Gulfside Hospice, Inc.

“Based on record review, the grievance and incident log, and interviews, the hospice provider did not document a voiced grievance for 1 (Patient #3) of 6 sampled patients and their caregivers about the lack of services during an acute situation. Findings included:Review of the hospice provider’s complaint/reportable/incident log from December 2025 to June 2026 showed one complaint/grievance was documented on 5/29/26 for Patient #3. The log showed on 1/27 many calls were made concerning Patient #3s respirations, begging for oxygen (O2), vomiting, almost no urine output, and “no one gave a crap to return call”. The follow up, on 6/8/26, showed Staff E, Clinical Care Manager (CCM) reported the caregivers’ issues were previously addressed and the caregiver was having “complicated grieving and declining offers for support” and “it is documented that staff could not reach primary caregiver (PCG) upon numerous attempts to return her”. The CCM documented the protocol was followed in this situation. Social work and nursing CCM’s both made follow up (f/u) calls to attempt to explore ways to assist PCG and make (pronoun) feel heard.”Review of Patient #3s face sheet revealed a start of care date of 10/1/25 and discharge date of 1/27/26. The principal diagnosis was unspecified severe protein-calorie malnutrition and other pertinent diagnoses were not limited to unspecified chronic obstructive pulmonary disease, and unspecified heart failure. The face sheet showed the emergency contact and primary caregiver was the patient’s spouse and included one phone number and an email address.Review of the Triage Communication Note dated 2/11/26 at 4:08 p.m. showed the PCG called to “file formal complaint she is furious wanted emails and full names of staff, writer advised manager will follow up to receive complaints once available. Reports no follow up since patient death and is irate on the phone. Requesting callback as soon as possible. Team notified.”Review of Miscellaneous Communication Note dated 2/12/26 (Thursday) at 10:49 a.m. showed Staff E, CCM returned call to PCG who sounded like (pronoun) was sleeping. “Asked if (pronoun) would like a call later in the day, or tomorrow advising writer has a meeting grom 2-5 pm today. (PCG) asked that writer returns call prior to 2 pm meeting.” The next note was dated 2/17/26 (Tuesday) at 3:40 p.m. created by Staff E revealed “Attempted to reach back out to PCG at this time due to PCG preferring later time in the day for calls. Unable to reach (PCG), left message for (pronoun) to call back when (pronoun) is available.” The call on 2/17/26 was made 5 days after the PCG requested for Staff E to return call later in day (on 2/12/26).Review of Triage note showed on 2/17/26 at 3:52 p.m. Patient #3s PCG returned Staff E’s call, and the staff member was not available. “PCG became increasingly upset reporting the CCM called exactly 1 minute prior to (pronoun) calling back and is reporting no one is following up or calling appropriately and calling from a private number and is very upset. Writer advised team to be notified for follow up. Team notified”. A note dated 2/17/26 at 5:08 p.m. showed Staff E attempted to return call and received voicemail.An interview was conducted on 6/30/25 at 10:05 a.m. with the Director of Quality and Accreditation (DQA) and the Chief Operating and Business Innovations Officer (COB). The DQA stated the grievance from the Patient #3s PCG had resulted from a survey, and Staff E had reached out multiple times only able to get a hold of the PCG one time and (pronoun) was sleeping wanting Staff E to call back later. Review of the note on 2/11/26 which the DQA stated was a missed opportunity to file a complaint and whoever logged the call should have logged the complaint. The DQA stated there was an opportunity for improvement in documentation and re-education of the management team to ensure documentation of attempts in communication.Review of the policy, Complaint and Grievance Procedure, published on 11/15/21, revealed its purpose was “To set forth guidelines for the resolution of complaints and grievances to ensure that all patients, families, caregivers, and all other individuals receive the appropriate care, treatment, and services, are treated with dignity and respect, and are completely satisfied with their experience.” The policy showed “patients, family/ caregivers or patient representatives may freely voice and/ or submit complaint/ grievances without being subject to cohesion, discrimination, reprisal, or unreasonable interruption of care, treatment or services.” “An incident report will be completed by a Gulfside Healthcare Services employee when a complaint/ grievance is received as appropriate.”The procedure instructed the following:1. If a patient, caregiver, representative, or other individual expresses a complaint or grievance to any GHS representative and the staff person or other staff members immediately available are able to resolve the complaint or grievance to the patient, caregiver, representative or other individuals’ satisfaction, the complaint or grievance is then considered resolved and no further action is required.2. If the complaint or grievance cannot be resolved to the person’s satisfaction the GHS staff person will immediately notify their manager or director. The manager and/or director or designee will document the complaint or grievance via the incident reporting system.3. Upon receipt of an incident report the compliance department will review for completeness. If any additional information is needed or additional actions need to be taken in response to the incident, the compliance department will reach out to the appropriate sorry for further completion.4. The compliance department will notify executive leadership of any incident reports received that are urgent, high risk, or of other importance that they should be aware of.5. Incident reports will be kept in the incident database will be tracked and trended to identify possible improvement opportunities. This information will be reported to leadership at least annually.”

