Hadassa Hospice

“Based on observation, interview, and record review, the hospice agency failed to develop an individualized plan of care (an individualized plan that provides direction on the type of care a patient needs) for one of 16 sampled patients (Patient 2). This failure had the potential for staff not to be informed of the type of care Patient 2 requires. Findings: During a review of Patient 2’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 2 had a diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, worsening thinking skills, and changes in behavior). During a concurrent on-site visit and interview on 7/21/2026 at 10:13 a.m., with the Director of Nursing (DON), at the assisted living facility (ALF) where Patient 2 resided, Patient 2 was in her room, awake and lying on her bed. Patient 2 had a floor mat on the right side of her bed, a tab alarm (a fall prevention device which has a pull-string cord, a clothing clip, and a loud alert sound) attached on the right side of her blouse, bilateral arm sleeves (sleeves to prevent skin breakdown), and an abdominal binder (a wide elastic wrap worn around the abdomen). The DON stated Patient 2 had dementia (a decline in mental function severe enough to interfere with daily life) and had been declining. The DON stated Patient 2 required full assistance with her activities of daily living (ADL, basic self-care tasks required to manage everyday physical needs and live independently) and had skin tears on her forearms. The DON confirmed Patient 2 had a floor mat on the right side of her bed, a tab alarm attached on the right side of her blouse, bilateral arm sleeves, and an abdominal binder. During a review of Patient 2’s “Active Plan of Care,” current as of 7/20/2026, the active plan of care was not individualize and did not list the floor mat, the tab alarm, the arm sleeves, and the abdominal binder on the plan of care. During an interview on 7/21/2026 at 2:46 p.m., with the DON, the DON confirmed the floor mat, the tab alarm, the arm sleeves, and the abdominal binder should have been in Patient 2’s plan of care to specify the type of interventions Patient 2 needs. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. 12. The written plan of care will contain, but will not be limited to, the following:… F. safety measures.””

“Based on interview and record, the hospice agency’s interdisciplinary group (IDG, multidisciplinary team composed of doctors, nurses, social workers, and chaplain, who work with the patient, family/caregiver to develop a coordinated comprehensive care plan), failed to review and document for one of 16 sampled patients (Patient 6), plan of care (POC, an individualized plan that provides direction on the type of care a patient needs), every 15 calendar days. This failure had the potential for staff not having the most current information of care and services that Patient 6 requires. Findings: During a review of Patient 6’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 6 had a diagnosis of hypertension (high blood pressure) and Chronic Kidney Disease (a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and extra fluid from the blood). During a review of Patient 6’s “Plan of Care/IDG Review,” for the months of April and May 2026, there was missing documentation from the interdisciplinary group between the dates of 4/23/2026 and 5/21/2026. Further review of the IDG, indicated the next review was to be done no later than 14 days (5/7/2026). During an interview on 7/23/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON stated the next IDG review should have been on 5/7/2026. The DON stated staff held an IDG meeting for Patient 6 on 5/7/2026 but did not document the meeting updates on Patient 6’s medical record. The DON was unable to provide documentation of Patient 6’s IDG review held on 5/7/2026. During a follow-up interview on 7/24/2026 at 10:14 a.m., with the DON, the DON stated the expectation was to hold IDG meetings every other Thursday and to document the meeting on Patient 6’s medical record because that was when staff were updated on any changes on Patient 6’s care. During a review of the facility’s policy and procedure (P&P) titled, “Human Resource,” dated 1/6/2026, the P&P indicated, “2. Documentation Standards. All notes must be accurate and complete. Notes should accurately reflect the care provided, patient status, and any changes in the patient’s condition.” During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Group Membership and Responsibilities,” dated 1/5/2026, the P&P indicated, “3. The interdisciplinary group will: Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services. C. Provide and/or supervise and coordinate hospice care and services.””

