fax on Monday 05/12/25, the Administrative Assistant then proceeds to upload the document to our clinical software, then at that point it is my job to communicate that change to the LVN in charge of that patient.” Surveyor asked Alt Adm/DON what negative outcomes could occur if coordination of care is not followed correctly, Alt Adm/DON responded, “Well what happened since it wasn’t communicated timely, old orders and incorrect medications will be applied to the wound, which could range from hospitalization to wound becoming septic (the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body) or worse.” Surveyor asked Alt Adm/DON what process would be implemented to prevent this from happening in the future, Alt Adm/DON responded, “So right away I will have to communicate to the main nurse as soon as an order is received, I will also re-iterate to the nurses to always check the clinical record for any changes prior to the visits.” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 05/16/25.”