“Based on record review, facility documents, interviews, and the facility’s policy, the facility did not thoroughly investigate an alleged abuse incident involving one (#1) patient of 1 patients sampled. Findings included: Review of Patient #1s face sheet revealed the start of care date of 10/24/24. The diagnoses revealed the 93 year old patient’s principal diagnosis was unspecified Alzheimer’s disease and included type 2 diabetes mellitus without complications, full incontinence of feces, unspecified urinary incontinence, and adult body mass index (BMI) 25.0-25.9. The patient resided in a memory care unit of a healthcare facility. Review of Patient #1s orders showed the hospice was to provide skilled nursing visits one (1) time a week for nine (9) weeks and aide visits twice (2) a week for nine (9) weeks. Review of the provider’s incident/complaint/grievance log showed an “Unanticipated Event” had occurred on 12/30/25 with Patient #1. The log showed on 12/30/25 Staff C, Case Manager/Nurse Supervisor (CCM) received a call at 11:36 a.m. from the Director of Nursing (DON) of Patient #1s residence. The log did not include a full description of the conversation between the CCM and DON. An investigation follow up by the provider’s Director of Patent Care Services (DPCS) on 2/26/26 showed the Department of Children and Families (DC) and police were involved in the investigation. “Police found that the incident involved the facility staff being resentful towards (Staff A). DCF performed their own investigation, nursing staff does not have access to the report. Nothing else needed to…”. The follow up action plan documentation showed the DPCS on 2/26/26 wrote “Once DCF completed their official investigation, (Staff A) was returned to work after being off with pay until investigation was completed. (Staff A) was moved to a different facility so that there was no further interaction with (Patient #1 residence) staff.” Review of the visit management for Patient #1 showed Staff A had visited the patient on 12/30/25 from 9:30-10:30 a.m. and Staff B had visited from 10:15-10:45 a.m. Review of Staff As visit note, on 12/30/25 showed the aide had assisted Patient #1 from 9:30 to 10:30 a.m. The documentation revealed the aide had completed shampoo, incontinent care, assist with dressing, skin care, and bath with shower chair. The note showed the patient had discolorations to hands, skin was intact, and “Patient was combative she was hitting and and biting the patient bite my hand, hit and scratched me when I was behind her giving a shower. (Unknown person) was holding (patient pronoun) hands up so I could get to wash under (patient pronoun) arms. I reported it to nurse (Staff B).” Review of Staff Bs visit note on 12/30/26 at 3:18 p.m. showed a new order was obtained to increase Lorazepam twice weekly on shower mornings only to 0.75 milligram (mg). The note showed Patient #1 was sitting in wheelchair in the common area of memory care unit “upon arrival having just finished with a shower”. The note showed the patient was withdrawn and told the staff member “just leave me alone”. The provider aide reported the patient “was combative and aggressive with shower today and it took assist x3 for shower to be completed”. The note showed Staff B had discussed medications, safety and fall precautions, and to contact the hospice provider should any questions or needs arise with the facility’s staff member and Wellness Director. Review of the incident report, provided by the Director of Quality and Accreditation (DQA), revealed an “Other Unanticipated Event” had occurred on 12/30/25 at 11:36 a.m. (neither Staff A or B were documented as being at facility at that time) with Patient #1 and staff member. A. The person reporting the incident was Staff C, Assistant DPCS. The report showed on 12/30/25 at 11:36 a.m. the DPCS received a call from the Director of Nursing (DON) of Patient #1s residence. The DPCS reported the Wellness Director had been notified by the facility staff that Staff A “hit” the patient (pt) causing bruising and pt saying “Ow!” so an x-ray was needed. The Wellness Director reported not wanting Staff A back to the facility. Staff C and the DPCS contacted Staff A and requested to remove self from the facility and to come to the office. Upon arriving at the East Clinical office (ECO) the staff member reported asking two facility staff members to assist with bathing due to the patient’s combativeness. The facility staff members informed Staff A of not believing the patient had been pre-medicated before wheeling the patient into the shower where the pt became combative by “flailing (pronoun) arms around and grabbing, scratching and digging (pronoun) fingernails into (staff member pronoun). Staff A reported one facility staff member was standing behind the pt due to the pt trying to lay back and the other staff member was holding the pt’s arms up by holding both forearms so Staff A could wash under arms. Staff A reported moving to the pt’s back side and asked the facility staff member to step to the side as the staff member “was becoming frightened due to the patient being combative”. As the staff member “began to wash (patient pronoun) back side, the patient leaned down and bit (Staff A) right arm and dug (patient pronoun) fingernails into (Staff A) arm.” Staff A removed arm from the patient’s mouth by “moving (pronoun) mouth off (pronoun) arm to avoid the patient