“Based on interview and record review, the hospice agency failed to revise the plan of care (POC, an individualized plan that provides direction on the type of care a patient needs), for five of 16 sampled patients (Patients 2, 9, 6, 7, and 5) to reflect changes in patients’ condition when: 1. Patient 2’s plan of care was not revised.2. Patient 9’s plan of care was not revised after a skin tear was healed. 3. Patient 6’s plan of care was not revised.4. Patient 7’s plan of care was not revised after Patient 7 was diagnosed and treated for an infection. 5. Patient 5’s plan of care was not revised after new treatment was ordered for constipation (problem with passing stool). These failures had the potential for staff not to provide the most current care and services to the patients. 1. During a review of Patient 2’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 2 had a diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, worsening thinking skills, and changes in behavior). During a review of Patient 2’s “Active Plan of Care,” as of 7/20/2026, the plan of care for bereavement (the period of deep sorrow and the state of being deprived of a loved one through death), for integumentary/skin, for musculoskeletal, for neurological/mental, for nutrition, and for sleep had goal dates of 5/6/2026. During an interview on 7/21/2026 at 2:46 p.m., with the Director of Nursing (DON), the DON confirmed Patient 2’s care plans for bereavement, integumentary/skin, musculoskeletal, neurological/mental, nutrition, and sleep had goal dates of 5/6/2026. The DON stated the care plans should have been reviewed and updated before/on 5/6/2026. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” 2. During a review of Patient 9’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 9 had a diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, worsening thinking skills, and changes in behavior). During a review of Patient 9’s “Licensed Vocational Nurse Visit Note,” dated 7/12/2026, the note indicated Patient 9’s skin was assessed and there was no skin issue reported. During a review of Patient 9’s “Integumentary/Skin Plan of Care (POC, an individualized plan that provides direction on the type of care a patient needs),” dated 2/10/2025, the plan of care indicated Patient 9 had a left back hand skin tear. During an interview on 7/23/2026 at 2:51 p.m., with the Director of Nursing (DON), the DON stated Patient 9 had no skin tear on her left back hand. The DON stated the plan of care for Patient 9 should have been discontinued when the skin tear was healed. The DON stated the registered nurse case manager and/or the DON should have updated the plan of care during the interdisciplinary group (IDG, multidisciplinary team composed of doctors, nurses, social workers, and chaplain, who work with the patient, family/caregiver to develop a coordinated comprehensive care plan), meeting and/or as needed. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” 3. During a review of Patient 6’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 6 had a diagnosis of hypertension (high blood pressure) and chronic kidney disease (a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and extra fluid from the blood). During a review of Patient 6’s “Active Plan of Care (POC, an individualized plan that provides direction on the type of care a patient needs),” as of 7/23/2026 the plan of care for bereavement (the period of deep sorrow and the state of being deprived of a loved one through death), for cardiovascular (relating to the heart and blood vessels), for endocrine (related to tissues that make and release hormones), for genitourinary (related to genital and urinary organs or function), for integumentary/skin, for neurological/mental, for nutrition, for pain, for psychosocial, for respiratory and for sleep were last updated on 7/2/2026. During an interview on 7/23/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON confirmed Patient 6’s care plans were not updated and should have been updated before/on the goal date. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” 4. During a review of Patient 7’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 7 had a diagnosis of Alzheimer’s (progressive memory loss, worsening of thinking skills, and behavior changes). During a review of Patient 7’s “Interdisciplinary Group (IDG, multidisciplinary team composed of doctor, nurses, social worker, and chaplain who work with the patient and family to develop a coordinated comprehensive care plan) Notes,” dated 7/16/2026, the notes indicated Patient 7 had a urinary tract infection (UTI, bacterial infection of urinary tract system) and received a seven-day treatment of antibiotics. The notes indicated there was no care plan initiated by the IDG to address Patient 7’s infection. During a concurrent interview and record review on 7/23/2026 at 11:31 a.m. with the Director of Nursing (DON), Patient 7’s “Plan of Care (POC),” current as of 7/23/2026 was reviewed. The plan of care did not include a care plan in place to address Patient 7’s UTI. The DON confirmed no care plan was initiated for Patient 7’s UTI and stated the IDG should have initiated an infection or genitourinary care plan for Patient 7. