Blue Summit Hospice of Roswell

“Based on clinical record reviews, review of agency policies and staff interviews, it was determined that the agency failed to comply with the nursing services one- hour response time of a patient experiencing a crisis situation or change in condition for eight patients (P) (P1, P2, P3, P4, P5, P6, P7, P8) of eight patients sampled from the agency’s on-call report Findings include: RESPONSIBILITIES13. Additional activities to the Governing Body include:Provision of care and services that optimize comfort and dignity and that is consistent with family and family needs and goals as priority.Review of the agency policy undated, titled, “Patient Rights and Responsibilities”, revealed the following:Quality of care-Receive effective pain management and symptom control from the hospice for conditions related to your terminal illnesses. Review of agency policy undated titled, “After Hours Accessibility” revealed the following:Procedure:5. For reported falls, change in condition, uncontrolled symptoms, or other concerns requiring a physical assessment, the Registered Nurse (RN) will arrange a follow-up visit within 1 hour, unless the patient or family declines or emergency services are required. 1. Review of the agency on-call report revealed that on 06/28/2026, at 7:13 AM, the family of P2 called to report change in patient’s condition. Family reported that P2 appears to be in a stupor and is difficult to arouse. The on-call note revealed that the Triage Nurse will notify the care team about the change in the patient’s condition and request a nurse to come to assess P2. The on-call log revealed that the triage nurse made numerous calls to the care team with no response. Review of P2’s record reveal that no visit was made on 06/28/2026. 2.Review of the agency on call report revealed that on 12/26/2025, at 11:14PM, the family of P3 called to report that P3 has passed away. Record review for P3 revealed that no visit was made to pronounce patient’s death. Review of On-call log dated 12/27/26 at 12:17 AM revealed the RN on-call advised the triage nurse to tell the family of P3 to call 911, and have someone pronounce the grandmother and to arrange services for P3. Furthermore, review of the Unattended Death visit note dated 12/29/2025, revealed P3 expired on 12/27/2025, at 2:00 AM.Review of on-call log dated 12/26/2025, revealed family of P3 called local police to come out and pronounce P3 of death. 3. Review of the agency on call report for P5 revealed that on 04/03/26, at 5:34 PM, Caregiver (CG) called agency for assessment and review of medication Lorazepam (It treats anxiety disorders, insomnia, and active seizures). The review of the on-call log revealed that at 5:37PM the on-call nurse stated he would follow up and someone to be sent. At 5:41PM message on the on-call log report reads, “I will follow up and address the patient’s needs.” At 6:00 PM, family of P5 called regarding concerns and questions about the medication lorazepam (medication to treat anxiety). Review of clinical record failed to reveal a phone call, or visit made to address P5’s concerns about medications. Further review of the on-call report revealed that at 7:00PM, message response was “I will follow-up and address the patient’s needs.” Record reviewed for P5 failed to show a follow-up visit on 4/3/2026. 4.Review of the agency on call report revealed family of P1 called the agency on 12/13/2025, at 11:06 AM and requested “a nurse to come help her with the patients new bed sores and wants an evaluation”. Review of P1’s clinical records revealed as RN visit was conducted at 1:44 PM on 12/13/2025. Furthermore, review of the agency on call report revealed that family of P1 called the agency on 12/20/2025, at 3:46 PM and requested a nurse. Review of on call report reveals the family of P1called the agency again on 12/20/2025, at 7:52 PM to report P1 had died. On 07/07/2026 at 2:30 PM, during an office interview, Licensed Practical Nurse (LPN) LPNAA confirmed she could not verify a nurse in home visit time for death pronouncement on 12/20/2026. 5.Review of the agency on-call report revealed family of P4 called the agency on 03/20/2026, at 8:26 PM regarding the medication for throat gurgling noises. The patient’s spouse called the agency again on 3/20/2026, at 9:38 PM, to report that P4 is experiencing worsening of gurgling noises, the caller is concerned about the severity of the symptoms and P4’s comfort. The patient’s spouse called again on 3/20/26, at 10:07 PM to report the death of P4. Record review revealed that the nurse arrived at the home of P4 at 11:44 PM on 3/20/2026. 6.Review of the agency on-call report revealed that on 06/02/2026, at 7:30 PM, the family of P6 called to report P6 is hallucinating. Review of clinical record for P6 failed to reveal a follow up phone call or home visit was made on 06/2/26. On 06/04/2026, at 6:17 PM, the family of P6 called and reported that P6 is having redness and swelling on arm and feeling very hot. P6 is uncontrollable. Family of P6 reported the agency failed to send a nurse out to the home to access P6. Review of clinical record of P6 revealed patient discharged per CG request. 7.Review of the agency on-call report revealed that on 05/02/2026, at 5:30 AM, family of P7 called and reported that P7 is unresponsive, blood sugar is 46. Family called the agency on 05/02/2026 at 8:52 PM reporting that P7 is unresponsive. The on-call note revealed the facility called Emergency Medical Service (EMS), and IV (intravenous) fluids were given, and labs were drawn on P7. Review of P7’s clinical records failed to reveal a nurse visit on 5/2/2026. Record review for P7 revealed that a nurse made a visit on 05/05/2026. 8.Review of the agency on-call report revealed that on 05/07/2026, at 8:10 PM family called to say that P8 is having left side chest pain. Record review for P8 revealed that nurse made a visit on 5/7/2026 at 9:55 PM. On 07/06/2026 at 1:30PM, an office interview was conducted with the Administrator who stated that all notes are given as requested.On 07/07/2026 at 10:50 AM, a phone interview was conducted with the on-call RN AA. RNAA stated that he did on-call weekends and weekdays. He stated that he did not have an official backup person. He stated he would call the manager if he needed backup. He stated that he did on-call for both offices and he lived in Alpharetta and was not able to reach the patients on the far end of Cartersville (branch office) if need be. He stated that he did triage after he received a call from the triage company and he would determine if the patient needed a visit. He stated he does not recall any specifics about any of the patients (P1, P2, P3, P4, P5, P6, P7, P8). He stated that he normally would put in a note in the coordination notes. Further review failed to reveal any notes found for any of the patients mentioned above.”