from breaking (pronoun) skin.” The incident report showed a facility med tech arrived “due to the patient hollering” and asked one of the staff to leave the patients room to go assist with another patient, acknowledging it took 3 persons to assist the patient with personal care. Staff A reported leaving the patient at the med cart per facility request and updated Staff B of the occurrence as the staff member was communicating with the med tech. Staff A reported notifying staff, having a brief conversation (not reported with whom), and left with no staff members mentioning the patient being hit and discoloration on patient’s arms prior to visit. The report showed there were no witnesses to the event. The follow up investigation details on 2/26/26 at 9:04 a.m. (58 days after the incident), showed the DPCS documented the “DCF and police were in involved in the investigation. Police found the incident involved the facility staff being resentful towards (Staff A). DCF performed their own investigation, nursing staff does not have access to the report. Nothing else needed to be added to the initial report.” The action plan showed on 2/26/26 at 9:05 a.m. the DPCS documented “Once DCF completed their official investigation, (Staff A) was returned to work after being off with pay until investigation was completed. (Staff A) was returned to work after being off with pay until investigation was completed. (Staff A) was moved to a different facility so that there was no further interaction with (Patient #1 facility) staff member.” The follow up notes by the DQA on 1/9/26 at 4:17 p.m. showed the DCF investigator and law enforcement were reported to have interviewed Staff A per Staff D, Human Resources Generalist. Staff D reported a conversation was had with Staff A and Staff C. The conversation revealed:1. The sheriff deputy had advised Staff A if (pronoun) believed Staff A had committed the alleged action the staff member would be taken into custody immediately and believed the complaint “maybe” a personal vendetta. DCF investigator “reportedly” reinforced this belief during the interview. (Law Enforcement and DCF performed separate interviews with Staff A).2. The incident occurred at Patient #1s residence facility.3. Patient had feces on back and Staff A provided shower. A facility employee preferred the patient receive a bed bath instead.4. During care patient bit Staff A. (At time of conversation a red mark was observed and photographed).5. The DPCS was informed by the Wellness Director that facility staff alleged Staff A had struck the patient.6. Staff A clarified moving the patient’s face “gently” away from arm to prevent further biting while verbally redirecting the patient.7. Staff A reported having a prior incident with the believed complainant.The incident report showed the DQA had requested records from the sheriff office and DCF. The report showed on 1/6/25 the CCM had received call from DCF investigator informing of the closure of case and it would be referred to the state attorney’s office. The report showed on 1/30/26 the DCF findings were substantiated and escalation to state attorney. A request was made with the Wellness Director for medical records on 2/2/26 as there was “conflicting information” with the deputy and DCF reports. The provider closed the incident on 5/21/26 as medical records were not received and no escalation to the state level. “Will close IR”. The hospice provider was unable to provide a written statement from Staff A. The documentation did not show any other hospice staff member or the Wellness Director was further interviewed regarding the allegation. Review of Patient #1s care plan included the problems:Facility Joint Plan of Care – Nursing. The interventions instructed staff to assess for history of falls and the facility staff were to notify hospice provider of any falls or injuries, assessment of pain with facility staff notifying hospice of increased and/or uncontrolled pain, elimination, notification by facility of any signs of urinary tract infection and any new skin breakdown.Activities of Daily Living (ADLs) included the intervention of “Hygiene – Bath – Bed if patient refuse shower, start date 10/14/25.The review of Patient #1s care plan on 6/29/26 did not reveal the patient exhibited or had a history of any behaviors. An interview was conducted with the DQA on 6/29/26 at 12:14 p.m. The DQA provided the incident/reportable/grievance log, stating the one log contained incidents and grievances and the provider did not have any reportable incidents. A continued interview was conducted on 6/29/26 at 3:16 p.m. with the DQA. The DQA stated the DCF and sheriff came together to the ECO on 12/30/25 at 10:00 a.m. and interviewed Staff A. Staff D interviewed Staff A on 12/30/25, the incident report does not record what time the interview was conducted, regarding an incident occurring when showering Patient #1 who was known to have aggression and should have been pre-medicated prior to ADLs. The DQA reported during care the patient bit Staff A on the arm which was reddened but the skin was not broken. Staff C was notified by the Wellness Director that Staff A struck the patient when bitten. Staff A had informed law enforcement of gently moving the patient’s face away from arm to keep away and redirected not to bite. The staff member was removed from duty. The DQA stated the hospice investigation showed the DCF and sheriff