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/6/2026, the P&P indicated, “The plan of care will be reviewed and revised as frequently as deemed necessary, but no less often than every 15 days, by the interdisciplinary group. Any change in the patient’s condition must result in a change in the plan of care.” 5. During a review of Patient 5’s “Face Sheet,” [undated], the face sheet indicated Patient 5 started hospice service on 12/6/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (progressive respiratory problem resulting to difficulty breathing). During a review of Patient 5’s “Physician Orders,” dated 7/17/2026, the physician orders indicated two newly prescribed medications, Docusate Sodium (anti-constipation medication used for problem with passing stool), 100 milligrams (mg), tablet, once daily and Miralax (anti-constipation medication), 17 grams, powder for solution as needed. During a concurrent interview and record review on 7/21/2026 at 11:25 a.m. with the Administrator (Admin), Patient 5’s “Interdisciplinary Group Plan of Care,” dated 1/30/2025 was reviewed. The plan of care indicated Patient 5’s occasional constipation issue was initiated on 12/6/2024 and was resolved on 1/30/2025. The Admin stated the plan of care should have been updated to reflect the newly ordered interventions to treat Patient 5’s constipation. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/6/2026, the P&P indicated, “4. The plan of care will identify the patient’s needs and services to meet those needs, including… symptom relief… 9. The plan of care will be reviewed and revised as frequently as deemed necessary. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” Findings: 1. During a review of Patient 2’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 2 had a diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, worsening thinking skills, and changes in behavior). During a review of Patient 2’s “Active Plan of Care,” as of 7/20/2026, the plan of care for bereavement (the period of deep sorrow and the state of being deprived of a loved one through death), for integumentary/skin, for musculoskeletal, for neurological/mental, for nutrition, and for sleep had goal dates of 5/6/2026. During an interview on 7/21/2026 at 2:46 p.m., with the Director of Nursing (DON), the DON confirmed Patient 2’s care plans for bereavement, integumentary/skin, musculoskeletal, neurological/mental, nutrition, and sleep had goal dates of 5/6/2026. The DON stated the care plans should have been reviewed and updated before/on 5/6/2026. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” 2. During a review of Patient 9’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 9 had a diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, worsening thinking skills, and changes in behavior). During a review of Patient 9’s “Licensed Vocational Nurse Visit Note,” dated 7/12/2026, the note indicated Patient 9’s skin was assessed and there was no skin issue reported. During a review of Patient 9’s “Integumentary/Skin Plan of Care (POC, an individualized plan that provides direction on the type of care a patient needs),” dated 2/10/2025, the plan of care indicated Patient 9 had a left back hand skin tear. During an interview on 7/23/2026 at 2:51 p.m., with the Director of Nursing (DON), the DON stated Patient 9 had no skin tear on her left back hand. The DON stated the plan of care for Patient 9 should have been discontinued when the skin tear was healed. The DON stated the registered nurse case manager and/or the DON should have updated the plan of care during the interdisciplinary group (IDG, multidisciplinary team composed of doctors, nurses, social workers, and chaplain, who work with the patient, family/caregiver to develop a coordinated comprehensive care plan), meeting and/or as needed. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” 3. During a review of Patient 6’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 6 had a diagnosis of hypertension (high blood pressure) and chronic kidney disease (a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and extra fluid from the blood). During a review of Patient 6’s “Active Plan of Care (POC, an individualized plan that provides direction on the type of care a patient needs),” as of 7/23/2026 the plan of care for bereavement (the period of deep sorrow and the state of being deprived of a loved one through death), for cardiovascular (relating to the heart and blood vessels), for endocrine (related to tissues that make and release hormones), for genitourinary (related to genital and urinary organs or function), for integumentary/skin, for neurological/mental, for nutrition, for pain, for psychosocial, for respiratory and for sleep were last updated on 7/2/2026. During an interview on 7/23/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON confirmed Patient 6’s care plans were not updated and should have been updated before/on the goal date. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/5/2026, the P&P indicated, “9. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.” 4. During a review of Patient 7’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 7 had a diagnosis of Alzheimer’s (progressive memory loss, worsening of thinking skills, and behavior changes). During a review of Patient 7’s “Interdisciplinary Group (IDG, multidisciplinary team composed of doctor, nurses, social worker, and chaplain who work with the patient and family to develop a coordinated comprehensive care plan) Notes,” dated 7/16/2026, the notes indicated Patient 7 had a urinary tract infection (UTI, bacterial infection of urinary tract system) and received a seven-day treatment of antibiotics. The notes indicated there was no care plan initiated by the IDG to address Patient 7’s infection. During a concurrent interview and record review on 7/23/2026 at 11:31 a.m. with the Director of Nursing (DON), Patient 7’s “Plan of Care (POC),” current as of 7/23/2026 was reviewed. The plan of care did not include a care plan in place to address Patient 7’s UTI. The DON confirmed no care plan was initiated for Patient 7’s UTI and stated the IDG should have initiated an infection or genitourinary care plan for Patient 7. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/6/2026, the P&P indicated, “The plan of care will be reviewed and revised as frequently as deemed necessary, but no less often than every 15 days, by the interdisciplinary group. Any change in the patient’s condition must result in a change in the plan of care.” 5. During a review of Patient 5’s “Face Sheet,” [undated], the face sheet indicated Patient 5 started hospice service on 12/6/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (progressive respiratory problem resulting to difficulty breathing). During a review of Patient 5’s “Physician Orders,” dated 7/17/2026, the physician orders indicated two newly prescribed medications, Docusate Sodium (anti-constipation medication used for problem with passing stool), 100 milligrams (mg), tablet, once daily and Miralax (anti-constipation medication), 17 grams, powder for solution as needed. During a concurrent interview and record review on 7/21/2026 at 11:25 a.m. with the Administrator (Admin), Patient 5’s “Interdisciplinary Group Plan of Care,” dated 1/30/2025 was reviewed. The plan of care indicated Patient 5’s occasional constipation issue was initiated on 12/6/2024 and was resolved on 1/30/2025. The Admin stated the plan of care should have been updated to reflect the newly ordered interventions to treat Patient 5’s constipation. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care,” dated 1/6/2026, the P&P indicated, “4. The plan of care will identify the patient’s needs and services to meet those needs, including… symptom relief… 9. The plan of care will be reviewed and revised as frequently as deemed necessary. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.””

“Based on interview and record review, the hospice agency failed to ensure frequency visits were conducted for three of 16 sampled patients (Patients 5, 13, and 11), according to the Interdisciplinary Group’s (IDG, multidisciplinary team composed of doctor, nurses, social worker, and chaplain who work with the patient and family to develop a coordinated comprehensive care plan), Plan of Care (POC, an individualized plan that provides direction on the type of care the patient needs) as follows: 1. Frequency visits from a skilled nurse (SN) and Hospice Aide (HA) for Patient 5. 2. Frequency visits from Hospice Aide (HA) for Patient 13. 3. Frequency visits from a skilled nurse (SN) for Patient 11. This failure resulted in missed visits and patients not receiving the care needed. 3. During a review of Patient 11’s “Face sheet (demographics),” [undated], the face sheet indicated Patient 11 had a primary diagnosis of Parkinsonism (a brain condition that causes tremors, muscle stiffness, and slow movement, signs of underlying). Further review of the face sheet indicated Patient 11 had started receiving hospice care on 9/11/2025 with an order for skilled nurse visit once a week and as needed. During a concurrent interview and record review on 7/23/2026 at 2:30 p.m. with the Director of Nursing (DON), the “Visits Calendar,” for the month of February 2026 was reviewed. The visits calendar indicated there was no visit by a skilled nurse for Patient 11 during the week of 2/1/2026 to 2/7/2026. The DON confirmed there was no skilled nurse visit and no documentation for that week. The DON further stated the visit was missed. During a concurrent interview and record on 7/23/2026 at 4 p.m. with the Licensed Vocational Nurse (LVN 3), the “Visits Calendar,” for the month of February 2026 was