Hands of Grace Hospice

“Based on clinical record reviews, policy titled “Comprehensive Assessment-Initial,” and staff interview, it was determined the agency failed to complete an initial assessment within 48 hours after the election of hospice care for one patient (P) (P#8) and failed to ensure the comprehensive assessment included all medications for one patient (P#5) of 14 sampled patients. Findings include: Review of undated policy titled Comprehensive Assessment- Initial,” Policy number PC.C33 revealed the following:PROCEDURES:1. A hospice RN conducts an initial assessment of the patient’s immediate care and support needs within 48 hours of the patient’s election of hospice care. 1. Review of the clinical record for P#8 revealed the patient was admitted to hospice on 1/26/2025. The initial nursing visit was documented on 1/29/2025, three days after the election of the hospice benefit. 2. During a home visit with P#5 on 3/18/2025, the DON was observed reviewing patient’s current medications. Clinical record review for P#5 failed to reveal any medications on the drug profile. On 3/18/2025 at 11:00 a.m., an interview was held in the office with the Director of Nursing (DON). The DON revealed all documentation for P#8 and P#12 had been provided and confirmed that P#5’s medication profile did not include current medications. Cross reference to L0522 relating to the completion of initial nursing assessments.Cross reference to L0530 relating to the content of the comprehensive assessment.”

“Based on clinical record reviews, review of policies and procedures, and staff interviews, it was determined the agency failed to communicate and coordinate patient care with the Interdisciplinary Group (IDG). Specifically, the agency failed to establish a plan of care for two patients (P) (P#12, P#14), failed to provide caregiver education for one patient (P#8), failed to include goals and measurable outcomes in comprehensive assessments for nine patients (P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14), and failed to ensure services were provided according to the plan of care for three patients (P#8, P#9, P#11) of fourteen sampled patients. Findings include: 1. A review of the clinical records for P#12 and P14 failed to reveal a plan of care. 2. Review of the clinical record for P#8 reveals an order for daily wound care with nursing visits ordered two times per week. The clinical record failed to reveal education was provided to the PCG on providing wound care. 3. Clinical records review for P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14 failed to include goals and measurable patient outcomes. 4. Review of the clinical records for P#8, P#9, and P#11 failed to include services provided according to the plan of care for three patients Review of undated policy titled “Plan of Care”, policy number PC. P40 reveals the following:POLICY: The care and services provided to patients and their families are in accordance with an individualized written plan of care established by the hospice IDG in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient and/or his/her representative. An interview was conducted at the agency with the Director of Nursing (DON) on 3/19/2025 at 12:00 pm, who confirmed all documentation had been provided. Cross reference to L0544 relating to education and training for the caregiver.Cross reference to L0548 relating to measurable outcomes in the plan of care.Cross reference to L0553 relating to patient goals and progress towards those goals.Cross reference to L0555 relating to plan of care frequencies not being met.”

“Based on clinical record reviews and staff interviews it was determined the agency failed to provide comfort and dignity with change of patient assessment for one patient (P) (P#8) of 14 patients sampled. Findings include: Review of records for P#8 revealed that wound care was ordered daily. Skill nursing was ordered initially three times a week, then two times a week. The record revealed P#8 was seen one time a week on week of 2/2/25, then no visits the week of 2/9//25, one time the week of 2/26/25 and no nursing visit the week of 2/23/25. The record lacks patient/family member education on wound care to P#8. The record revealed that P#8 had diarrhea (loose, watery and more frequent bowel movements) for 1 month on 1/29/25. The agency failed to obtain orders to treat symptoms until 2/12/25. During an interview on 3/18/25 at 3:30 p.m. the Administrator she was unable to answer as to why there was missed visits. During an interview on 3/18/25 at 3:35 p.m. Registered Nurse (RN) RN AA was unable to recall the details of P#8’s care. RN AA acknowledged that she assessed/charted that P#8 had diarrhea times 1 month in the clinical record. Policy relating to missed visits was not available.”