report did not correlate and the DCF investigator had informed the DPCS that staff should allow the patient to continue to bit and not push them away. The DQA stated they investigated with the Human Resource team and waited for the DCF and sheriff reports. The DQA stated the HR department interviewed Staff A and the provider had reached out to their legal department based on the DCF and sheriff report. The DQA stated Staff A was interviewed with Staff C, who had not been at the facility, the staff member had been by self. The DQA stated Staff C had spoken with the Wellness Director who reported Staff A had hit the patient. The interview continued with the DQA reporting Staff A was right-handed, admitted to not knowing where the staff member was positioned when bitten on the right arm as the staff member washed the patient’s ‘back side”, and Staff B was not interviewed as the registered nurse hadn’t been there. Reviewed with the DQA of documentation showing Staff A had informed Staff B of the incident as the nurse was sitting with the facility med tech and Staff B had documented arriving at the facility as the patient, had just finished shower. During an interview on 6/29/26 at 3:46 p.m. the DQA stated the provider did not report the incident to the Agency for Healthcare Administration (AHCA) and this incident was an allegation of abuse. During an interview on 6/30/26 at 11:00 a.m. the DQA and the Chief Operating and Business Innovations Officer (COB) did not respond with the meaning of a staff member continuing care when a patient was physically refusing. Review of the policy – Abuse, Neglect, Abandonment, Mistreatment, and Exploitation, published on 10/26/21, revealed its purpose was “To provide guidelines for identification of suspected abuse, neglect/ self-neglect, abuse, abandonment or exploitation of all patients.” “The organization will ensure all federal and state reporting requirements, including mandated reporting requirements set forth in chapter 415 of Florida statutes, concerning abuse, neglect, abandonment, mistreatment or exploitation are followed including, but not limited to, reporting requirements related to:1. Knowledge or reasonable suspicion by any person of the abuse, neglect, or exploitation of a vulnerable adult.3. Alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of Hospice or by any one related to hospice.The definitions section defined:1. Abuse: The intentional and non-therapeutic infliction of pain, injury, or any persistent course of conduct intended to produce mental or emotional distress.The procedures showed:4. The immediate supervisor, clinical administrator/ manager and/ or the director of clinical social work services shall promptly coordinate an investigation regarding the alleged violation and direct employee, intern, or volunteer to contact the abuse hotline to make a verbal report.5. If the allegation is verified, Gulfside Hospice Services (GHS) staff will work with the appropriate state and local bodies having jurisdiction (inclusive but not limited to law enforcement, Department of Children and families (DCF) and/ or adult Protective Services (APS) and/ or Agency for Healthcare Administration (AHCA) to ensure the appropriate corrective action is taken in safety of patient assured.7. All involved clinical staff will document interventions in the patient’s medical record. Findings included:Review of Patient #1s face sheet revealed the start of care date of 10/24/24. The diagnoses revealed the 93-year-old patient’s principal diagnosis was unspecified Alzheimer’s disease (an irreversible, progressive brain disorder and the most common cause of dementia) and included type 2 diabetes mellitus(a chronic condition where your body either doesn’t make enough insulin or resists it) without complications, full incontinence (the unintentional or involuntary loss of control over your bladder (urinary incontinence) or bowels (fecal incontinence) of feces, unspecified urinary incontinence, and adult body mass index (BMI) 25.0-25.9. The patient resided in a memory care unit of a healthcare facility.Review of Patient #1s orders showed the hospice was to provide skilled nursing visits one (1) time a week for nine (9) weeks and aide visits twice (2) a week for nine (9) weeks.Review of the visit management for Patient #1 revealed Staff A visited Patient #1 on 12/30/25 from 9:30-10:30 a.m. and Staff B had visited from 10:15-10:45 a.m.Review of “Aide Visit Note”, dated 12/30/25 09:30 a.m.- 10:30 a.m. signed by Staff A, CNA (certified nursing assistant) revealed Patient #1 received assistance with shampoo, incontinent care, assist with dressing, skin care, and bath with shower chair. Patient #1 had discolorations to hands and skin was intact. “Patient was combative; she was hitting and biting. The patient bit my (Staff A, CNA) hand, hit and scratched me (Staff A, CNA) when I was behind her giving a shower. Another staff member was holding her hands up so I could get to wash under her arms. It was reported to Staff B, RN (registered nurse).”Review of Interdisciplinary Communication Note dated 12/30/2025 3:18 p.m. signed by Staff B, RN revealed new order was obtained to increase Lorazepam (slows brain activity to promote relaxation) twice weekly on shower mornings only to 0.75 milligram (mg). Patient #1 was sitting in wheelchair in the common area of memory care unit “upon arrival having just finished with a shower”. Patient #1 was