reviewed. The visit calendar indicated, there was no visit by a skilled nurse for Patient 11 during the week of 2/1/2026 to 2/7/2026. Further review of the visit calendar indicated Patient 11 was last visited by a registered nurse on 1/29/2026. LVN 3 confirmed, Patient 11 was not seen by a registered nurse. LVN 3 stated, she was responsible for creating the schedule of the staff visits based on the frequency ordered for the patients and the facility’s policy and procedures. During an interview on 7/24/2026 at 9:55 am with the Administrator (Admin), the Admin stated, it is part of our policy and procedure to check the visit schedule the week before/weekly, so no visits are missed. During a review of facility’s policy and procedure (P&P), titled “Staff Responsibilities,” dated 1/5/2026, the P&P indicated “The purpose was to establish a consistent process for creating, reviewing, confirming, and maintaining the weekly schedule of hospice visiting staff so that all ordered and planned services are assigned before the start of each week. This policy is intended to prevent missed, delayed visits, preserve continuity of care, and ensure that staffing assignments remain consistent with each patient’s current individualized plan of care. The Intake Coordinator and Registered Nurse Case Manager share responsibility for ensuring that a complete and workable staff schedule is in place for every active hospice patient before the next scheduling week begins. The intake coordinator is responsible for the administrative preparation, communication, tracking, and release of the schedule. The Registered Nurse Case Manager is responsible for clinical verification of visit frequencies, patient priorities, and changes affecting the plan of care.” Findings:1. During a review of Patient 5’s “Face Sheet,” [undated], the face sheet indicated Patient 5 started hospice service on 12/6/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (progressive respiratory problem resulting to difficulty breathing).During a review of Patient 5’s “Interdisciplinary Group-Plan of Care,” dated 12/19/2024, the plan of care indicated the following frequency visit: Hospice Aide (HA) three times a week and Skilled Nurse (SN) twice a week.During a review of Patient 5’s “Visit Calendar,” for the month of February 2025, the visit calendar indicated only one skilled nurse visit was conducted on 2/13/2025, for the week of 2/9/2025 to 2/15/2025. The visit calendar further indicated only one hospice aide visit was conducted on 2/27/2025, for the week of 2/23/2025 to 3/1/2025.During a review of Patient 5’s “Plan of Care,” dated 6/18/2026, the plan of care indicated the skilled nurse frequency visit of twice a week.During a review of Patient 5’s “Visit Calendar,” for the month of June 2026, the visit calendar indicated only one skilled nurse visit was conducted, on 7/2/2026, for the week of 6/28/2026 to 7/4/2026.During an interview on 7/21/2026 at 3:50 p.m. with the Director of Nursing (DON), the DON stated for Patient 5, there should have been two skilled nurse visits for the week of 2/9/2025 to 2/15/2025, and three hospice aide visits for the week of 2/23/2025 to 3/1/2025. DON further stated for Patient 5, there should have been two skilled nurse visits for the week of 6/28/2026 to 7/4/2026, per the interdisciplinary group plan of care.During a review of the facility’s policy and procedure (P&P) titled, “Hospice Nursing Care,” dated 1/5/2026, the P&P indicated, “The Case Manager will assure that components of the plan of care are established and implemented by the interdisciplinary group. The Case Manager will determine the scope and frequency of services needed based on acuity and patient and family/caregiver needs.” 2. During a review of Patient 13’s “Face Sheet,” [undated], the face sheet indicated Patient 13 started hospice service on 6/23/2026 with a primary diagnosis of End Stage Renal Disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant).During a review of Patient 13’s “Initial Interdisciplinary Group-Plan of Care,” dated 6/23/2026, the plan of care indicated the following frequency visit: Hospice Aide (HA) three times a week.During a concurrent interview and record review on 7/23/2026 at 3 p.m. with the Administrator (Admin), the “Hospice Aide Visit Notes,” for the month of June to July 2026 was reviewed. The visit notes indicated there was a missing hospice aide visit for the week of 6/23/2026 to 6/27/2026 and the week of 6/28/2026 to 7/4/2026. The Admin stated Patient 13’s plan of care for hospice aide visits was three times week and this should have been followed.During a review of the facility’s policy and procedure (P&P) titled, “Hospice Nursing Care,” dated 1/6/2026, the P&P indicated, “The Case Manager will assure that components of the plan of care are established and implemented by the interdisciplinary group. The Case Manager will determine the scope and frequency of services needed based on acuity and patient and family/caregiver needs.””