“Based on review of policy titled “Comprehensive Assessment- Initial,” clinical record review and staff interview, it was determined the agency failed to complete an initial nursing assessment within 48 hours after the election of hospice care for one patients (P) (P#8) of 14 sampled patients. Findings include: Review of the undated policy titled “Comprehensive Assessment- Initial,” policy number PC.C33, revealed the following:PROCEDURES:1. A hospice RN conducts an initial assessment of the patient’s immediate care and support needs within 48 hours of the patient’s election of hospice care. Review of the clinical record for P#8 revealed the patient was admitted to hospice on 1/26/2025. Review of document titled “Clinical Note- Nursing”, revealed the initial nursing visit by Registered Nurse (RN) AA on 1/29/2025, three days after the election of the hospice benefit. On 3/18/2025 at approximately 11:00 am, an interview was held at the agency with the DON, who revealed all documentation for P#8 had been provided. The DON acknowledged that the initial assessment was late.”

“Based on review of the policy titled “Comprehensive Assessment-Content,” observation, clinical record review, and staff interview, it was determined the agency failed to ensure the comprehensive assessment included a review of all patient’s medications for one patient (P) (P#5) of 14 sampled patients. Findings include: Review of the undated policy titled, “Comprehensive Assessment- Content”, Policy number PC.C32, reveals the following:Procedures:1. The comprehensive assessment of the patient consists of discipline-specific assessment tools that address the following factors:f. a review of all the patient’s prescription and over-the counter drugs, herbal remedies and other alternative treatments that could affect drug therapy During a home visit with P#5 on 3/18/2025, the Director of Nursing (DON) was observed reviewing patient’s current medications. A review of the clinical record for P#5 failed to reveal any medications on the drug profile. An interview on 3/19/2025 at approximately 11:30 a.m., was conducted at the agency with the DON, who confirmed P#5’s medication profile did not list P#5’s current medications.”

“Based on a review of policy titled “Plan of Care,” clinical record reviews, and staff and caregiver interviews, it was determined the hospice failed to ensure that the primary caregiver (PCG) received education and training on daily wound care for one patient (P) (P#8) of fourteen sampled patients. Findings include: A review of the undated policy titled, “Plan of Care,” PC. P40, revealed the following:Procedures:2. Each patient and his/her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care. Review of the clinical record for P#8 reveals an order for daily wound care with nursing visits ordered two times per week. The clinical record failed to reveal education was provided to the PCG on providing wound care. Review of hospital “Critical Care H&P” document revealed P#8 was admitted to the hospital on 3/15/2025. The document includes the following: Diagnosis, Assessment & PlanImpression:1. Severe sepsis2. Community acquired pneumonia3. Urinary tract infection4. Wound infection The document further revealed P#8 was admitted to the Intensive Care Unit (ICU). A telephone interview was conducted with the family member of P#8 on 3/18/2025 at approximately 1:00 p.m. The family member revealed the patient was taken to the hospital on 3/15/2025 for an infection in his leg wound and was still in the ICU. An interview was conducted at the agency with the Director of Nursing (DON) on 3/18/2025 at approximately 2:00 p.m. The DON revealed P#8 had a wound before being admitted to hospice, and that the family was proficient at doing the wound care independently. The DON confirmed the clinical record lacked documentation of education to the family on providing wound care per physician orders.”