withdrawn and stated, “just leave me alone”. Staff A, CNA reported Patient #1 “was combative and aggressive with shower today and it took assist x3 for shower to be completed”. Staff B, RN had discussed medications, safety and fall precautions, and to contact the hospice provider should any questions or needs.Review of the incident report, provided by the DQA (Director of Quality and Accreditation), revealed an “Other Unanticipated Event” dated 12/30/25 at 11:36 a.m. involving Patient #1 and Staff A, CNA. The person reporting the incident was Staff C, Assistant DPCS (Director of Patient Care Services). The report gave a brief description of the event including the mention of 3 staff members from Patient #1’s residence. It was also documented there were “no witnesses” to the event. Quality/Compliance review was due on 01/04/2026 and status marked “complete” and follow up required.On 01/09/2026 at 4:17 p.m., a note entered by the DQA revealed DCF (department of children and family) and law enforcement present to interview Staff A, CNA. DCF and law enforcement both stated, “Staff A, CNA was the subject of the allegation and investigation.” No information was provided following both DCF and law enforcement interviews and Staff A, CNA was placed on suspension with pay; phone and access badge was retained until suspension was concluded. At 4:18 p.m., DCF called and reported the case was substantiated and submitted to state attorney office.On 01/22/2026 at 1:54 p.m., DQA spoke with DCF for additional documentation.On 01/30/2026 at 12:36 p.m., DCF report obtained with substantiated findings and escalation to state attorney.On 02/02/2026 at 12:38 p.m., DQA spoke with DON at Patient #1 residence requesting medical record since DCF and law enforcement report have conflicting information.On 05/21/2026 at 2:31 p.m., DQA documented no medical record received and no escalation to state level investigation. Will close case.Review of facility electronic mail dated 01/23/2026 at 3:19 p.m. from COO (Chief Operating Officer), revealed “Based on the information from law enforcement report and the DCF review, which was closed, Staff A, CNA may return to work. While the DCF report indicates a referral to the State’s attorney office, we have not received any request from that office. Law enforcement report indicates no findings and that he felt that Staff A, CNA, was trying to defend herself from a patient bite. I recommend that Staff A, CNA not be given assignments in the facility where the incident occurred.Review of facility training certificates revealed last education “Identifying and Addressing Older and Dependent Adult Abuse” completed by Staff A, CNA was dated 09/26/2024. No education was provided or recommended prior to return to work.During an interview on 6/29/26 at 12:14 p.m., the DQA stated on 12/30/25 at 10:00 a.m. DCF and law enforcement came together to the facility and interviewed Staff A, CNA. HR (human resources) then interviewed Staff A, CNA on 12/30/25 (there is no recorded time the interview took place). Staff A, CNA was removed from duty. The DQA stated they investigated with HR and waited for the DCF and law enforcement reports. The DQA stated HR had reached out to their legal department based on the DCF and law enforcement report. Staff B, RN was not interviewed as she had not been in Patient #1 residence at the time.During an interview on 6/29/26 at 3:46 p.m. the DQA stated HR interviewed Staff C, CCM and Staff A, CNA together. At which that time they suspended Staff A, CNA. They reviewed the note from Staff C, CCM and found no issues. Did not interview any other facility staff members.Review of the policy – Abuse, Neglect, Abandonment, Mistreatment, and Exploitation, published on 10/26/21, revealed its purpose was “To provide guidelines for identification of suspected abuse, neglect/ self-neglect, abuse, abandonment or exploitation of all patients.” “The organization will ensure all federal and state reporting requirements, including mandated reporting requirements set forth in chapter 415 of Florida statutes, concerning abuse, neglect, abandonment, mistreatment or exploitation are followed including, but not limited to, reporting requirements related to:1. Knowledge or reasonable suspicion by any person of the abuse, neglect, or exploitation of a vulnerable adult.3. Alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of Hospice or by any one related to hospice.The definitions section defined:1. Abuse: The intentional and non-therapeutic infliction of pain, injury, or any persistent course of conduct intended to produce mental or emotional distress.The procedures showed:4. The immediate supervisor, clinical administrator/ manager and/ or the director of clinical social work services shall promptly coordinate an investigation regarding the alleged violation and direct employee, intern, or volunteer to contact the abuse hotline to make a verbal report.5. If the allegation is verified, Gulfside Hospice Services (GHS) staff will work with the appropriate state and local bodies having jurisdiction (inclusive but not limited to law enforcement, Department of Children and families (DCF) and/ or adult Protective Services (APS) and/ or Agency for Healthcare Administration (AHCA) to ensure the appropriate corrective action is taken in safety of patient assured.7. All involved clinical staff will document interventions in the patient’s medical record.”

