Columbus Hospice, Inc.

“Based on observation and staff interviews it was determined the facility failed to maintain the attic access door in the closed position.This affects residents and staff in the entire facility. The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the attic access door was left in the open position in the janitor room. In the event of fire, smoke and heat would have spread into the attic.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 19.3.1”

“Based on observation and staff interviews it was determined the facility failed to properly maintain the safety precautions surrounding the fire alarm breaker.This affects residents and staff in the entire facility. The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that the fire alarm circuit breaker was not identified in red and did not include a breaker lock to prevent the disconnection of power to the fire alarm system.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, 19.5.1.1, 9.1.2 and 2011 NFPA 70, 760.41(A)(B), 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 through 10.5.5.2.4”

“Based on observation and staff interviews it was determined the facility failed to maintain access to the electrical panel and protect electrical wires on the panel from exposure.This affects residents and staff in the entire facility. The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that access to the electrical panels was blocked by a portable cart. The electrical panel was missing a metal plate exposing electrical wires.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 110.26, Article 408.7”

“Based on observation and staff interviews it was determined the facility failed to maintain safe power strip usage.This affects residents and staff in the in or near the breakroom. The findings include:During a tour of the facility with Staff M on 5/19/2025 between 1:00 pm and 4:30 pm observation revealed that a vending machine was plugged into a power strip located on the floor of the breakroom. The vending machine should be plugged directly into the wall.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 99, Chapter 10, Sections 10.4.2.1 through 10.4.2.3 and CMS S&C letter 14-46-LSC”

“Based on clinical record review, staff interview, and review of policy titled “Bereavement Protocol,” it was determined the interdisciplinary group failed to ensure that the initial bereavement assessments were completed for three patients (P) (P#1, P#12, P#21) of 25 sampled patients. Findings include: Review of policy titled “Bereavement Protocol,” revised February 7, 2025, reveals the following:Procedures:1. A Pre-Bereavement Assessment will be completed and documented by the team Social Worker during the comprehensive initial assessment of the patient. 1. Review of the clinical record reveals P#1 was admitted on 6/20/2023.The clinical record failed to indicate that the initial bereavement assessment was completed and failed to reveal documentation regarding the delay in completing the assessment. 2. Review of the clinical record reveals P#12 was admitted on 11/7/2024.The clinical record failed to indicate that the initial bereavement assessment was completed and failed to reveal documentation regarding the delay in completing the assessment. 3. Review of the clinical record for reveals P#21 was admitted on 2/8/2024.The clinical record failed to indicate that the initial bereavement assessment was completed and failed to reveal documentation regarding the delay in completing the assessment. On 4/29/2025 at 1:58 p.m., an interview was conducted with the compliance officer, who said that the initial bereavement assessment was not done. The compliance officer also confirmed that all available documentation for the clinical record has been provided.”

“Based on review of narcotic verification sheets, review of policy titled “Medication Administration and Management,” and staff interview, it was determined that the nurse failed to sign shift counts of the narcotic medications in the IPU (in patient unit). The findings include:Review of policy titled “Medication Administration and Management,” revised November 20, 2024, reveals the following:Medication Administration in the Inpatient Unit:2- A full count of all controlled substances is done at each shift change. Review of the “Narcotic Verification Sheet,” in the IPU medication room revealed that the signatures of nurses working in the IPU were missing in the narcotic medications count sheets. Missed shift signatures reveal the following: • 2/4/25 7 a.m., outgoing nurse, and 7 p.m., incoming nurse • 2/5/25: 7 a.m., outgoing and 7 p.m., outgoing signatures were blank • 2/8/25: 7 p.m., outgoing signature page was blank • 2/14/25: 7 a.m., outgoing signature page was blank• 2/19/25: 7 p.m., incoming signature page was blank • 2/20/25: 7 a.m., outgoing signature page was blank • 2/22/25: 7 a.m., outgoing signature page was blank • 2/27/25: 7 a.m., outgoing signature page was blank • 2/28/25: 7 p.m., outgoing signature page was blank• 3/3/25: 7 p.m., outgoing signature page was blank • 3/5/25: 7 a.m., outgoing signature page was blank • 3/9/25: 7 p.m., outgoing signature page was blank • 3/10/25: 7 a.m., incoming signature page was blank, 7 p.m., outgoing signature page was blank • 3/12/25: 7 p.m., outgoing signature page was blank • 3/13/25: 7 a.m., incoming signature page was blank • 3/14/25: 7 p.m., outgoing signature page was blank • 3/16/25: 7 p.m., outgoing signature page was blank • 3/18/25: 7 p.m., incoming signature page was blank • 3/19/25: 7 a.m., outgoing signature page was blank• 3/20/25: 7 a.m., outgoing signature page was blank, 7 p.m., outgoing signature page was blank • 3/21/25: 7 p.m., outgoing signature page was blank • 3/23/25: 7 p.m., outgoing signature page was blank• 4/1/25: 7 a.m., outgoing signature page was blank • 4/3/25: 7 p.m., outgoing signature page was blank • 4/9/25: 7 a.m., outgoing signature page was blank • 4/17/25: 7 p.m., incoming signature page was blank • 4/18/25: 7 a.m., outgoing signature page was blank • 4/22/25: 7 p.m., incoming signature page was blank • 4/23/25: 7 a.m., outgoing signature page was blank On 4/28/25 at 11:35 a.m., an interview was conducted with Hospice House Director (HHD), who said that she did not know why the nurses were not signing the narcotic counts sheets at IPU medication room. HHD also said that the nurses involved were not available for interview.”