“Based on review of policy titled “Comprehensive Assessment- Patient Outcome Measures,” clinical record review, and staff and interview, it was determined the agency failed to include measurable outcomes in the plan of care and updated comprehensive assessments for 9 patients (P) (P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14) of fourteen sampled patients. Findings include: Review of the undated policy titled, “Comprehensive Assessment- Patient Outcome Measures”, policy number PC.C34, reveals the following:Policy:The comprehensive assessment includes data elements that allow for the measurement of patient outcomes.Procedures:1. Members of the IDG document data elements that measure patient outcomes in the same manner for each patient. Selected outcome measures may include, but are not limited to:a. safe and comfortable dying (which includes pain and symptom management);2. The data elements related to selected outcome measures are an integral part of the comprehensive assessment and reassessment tools and are documented in a systematic and retrievable manner for each patient.3. The data collected from the patient’s comprehensive assessment is used to provide individualized care planning, appropriate interventions and for the coordination of services for each patient. 1. Clinical record review for P#5 revealed documents titled “IDG Update”. A review of IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal measurable patient outcomes. 2. Clinical record review for P#7 revealed documents titled “IDG Update”. Review of IDG Updates effective 2/13/2025 and 3/13/2025 failed to reveal measurable patient outcomes. 3. Clinical record review for P#8 revealed documents titled “Initial Plan of Care”, dated 1/26/2025 and “IDG Update”, effective 2/13/2025, 2/27/2025, and 3/13/2025. Review of the documents failed to reveal measurable patient outcomes. 4. Clinical record review for P#9 revealed documents titled “IDG Update”. Review of the IDG Updates effective 10/18/2024, 2/27/2025, and 3/13/2025 failed to reveal measurable patient outcomes. 5. Clinical record review for P#10 revealed documents titled “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal measurable patient outcomes. 6. Clinical record review for P#11 revealed documents titled “IDG Update”. Review of the IDG Updates effective 10/18/2024, 2/27/2025, and 3/13/2025 failed to reveal measurable patient outcomes. 7. Clinical record review for P#12 revealed documents titled “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal measurable patient outcomes. 8. Clinical record review for P#13 revealed documents titled “IDG Update”. Review of the IDG Updates effective 2/13/2025, 2/27/2025, and 3/13/2025 failed to reveal measurable patient outcomes. 9. Clinical record review for P#14 revealed documents titled “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal measurable patient outcomes. An interview was conducted at the office with the Director of Nursing (DON) on 3/19/2025 at 12:00 p.m., who confirmed all documentation for P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14 had been provided. The DON confirmed records lacked measurable patient outcomes.”

“Based on review of policy titled “Wounds-Wound Care & Documentation,” clinical record review, and staff interview, it was determined the agency failed to include patients’ goals and progress towards goals in the plan of care and updated comprehensive assessments for 9 patients (P) (P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14) of fourteen sampled patients. Findings include: Review of the undated policy titled “Wounds- Wound Care & Documentation”, policy number PC. W10, reveals the following:Procedure:3. It’s important to set appropriate goals based on the prognosis, condition and potential for healing. Goals for hospice patients may include:• Preventing complications of the wound, such as infection or odor• Preventing additional breakdown of the skin• Minimizing harmful effects of the wound on the patient’s overall condition4. When developing a care plan for a patient, it is important to factor in their status and desires. Interventions should be re¬ evaluated every two weeks to determine whether the plan is still appropriate. 1. Clinical record review for P#5 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal documentation of P#5’s progress towards goals. 2. Clinical record review for P#7 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 2/13/2025 and 3/13/2025 failed to reveal documentation of P#7’s progress towards goals. 3. Clinical record review for P#8 revealed documents titled, “Initial Plan of Care”, dated 1/26/2025 and “IDG Update”, effective 2/13/2025, 2/27/2025, and 3/13/2025 failed to reveal documentation of P#8’s progress towards goals. 4. Clinical record review for P#9 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 10/18/2024, 2/27/2025, and 3/13/2025 failed to reveal documentation of P#9’s progress towards goals.5. Clinical record review for P#10 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal documentation of P#10’s progress towards goals. 6. Clinical record review for P#11 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 10/18/2024, 2/27/2025, and 3/13/2025 failed to reveal documentation of P#11’s progress towards goals. 7. Clinical record review for P#12 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal documentation of P#12’s progress towards goals. 8. Clinical record review for P#13 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 2/13/2025, 2/27/2025, and 3/13/2025 failed to reveal documentation of P#13’s progress towards goals. 9. Clinical record review for P#14 revealed documents titled, “IDG Update”. Review of the IDG Updates effective 2/27/2025 and 3/13/2025 failed to reveal documentation of P#14’s progress towards goals. An interview was conducted at the office with the Director of Nursing (DON) on 3/19/2025 at 12:00 p.m., who confirmed all documentation had been provided. The DON confirmed care plans lacked patient goals in the plan of care.”