“Based on medical record review and interviews, the facility failed to provide care in accordance with the patient’s established plan of care by failing to ensure ordered nursing and home health aide visits were completed or appropriately documented when missed in 1 (Patient #4) of 1 patient samples. Findings included: Review of the clinical record for Patient #4 revealed the physician ordered plan of care included skilled nursing visits one time per week and home health aide (HHA) visits two times per week. Record review of scheduled visits from 5/26/2026, through 6/25/2026 showed:One scheduled HHA visit on 6/4/2026 was missed. The patient record did not contain a reason for the missed visit.Record review of scheduled visits from 3/26/2026 through 5/24/2026 showed five missed scheduled visits:A scheduled skilled nursing visit on 5/25/2026 was missed. The patient record did not contain a reason for the missed visit.A scheduled HHA visit on 5/21/2026 was missed. The patient record did not contain a reason for the missed visit.A scheduled HHA visit on 4/30/2026 was missed. Patient record documented patient was unavailable.A scheduled HHA visit on 4/22/2026 was missed. Patient record documented patient was unavailable and included a comment that patient had a physician appointment that day.A scheduled HHA visit on 4/20/2026 was missed. The patient record did not contain a reason for the missed visit. During an interview on 6/30/2026 at 11:35 a.m., the Director of Quality stated that neither the director or the office nurse manager was aware of any missed visits and will follow up. The DQA stated hospice does not have a policy for missed visits.”

“Based on medical record review, interviews and facility policy, the hospice provider failed to develop an individualized plan of care related to a history and ongoing exhibited behaviors for 1 (Patient #1) of 4 sampled patients. Findings included: Review of Patient #1s face sheet showed the patient’s start of care date was 10/24/24 and included the principal diagnosis of unspecified Alzheimer’s disease ((an irreversible, progressive brain disorder and the most common cause of dementia). The other pertinent diagnoses included but not limited to unspecified severity Dementia (decline in memory, reasoning, and communication—that is severe enough to impair daily life ) and other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (feelings of apprehension or dread). Review of Patient #1s medication orders showed the resident was receiving:Depakote sprinkles 125 milligram (mg) delayed release – 2 capsules three times a day for mood.Seroquel 100 mg tablet twice a day at 5:00 a.m. and 5:00 p.m. for mood.Seroquel 50 mg tablet once a day at 11:00 a.m. for moodLorazepam 0.5 mg tablet – take 0.75 mg twice a week on shower mornings only for anxiety.Sertraline 50 mg once a day for mood. Review of Patient #1s communication notes showed a note written on 12/12/25 at 1:02 p.m. by Staff B, Registered Nurse (RN) revealing a palliative performance scale (PPS) of 40%. The note revealed the patient no longer recognized family member pictures, speech was garbled and nonsensical at times and exhibited increased agitation and combativeness with care/showers “as evidenced by patient spitting at hospice aide and tearing (aide pronoun) shirt.” Pt is resistant to following directions”. Review of Patient #1s Interdisciplinary Communication Note, dated 12/30/25 at 3:18 p.m. showed Staff B, RN reported Staff A, Certified Nursing Assistant (CNA) had reported the patient was combative and aggressive with shower and took 3 aides to assist the resident with the shower. An order was received to increase lorazepam to 0.75 mg twice weekly on shower mornings. Review of Patient #1s Interdisciplinary Communication Note, dated 1/8/26 at 12:30 p.m. showed Staff B, RN documented the patient had been reported to having increased agitation/combativeness at night with an increase of the 5:00 p.m. dose of Seroquel. A review was conducted on 6/29/26 which showed the Patient’s behavior of aggression and combativeness was not included as well as the use of psychotropic medications. During an interview on 6/30/26 at 11:00 a.m. the Director of Quality and Accreditation (DQA) and the Chief Operating and Business Innovations Officer (COB) stated the care plan should include behaviors. The DQA reported having informed the team to include the intervention to make sure Patient #1 was medicated prior to Activities of Daily Living (ADL) care. Review of the policy – The Plan of Care, published 8/20/25, revealed its purpose was “To ensure that an individualized plan of care is developed for each patient that complies with the Hospice conditions of participation, payment, and other guidelines.” The policy revealed “An individualized written plan of care (POC) will be developed for each patient. The POC will reflect the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The planner care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:drugs and treatment necessary to meet the needs of the patient. Umminterventions to manage pain and symptoms.The interdisciplinary group (IDG) will review, revise, and document the individualized plan as frequently as needed, but no less than every 15 calendar days. Revisions to the plan of care will include information from the patients updated comprehensive assessment and note the patient’s progress towards outcomes and goals specified in the POC.”