“Based on observation, interview, and record review, the hospice agency failed to ensure physician medication orders were reconciled (process of comparing a patient’s current medication list to their new medication orders), between the hospice agency and the assisted living facility (ALF) for one of 16 sampled patients (Patient 3). This failure had the potential for medication administration discrepancies between the hospice agency and the assisted living facility for Patient 3. Findings: During a review of Patient 3’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 3 had a diagnosis of senile degeneration of the brain (an umbrella term for a decline in mental function severe enough to interfere with daily life). An on-site visit was conducted on 7/22/2026 at 1:01 p.m., with the Licensed Vocational Nurse (LVN 1), at the assisted living facility where Patient 3 resided. During a concurrent interview and record review on 7/22/2026 at 2:17 p.m., with LVN 1 and the Medication Aide (Med Aide), Patient 3’s “Physician Orders,” for the month of March 2026 was reviewed. The physician orders indicated the following: The following medications were active on the hospice agency’s physician orders but not on the assisted living facility physician orders as follows:-Order date of 3/18/2026, Gentamicin Sulfate 0.1% (a prescription antibiotic medicine used to treat bacterial skin infection), topical ointment as needed for right leg wound.-Order date 3/18/2026, Gentamicin Sulfate 0.1% topical ointment, three times a week until healed for right leg wound.-Order date 3/18/2026, Santyl (a prescription medication used to remove dead tissue from chronic skin ulcers and severe burns), 250 unit/gram, topical ointment as needed every dressing change for wound care.-Order date 3/18/2026, Santyl 250 unit/gram, topical ointment three times a week or every wound treatment for right leg wound. The following medications were active on the assisted living facility’s physician orders but not on the hospice agency’s physician orders as follows:-Acetaminophen (pain medication), ER (extended release), 650 milligrams (mg), 1 tablet by mouth every 8 hours routinely for pain.-Order date 2/8/2025, Milk of Magnesia (medication for antacid and constipation, problems on passing stool), 30 milliliters every 8 hours as needed for constipation (passing hard stools). LVN 1 stated she had never used Gentamicin Sulfate 0.1%, nor the Santyl ointment for Patient 3’s wound care. The Med Aide stated there was no medication in stock for Gentamicin Sulfate 0.1% and Santyl ointment for Patient 3’s wound care. LVN 1 confirmed, that the hospice agency physician order’s for Patient 3 had no order for the Milk of Magnesia and Acetaminophen ER 650 mg. The Med Aide stated Patient 3 had been receiving Acetaminophen ER 650 mg, routinely every 8 hours. LVN 1 stated during each skilled nurse on-site visit, Patient 3’s medications should have been reviewed. LVN 1 further stated she had not reconciled Patient 3’s medication between what the hospice agency has versus what the assisted living facility has. During an interview on 7/23/2026 at 2:51 p.m., with the Director of Nursing (DON), the DON stated the Gentamicin Sulfate 0.1% and the Santyl ointment orders should have been discontinued for non-use. The DON further stated the Acetaminophen ER 650 mg, should have been discontinued at the assisted living facility on 6/25/2026. The DON stated the hospice agency’s skilled nurse staff should have reconciled the hospice agency’s physician orders and the assisted living facility’s physician orders for Patient 3 during every skilled nurse on-site visit. During a review of the facility’s policy and procedure (P&P) titled, “Administration and Documentation of Medications,” dated 1/5/2026, the P&P indicated, “Procedure 1. As part of the assessment process, a drug history will be taken and a comparison made between the physician’s (or other authorized independent practitioner’s) orders and the current medication the patient is taking. Any discrepancies or contradictions should be reported to the physician for resolution.””