“Based on a review of clinical records, review of policy titled “Plan of Care, “and staff interview, it was determined the hospice failed to ensure services are provided in accordance with the plan of care by failing to provide visits as ordered for three patients (P) (P#8, P#9, P#11) of 14 sampled patients. The findings include: Review of undated policy titled “Plan of Care,” Policy Number: PC. P40 reveals the following:POLICY:The care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient and/or his/her representative. PROCEDURE:1. The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessments of the patient. 1. Record review reveals P#8 was admitted to hospice on 1/26/2025. The initial plan of care reveals a nursing frequency of three times a week for one week, then two times a week after that. Nursing visits are documented as follows:Week of 1/26/2025: One documented nurse visit made on 1/29/2025Week of 2/2/2025: One documented nurse visit on 2/7/2025Week of 2/9/2025: No documented nurse visitsWeek of 2/16/2025: One documented nurse visit madeWeek of 2/23/2025: No documented nurse visit Further review of the clinical record failed to reveal documentation for the missed visits. 2. Record review reveals P#9 was admitted to hospice on 3/8/2023. Review of “IDG Update,” effective 10/18/2024, reveals a nursing frequency of one visit per week and a Social Worker (SW) frequency of one time per month. Review of the clinical record reveals the most recent nurse visit on 10/16/2024. The Social Worker’s most recent visit is dated 10/29/2025. No nursing or SW visits are documented after 10/29/2024. Further review of the clinical record failed to reveal documentation for missed visits. 3. Record review for P#11 reveals patient was admitted to hospice on 4/8/2024. Review of the “IDG Update,” effective 10/18/2024 reveals a nursing frequency of one visit per week and Social Worker frequency of one time per month. Review of the clinical record reveals the most recent nurse visit on 10/16/2024. The Social Worker’s most recent visit is dated 10/29/2025. No nursing or SW visits are documented after 10/29/2024. Further review of the clinical record failed to reveal documentation for missed visits. Policy relating to missed visits was not available. An interview was conducted at the office with the Director of Nursing (DON) on 3/19/2025 at approximately 12:00 p.m. and revealed that missed visits are to be documented in the clinical record with the reason for the missed visit. The DON confirmed all documentation had been provided.”

“Based on review of facility documents and staff interview, it was determined that the agency failed to document the cost savings achieved through the use of volunteers. Findings include: Review of facility documents failed to reveal the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions. and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions. During an interview on 3/17/2025 at 2:30 p.m. the Volunteer Coordinator stated that she had just taken this position and was not aware that it was required to document cost savings. Policy relating to use of volunteers was unavailable.”

“Based on review of facility documents, and staff interviews, it was determined that the agency failed to document volunteers day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. Findings include: Review of facility documents failed to include documentation of volunteers providing day-to-to-day administrative and/or direct patient care services that equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. Review of facility document failed to indicate documentation to support the use of volunteers for patient care and administrative services and the type of volunteer services provided. During an interview on 3/17/25 at 2:30 p.m., the Volunteer Coordinator stated that she was unaware of what was required to document volunteer services as she had only been in this role since August 2025. She stated that most of the hospice’s volunteer services were provided in the community which was recorded in their volunteer book. Policy relating to the use of volunteers was not available.”