“Based on facility website, medical record reviews, interviews and facility policy, the hospice provider failed to provide care and services per individualized plan of cares and hospice philosophy’s for 2 (Patient #3, and Patient #6) of 6 sampled patients. Findings included: 1.Review of the provider’s website showed “Hospice is a philosophy of care provided to patients with life limiting illnesses and their families. Care is provided in the comfort, security, and privacy of wherever they call home. Hospice care addresses the physical, emotional, social, and spiritual needs of the patients. At Gulfside our mission is to provide patients with the greatest comfort and peace of mind at end of life.” Review of Patient #3s face sheet showed a start of care date 10/1/25 and a discharge on 1/27/26. The record revealed a principal diagnosis of unspecified severe protein-calorie malnutrition and other pertinent diagnoses not limited to unspecified heart failure (your heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet your body’s needs) and unspecified chronic obstructive pulmonary disease (incurable lung disease that restricts airflow and makes breathing difficult). Review of Patient #3s plan of care revealed a problem – Anxiety (feelings of apprehension or dread)/Stress related to terminal illness with an intervention not limited to “Assess for signs/symptoms of anxiety, fear, and agitation and assist patient/caregiver in dealing with their anxiety and feelings. Review of Patient #3s orders showed the patient was to receive skilled nursing 1 time a week for 10 weeks and 30 as needed (prn) visits. Review of Patient #3s visit management showed Staff F, Registered Nurse (RN) visited on 1/13/26 at 12:00 – 12:45 p.m. A note created by Staff F, RN dated 1/14/26 at 2:13 p.m. showed the RN had visited the patient and was observed lying in bed. The visit management did not reveal a nurse had visited the patient on 1/14/26 and the note did not show it was a late entry. The visit management showed a missed RN visit had occurred on 1/23/26 without documentation of reason why and if the patient/caregiver had been contacted related to missing the visit. The visit list did not show any skilled nursing visit between 1/13 and 1/27/26, a period of 14 days. Review of Patient #3s communication notes revealed the following:1/23/26 at 7:24 p.m., Triage: Call to spouse who reported patient was having constipation (no bowel movement) for 3 days. Triage encouraged and educated the spouse to administer lactulose (medication for constipation) in the morning. Spouse reported intermittent nausea related to constipation and the triage member initiated prochlorperazine (medication for nausea) from the comfort kit (CK). Encouraged to call for any needs.1/25/26 at 5:52 p.m. On-Call: called and spoke with spouse to follow up on new order for prochlorperazine. Spouse informed the writer of not having nausea medication and the comfort kit was lost. The spouse reported decreased urine output, not eating and sleeping most of the time. The writer offered to come straight catheterization (used intermittently to completely empty the bladder or obtain a urine sample) or have team follow up in the morning. The spouse stated the patient would not want to be catheterized and to see tomorrow. Triage notified to have team follow up on urine output and comfort kit.The notes did not reveal a telephone call to the spouse, or a skilled nursing visit was made on 1/26/26 to follow up regarding urine output and/or missing comfort kit.1/27/26 at 1:12 a.m. Triage: Message received from (answering service) reporting patient with increased shortness of breath, writer attempted callback with information provided and unable to reach spouse. Triage report updated.1/27/26 at 2:00 a.m. Triage: Second message received from (answering service) reporting patient with shortness of breath, phone number for patient is not currently in service. (Answering service) called by writer advising that phone number obtained is out of service and (answering service) reported they will transfer call should primary caregiver callback again. (Answering service) reports caller indicated possible emergency room (ER) transfer.1/27/26 Late entry at 8:10 a.m. for 1/27/26 at 2:57 a.m. Triage: Third message request received from (answering service) reporting patient is being taken to the ER, unknown which Er as the phone number listed is out of service and not receiving calls. Writer asked that (answering service) transfer the call to writer and they reported they attempted to, but primary caregiver (PCG) would not stay on the phone. Team notified.1/27/26 at 8:13 a.m. Triage: (provider) notified prior to ER transfer: “yes, PCG phone was not accepting call back and after-hours communication call center unable to transfer calls through to writer due to PCG declining to wait.”1/28/26 at 11:04 a.m. Intake: Death note. Time of Death (TOD) 1/27/26 at 9:41 p.m. Verified with hospital staff. An interview was conducted on 6/30/26 at 10:05 a.m. with the Director of Quality and Accreditation (DQA) and the Chief of Operating and Business Innovations Officer (COB). The DQA reported the caregiver was calling the provider through a company used as an answering service. The DQA reported there was multiple calls to the answering service to report shortness of breath and the patient “begged” to call ambulance. A second call from caregiver reporting shortness of breath and the third call was to inform the provider patient was being taken to ER. The DQA stated the provider had approved transfer of patient to inpatient (hospice) unit, but family declined and patient passed the next day. The DQA stated there was an opportunity for improvement in documentation and re-education of the management team to ensure attempts in communication. The DQA stated a nurse should have been set out to the residence to check on patient when communication was difficult. 