“Based on observation, interview, and record review, the hospice agency failed to follow infection prevention practices when the Hospice Aide (HA) did not implement Enhanced Barrier Precautions (EBP, infection prevention measures used to decrease the spread of infections for residents of a skilled nursing facility), for one of 16 sampled patients (Patient 1). This failure had the potential to result in the spread of infectious diseases to medically vulnerable patients such as Patient 1. Findings:During a review of Patient 1’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 1 started receiving care on 6/3/2026 with the diagnosis of senile degeneration of brain (progressive loss of memory and thinking capability) and resided in a Skilled Nursing Facility (SNF).During a review of Patient 1’s “Comprehensive Assessment,” dated 6/3/2026, the assessment indicated Patient 1 had a foley catheter (tubing inserted into bladder to assist with urinal voiding).During an observation on 7/21/2026 at 8:20 a.m. by Patient 1’s room, there was an EBP sign posted by the door above Patient 1’s name that instructed “Providers & Staff” to “wear a gown and gloves during resident care activities” which included “bathing” and “changing incontinence briefs.”During a concurrent observation and interview on 7/21/2026 at 8:24 a.m. with the HA in Patient 1’s room, HA bathed and changed the incontinence brief for Patient 1 while not wearing a gown. Patient 1 had a foley catheter. HA stated she did not have to wear a gown while giving a bed bath or cleaning Patient 1.During an interview on 7/21/2026 at 9:12 a.m. with the HA, the HA stated she had never heard or been trained on EBP and was unsure if it applied to her.During an interview on 7/21/2026 at 9:36 a.m. with the Registered Nurse (RN 1) from the SNF, RN 1 stated all health-care providers including hospice staff should follow the EBP sign posted in front of Patient 1’s door. RN 1 stated Patient 1 was on EBP because of his foley catheter.During an interview on 7/21/2026 at 2:13 p.m. with the Director of Nursing (DON), the DON stated he was not aware of EBP protocols but that the hospice staff visiting a patient residing at a SNF should follow the instructions on the EBP sign posted at the door. The DON further stated it was important to follow infection control precautions in place for patients because they wanted to protect their staff and other patients and they did not want to spread infection into the community.During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention/Control,” dated 1/6/2026, the P&P indicated, “Agency will observe the recommended precautions for hospice care as identified by the Centers for Disease Control and Prevention (CDC). The goal was to ensure employee and client safety and to reduce the risk of transmission of microbes from both recognized and unrecognized sources of infection.”During a review of the Centers for Disease Control and Prevention (CDC) guidance titled, “Implementation of Personal Protective Equipment (PPE, equipment to prevent the spread of infection such as gown and gloves) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MRDOs),” dated 7/12/2022, the guidance indicated, “CDC expanded residents for whom EBP applies to include any resident with an indwelling medical device. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.””

“Based on observation, interview, and record review, the hospice agency failed to provide infection control education for three of three employees (Hospice Aide [HA], HA 2 and HA 3), regarding Enhanced Barrier Precautions (EBP, infection prevention measures used to decrease the spread of infections for residents of a skilled nursing facility [SNF]).This failure had the potential to result in the spread of infectious diseases to medically vulnerable patients such as Patient 1. Findings:During a review of Patient 1’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 1 started receiving care on 6/3/2026 with a diagnosis of senile degeneration of the brain (progressive loss of memory and thinking capability) and resided in a skilled nursing facility.During a review of Patient 1’s “Comprehensive Assessment,” dated 6/3/2026, the assessment indicated Patient 1 had a foley catheter (tubing inserted into bladder to assist with urinal voiding).During an observation on 7/21/2026 at 8:20 a.m. by Patient 1’s room, there was an EBP sign posted by the door above Patient 1’s name that instructed “Providers & Staff” to “wear a gown and gloves during resident care activities” which included “bathing” and “changing incontinence briefs.”During a concurrent observation and interview on 7/21/2026 at 8:24 a.m. with the HA in Patient 1’s room, HA bathed and changed the incontinence brief for Patient 1 while not wearing a gown. Patient 1 had a foley catheter. HA stated she did not have to wear a gown while giving a bed bath or cleaning Patient 1.During an interview on 7/21/2026 at 9:12 a.m. with the HA, the HA stated she had never heard or been trained on EBP and was unsure if it applied to her.During an interview on 7/21/2026 at 9:36 a.m. with the Registered Nurse (RN 1) from the SNF, RN 1 stated all health-care providers including hospice staff should follow the EBP sign posted in front of Patient 1’s door. RN 1 stated Patient 1 was on EBP because of his foley catheter.During an interview on 7/21/2026 at 2:13 p.m. with the Director of Nursing (DON) and the Administrator (ADMIN), the DON and ADMIN confirmed they were not aware of EBP protocols for patients that resided in SNFs and have not included EBP in their infection control trainings for employees. The ADMIN stated they should have EBP in their training for staff so the staff know what to do when they visit patients that reside at a SNF.During a review of three employee files for HA, HA 2, and HA 3, there was no infection control education provided on EBP for the three employees.During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention/Control,” dated 1/6/2026, the P&P indicated, “Agency will observe the recommended precautions for hospice care as identified by the Centers for Disease Control and Prevention (CDC). The goal was to ensure employee and client safety and to reduce the risk of transmission of microbes from both recognized and unrecognized sources of infection.”During a review of the Centers for Disease Control and Prevention (CDC) guidance titled, “Implementation of Personal Protective Equipment (PPE, equipment to prevent the spread of infection such as gown and gloves), Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MRDOs),” dated 7/12/2022, the guidance indicated, “CDC expanded residents for whom EBP applies to include any resident with an indwelling medical device. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.””