“Based on record review, review of polices titled “Patient Rights and Responsibility,” “Plan of Care” and staff interview, it was determined the agency failed to provide comfort and dignity consistent with needs and goals for one patient (P) (P#8) of fourteen patients sampled. Findings include: Review of the undated policy titled “Patient Rights and Responsibilities,” Policy Number: AD.P15 revealed the following:PROCEDURES:3. The notice of the patient’s rights and responsibilities includes, but is not limited to, the patient’s right: f. to receive effective pain management and symptom control. Review of the undated policy titled “Plan of Care, “ Policy Number: PC.P40 revealed the following:PROCEDURES:2. Each patient and his/her primary caregiver receives education and training from hospice as appropriate to their responsibilities for the care and services provided in the plan of care. Record review revealed P#8 start of care began on 1/26/25. The initial assessment was completed on 1/29/25. The Registered Nurse (RN) AA noted on 1/29/25 that P#8 had experienced diarrhea for one month. The clinical record revealed that P#8 received treatment with Metronidazole 500 mg (antibiotic used to treat infectious diarrhea) on 2/10/25. The clinical record revealed orders for P#8 to receive daily wound care and skilled nurse to make three visits the first week and then two visits per week without an end date. The record failed to indicate family member/care giver education on wound care to achieve wound goals. During an interview on 3/18/25 at 3:00 p.m. the Director of Nursing (DON) states she is unsure as to why P#8’s initial assessment was late. She stated that she does not know why the treatment of diarrhea for P#8 was delayed. She acknowledged that changes in care, missed visits and caregiver educations should have been documented in the clinical record, The Director of Nursing (DON) stated that she assumed that the family member of P#8 knew how to perform wound care as P#8 had the wound prior to hospice election. During a telephone interview on 3/18/25 at 3:35 p.m., Registered Nurse (RN) RN AA stated that she could not recall specifically about P#8 and why the treatment was delayed.”

“Based on review of personnel files, staff interview, and review of policy titled “Competency Assessment,” it was determined that the agency failed to assess the skills and competence of all individuals that provide care. Findings include: Review of the agency’s undated policy titled “Competency Assessment.” Policy No. HR.CIO revealed the following: PROCEDURES:3. As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing care or assuming administrative responsibilities. 6. Competency assessment occurs during the orientation period, annually (as a component of performance evaluations), and as needed, when adverse patient outcomes are directly related to an individual’s performance.8. The competency of contracted staff is assessed in accordance with the terms of the written agreement in place with the contracted entity. Review of the visit notes dated 1/29/2025, 2/7, 2/21, and 3/1, revealed that Registered Nurse (RN) AA provided care to P#8. Review of RN AA’s personnel file failed to reveal that a competency check off has been completed. An interview was conducted at the agency on 3/18/25 at approximately 4:00 p.m., with the Executive Director (ED), who confirmed that the competency evaluation was not found in the personnel file for RN AA.”

“Based on record review, review of policy titled “Physician Orders,” and staff interview, it was determined that the agency failed to obtain physician orders for two patient’s (P) (P#10, P#14) of 14 sampled patients. Findings include: Review of undated policy titled “Physician Orders,” Policy Number: PC.P30, revealed the following:PROCEDURES:3. Some of the reasons orders are obtained from physicians include, but are not limited to:a. new medication, change in medication or discontinuance of medicationb. change in visit frequency if not within the range specified in the patient’ s plan of care;c. care, treatment and servicesd. dressing changes/ wound care; and/ore. added disciplines or services or equipment to meet the needs of the patient. Review of the records for P#10, and P#12 failed to include physician orders. During an interview on 3/18/25 at 2:00 p.m. the Executive Director (ED) stated that she was unsure as to why the records of P#10, and P#12 lacked physician orders.”

“Based on record review, policy titled “Clinical Records,” and staff interview, it was determined that the agency failed to authenticate entries in their electronic medical records in accordance with hospice policy and currently accepted standards of practice for four patients (P) (P#9, P#10, P#11, P#14) of 14 sampled patients. Findings include: Review of undated policy titled “Clinical Records,” Policy Number: PC.C15 revealed “only authorized individuals can make entries in patient clinical records and all signatures are authenticated to ensure the author is who s/he claims to be.” 1. Review of the “Hospice Aide Care Plan,” for P#9 reveals an electronic signature of the Executive Director with Registered Nurse (RN) credentials. 2. Review of the “Hospice Aide Care Plan Update,” for P#10 reveals an electronic signature of the Executive Director with RN credentials dated 8/14/2024. 3. Review of the “Hospice Aide Care Plan,” for P#11 reveals an electronic signature of the Executive Director with RN credentials dated 8/14/2024. 4. Review of the “Hospice Aide Care Plan,” for P#14 reveal an electronic signature of the Executive Director with RN credentials dated 1/1/2025. During an interview on 3/18/25 1:00 p.m. the Executive Director (ED) stated she was not a Registered Nurse and that there must have been a glitch in the electronic medical record (EMR) system. She stated she was unaware when she signed into the EMR system it was authenticating her in as a Registered Nurse.”