2.Review of Patient #6s face sheet revealed a start of care date of 1/11/26 and discharge date of 2/9/26. The principal diagnosis was chronic kidney disease (your kidneys are damaged and cannot filter blood properly, causing waste to build up) with heart failure (your heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet your body’s needs) and stage one through stage 4 chronic kidney disease or unspecified chronic kidney disease, other pertinent diagnosis included but not limited to vascular dementia (decline in cognitive abilities—such as memory, reasoning, and communication) unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, dependence on supplemental oxygen, and type 2 diabetes mellitus with diabetic cataract. Review of the incident/complaint/grievance log showed on 2/9/26 the provider received “an irate call” from Patient #6s primary caregiver (PCG) who requested immediate revocation from the provider “due to the lack of provided on Saturday 02/06/26.” The PCG reported a call was placed to the provider on 2/6/26 at 6:30 a.m. requesting a nurse visit with no visit. A follow up to the complaint on 3/5/26 the documentation “suggests that 2 calls received from PCG requesting on call nurse (OCN) visit. Unable to determine root cause of delay in responding to patient home.” Review of Patient #6s care plan revealed a problem related to fall prevention with an intervention “Educate care providers regarding contacting Hospice to ensure continuity of care and allow for continuing case management by Hospice team.” A problem for pain management instructed staff to assess patients’ pain severity, frequency, location, quality, precipitating factors, and side effects of pain. Review of Patient #6s notes revealed the following:2/5/26. Observed patient in no acute distress. PCG reported patient had a “very bad night due to pain crisis” and the patient had become verbally abusive and threatening. The patient had a history of threatening when in pain, agitated and confused. The PCG was informed to call 911 if feeling unsafe and “office for any concerns or questions”.2/6/26 at 2:57 p.m. Triage: requesting call from CCM directly, would not discuss any details with writer.2/6/26 at 3:09 p.m., return call to PCG who was appreciative of the care the registered nurse had provided since being on service.2/7/26 at 6:32 p.m. “Calls x2 from PCG asking for estimated time of arrival (ETA) of nurse. On call nurse (OCN) advised to follow up.”The notes did not show any communication related “Calls x2” between the 2/6/26 at 3:09 p.m. note and the 2/7/26 at 6:32 p.m. note.2/7/26 at 11:00 p.m. Triage. “0630 – phone call received from PCG (name) reporting patient’s spouse called (pronoun) to report patient is having increased confusion, (pronoun) is unsure if it’s from the change in medication or a decline in (patient) status.”2/8/26 at 12:12 a.m. On call. Triage received call about a fall and patient needing an assessment. The writer implied calling the patient’s family member who reported the patient had fallen again and was on the bathroom floor and had been there since 4 p.m. today. The writer arrived to find emergency services there and was loading the patient. PCG was upset about the time it took to get a nurse to visit, the confusion with communication.2/9/26 at 10:14 a.m. Triage. Requesting revocation be resent to PCG.2/9/26 at 5:31 p.m. Late Entry. “During conversation with the (spouse) after the patient left with emergency services (EMS), (spouse) stated that child called the office/800 number around 8 a.m. Saturday morning requesting visit for sudden confusion and weakness. Then a second call was placed for a fall that occurred between 7:15-7:30 p.m.” The note showed the nurse had called non-emergent number and was told they had received a call and had a team that at 7:56 p.m. and EMS was there when the nurse arrived.Review of the communication notes showed the PCG of Patient #6 had requested a nurse visit on 2/6/26 at 6:30 a.m. for a change in condition. The notes showed the family called multiple times before a nurse arrived. During an interview on 6/30/26 at 11:00-ish a.m. the DQA stated on 2/7/26 at 6:30 a.m. a call reported the patient was having increased confusion and requested a follow up. The provider did not make a visit on the seventh. The DQA confirmed there was a gap of almost 10 hours between the call and when a nurse arrived. The COB stated in the past year, patients in a home setting had become more difficult and the provider had looked at the nursing audit and the ratio (for nurse to patient) used to 1:20 but after the fiscal year (7/1/26) it was going to be 1:14. The provider discovered when a patient called there was too much resolving over the phone and now going to transport directly to care center instead of waiting for a nurse. The DQA stated the breakdown was an on-call nurse should have visited. Review of the policy – The Plan of Care, published on 08/20/25, revealed its purpose was “To ensure that an individualized plan of care is developed for each patient that complies with the Hospice conditions of participation, payment, and other guidelines.” The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:Interventions to manage pain and symptoms.A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.Measurable outcomes anticipated from implementing and coordinating the POCDrugs and treatment necessary to meet the needs of the patient.Medical supplies and appliances necessary to meet the needs of the patient.4. The scope and frequency of services necessary to meet the specific patient and family needs will be documented by each discipline or designee on the Interdisciplinary (IDG), including volunteers.A. The plan of care may include a range of visits and “provide as needed” or “PRN” orders for visit frequencies to ensure the most appropriate level of service is provided to the patient.”