“Based on interview and record review, the hospice agency failed to verified staff credentials and authorize a Licensed Vocational Nurse (LVN 4), contracted with the staffing agency, prior to visit assignments conducted for three of four sampled patients (Patients 14, 15, and 16).This failure had the potential to compromise patient safety. Findings: During a review of Patient 14’s “Face Sheet,” [undated], the face sheet indicated Patient 14 started hospice services on 5/28/2026 with a primary diagnosis of Alzheimer’s disease (progressive brain disorder that destroys memory and thinking skills).During a review of the “Progress Note,” from the assisted living facility, dated 6/4/2026, the progress note indicated LVN 4 provided Patient 14’s hospice care and services on behalf of the agency. During a review of Patient 15’s “Face Sheet,” [undated], the face sheet indicated Patient 15 started hospice service on 6/21/2026 with a primary diagnosis of Parkinsonism (medical term for a group of movement symptoms—specifically slow movement, muscle stiffness, and shaking).During a review of the “Progress Note,” from the assisted living facility, dated 6/27/2026, the progress note indicated LVN 4 performed assessment and wound care on Patient 15.During a review of Patient 16’s “Face Sheet,” [undated] the face sheet indicated Patient 16 started hospice service on 9/3/2025 with a primary diagnosis of Chronic Kidney Disease-Stage four (kidneys are moderately or severely damaged and are not properly filtering waste from your blood).During a review of the “Progress Note,” from the assisted living facility dated 6/5/2026, the progress note indicated LVN 4 provided hospice service to Patient 16 on 6/4/2026.During an interview on 7/22/2026 at 4:28 p.m. with the Director of Nursing (DON), the DON stated he does not know LVN 4 because LVN 4 was not on the authorized staffing list from the third-party staffing agency.During an interview on 7/23/2026 at 11:31 a.m. with the Administrator (Admin), the Admin stated he does not know LVN 4 and has not verified her credentials. The Admin further stated LVN 4 was not authorized to provide hospice care and services to patients on behalf of the facility.During a review of the facility’s policy and procedure (P&P) titled, “Written Agreements for Contracted Services,” dated 1/5/2026, the P&P indicated, “These contracted services will be defined by a written agreement before individuals from that source will be permitted to provide services on behalf of the organization. Hospice will maintain responsibility for the services provided under arrangements to ensure that they are provided in accordance with hospice standards and the patient’s Plan of Care.””

“Based on interview and record review, the hospice agency failed to document clinical notes in a timely manner for one of 16 sampled patients (Patient 7).This failure had the potential to result in inaccurate patient records that could lead to missed or delayed interventions and treatments. Findings:During a review of Patient 7’s “Face Sheet (demographics),” [undated], the face sheet indicated Patient 7 had a diagnosis of Alzheimer’s disease (progressive memory loss, worsening thinking skills, and behavior changes).During a review of Patient 7’s “Physicians Orders,” dated 2/6/2026, the physician order indicated the frequency of visits by a Skilled Nurse (SN) twice a week and as needed for pain and symptom management.During a review of Patient 7’s “Assisted Living Facility Sign-in Sheet,” a skilled nurse visited Patient 7 on 6/8/2026 and on 7/8/2026During a concurrent interview and record review on 7/23/2026 at 11:31 a.m. with the Director of Nursing (DON), Patient 7’s “Visit Notes,” dated June to July 2026, were reviewed. The notes indicated only one visit note on 6/10/2026 was documented by a skilled nurse for the week of 6/7/2026 to 6/13/2026. The notes indicated only one visit note on 7/6/2026 was documented by a skilled nurse for the week of 7/5/2026 to 7/11/2026. The DON stated the nurses failed to complete their documentation within seven days after their visits per their policy. The DON stated it was important to document in a timely manner to ensure the Patient 7’s chart was accurate and for the team to be informed of the status of Patient 7. During a review of the facility’s policy and procedure (P&P) titled, “Human Resource,” dated 1/6/2026, the P&P indicated, “All notes must be…Timely: Documentation should be completed and submitted within 7 days of service provision.””