“Based on record reviews, and staff interview, it was determined that the interdisciplinary group (IDG) failed to ensure comprehensive assessments were updated and included evaluation and documentation of the patient’s response to wound care treatment and progress toward desired outcomes. In addition, the agency failed to ensure assessment updates and changes were documented in the record for one patient (P) (P#4) of one patient reviewed for altered skin conditions. Findings include: Review of the plan of care revealed P#4 was admitted to hospice on 4/1/2023, with the diagnosis of severe protein-calorie malnutrition (a type of undernutrition), and stage III pressure ulcer to sacral area (full-thickness skin loss at the buttock area). Review of the document titled “;Physician Orders Treatment Profile” for P#4 reveals the following: cleanse wound with wound cleanser, pat dry with gauze, sprinkle Flagyl powder to wound bed, apply xeroform, cover with abdominal pad and secure with 9x9 sacral Opti foam. Change daily and PRN. Review of skilled nurse (SN) visit notes dated 4/1/2023, 4/4, 4/6, 4/11,4/20,5/11, 5/24, 6/12, 7/31, 6/14, and 1/23/2024, failed to reveal wound measurements and progress or lack of progress of wound status. Review of the Interdisciplinary group (IDG) meetings dated 4/5/2023, 4/19, 5/23, 7/11, 7/25 ,9/5, 9/19 10/31, 1/10, and 1/23/2024, failed to reveal documentation of the size of the sacral pressure ulcer wound, and progress or lack of progress of the wound. On 2/21/2024 at 9:15 a.m., an office interview was conducted with Executive Director (ED). ED revealed that the IDG and SN visit notes lack measurements and progress of the sacral wound. ED verbalized that the expectation of the SN is to measure the wound every week and the SN did not measure the wound as required. ED revealed that the SN is no longer with the agency. ED verbalized that there is no agency policy on wound care protocols. ED verbalized that at the time of discharge P4’s wound was improved.”

“Based on record review and staff interview, it was determined that the Administrator failed to provide adequate oversight, monitoring and ensuring staff continued education and the development of policies regarding skin care for patients identified with pressure ulcers and wound for one patient (P) (P#4) of one patient reviewed for altered skin conditions. Findings include: Review of the plan of care revealed P#4 was admitted to hospice on 4/1/2023, with the diagnosis of severe protein-calorie malnutrition (a type of undernutrition), and stage III pressure ulcer to sacral area (full-thickness skin loss at the buttock area). Review of the document titled “;Physician Orders Treatment Profile” for P#4 reveals the following: cleanse wound with wound cleanser, pat dry with gauze, sprinkle Flagyl powder to wound bed, apply xeroform, cover with abdominal pad and secure with 9x9 sacral Opti foam. Change daily and PRN. Review of skilled nurse (SN) visit notes dated 4/1/2023, 4/4, 4/6, 4/11,4/20,5/11, 5/24, 6/12, 7/31, 6/14, and 1/23/2024, lack wound measurements and progress or lack of progress of wound status. Review of the Interdisciplinary group (IDG) meetings dated 4/5/2023, 4/19, 5/23, 7/11, 7/25 ,9/5, 9/19 10/31, 1/10, and 1/23/2024 lacked documentation of the size, of the sacral pressure ulcer wound and progress or lack of progress of the wound. On 2/21/2024 at 9:15 a.m., an office interview was conducted with the Executive Director (ED). ED revealed that the IDG and SN visit notes lack measurements and progress of the sacral wound. ED verbalized that the expectation of the SN is to measure the wound every week and the SN did not measure the wound as required. ED revealed that the SN is no longer with the agency. ED verbalized that there is no agency policy on wound care protocols. ED verbalized that several in-services were conducted on wound care by a certified wound care nurse, but ED unable to provide Inservice sign in sheet and with title of the in-service to the surveyor.”