“Based on clinical record reviews, agency policy reviews, and staff interviews, it was determined the agency’s governing body failed to organize, manage, or administer its resources to provide hospice care and services necessary for the palliation and management of the terminal illness and related conditions. Specifically, the hospice failed to ensure the nursing services were made available within one hour of notification during afterhours (time when agency office is closed) as well as regular business hours to meet patients’ needs and failed to ensure patient’s rights were maintained by effectively managing pain and controlling symptoms for conditions related to the terminal illness and at the end of life for eight patients (P1, P2, P3, P4, P5, P6, P7, P8) of eight sampled patients. Findings include: RESPONSIBILITIES13. Additional activities to the Governing Body include:Provision of care and services that optimize comfort and dignity and that is consistent with family and family needs and goals as priority.Review of the agency policy undated, titled, “Patient Rights and Responsibilities”, revealed the following:Quality of care-Receive effective pain management and symptom control from the hospice for conditions related to your terminal illnesses. Review of agency policy undated titled, “After Hours Accessibility” revealed the following:Procedure:5. For reported falls, change in condition, uncontrolled symptoms, or other concerns requiring a physical assessment, the Registered Nurse (RN) will arrange a follow-up visit within 1 hour, unless the patient or family declines or emergency services are required. 1. Review of the agency on-call report revealed that on 06/28/2026, at 7:13 AM, the family of P2 called to report change in patient’s condition. Family reported that P2 appears to be in a stupor and is difficult to arouse. The on-call note revealed that the Triage Nurse will notify the care team about the change in the patient’s condition and request a nurse to come to assess P2. The on-call log revealed that the triage nurse made numerous calls to the care team with no response. Review of P2’s record reveal that no visit was made on 06/28/2026. 2.Review of the agency on call report revealed that on 12/26/2025, at 11:14PM, the family of P3 called to report that P3 has passed away. Record review for P3 revealed that no visit was made to pronounce patient’s death. Review of On-call log dated 12/27/26 at 12:17 AM revealed the RN on-call advised the triage nurse to tell the family of P3 to call 911, and have someone pronounce the grandmother and to arrange services for P3. Furthermore, review of the Unattended Death visit note dated 12/29/2025, revealed P3 expired on 12/27/2025, at 2:00 AM.Review of on-call log dated 12/26/2025, revealed family of P3 called local police to come out and pronounce P3 of death. 3. Review of the agency on call report for P5 revealed that on 04/03/26, at 5:34 PM, Caregiver (CG) called agency for assessment and review of medication Lorazepam (It treats anxiety disorders, insomnia, and active seizures). The review of the on-call log revealed that at 5:37PM the on-call nurse stated he would follow up and someone to be sent. At 5:41PM message on the on-call log report reads, “I will follow up and address the patient’s needs.” At 6:00 PM, family of P5 called regarding concerns and questions about the medication lorazepam (medication to treat anxiety). Review of clinical record failed to reveal a phone call, or visit made to address P5’s concerns about medications. Further review of the on-call report revealed that at 7:00PM, message response was “I will follow-up and address the patient’s needs.” Record reviewed for P5 failed to show a follow-up visit on 4/3/2026. 4.Review of the agency on call report revealed family of P1 called the agency on 12/13/2025, at 11:06 AM and requested “a nurse to come help her with the patients new bed sores and wants an evaluation”. Review of P1’s clinical records revealed as RN visit was conducted at 1:44 PM on 12/13/2025. Furthermore, review of the agency on call report revealed that family of P1 called the agency on 12/20/2025, at 3:46 PM and requested a nurse. Review of on call report reveals the family of P1called the agency again on 12/20/2025, at 7:52 PM to report P1 had died. On 07/07/2026 at 2:30 PM, during an office interview, Licensed Practical Nurse (LPN) LPNAA confirmed she could not verify a nurse in home visit time for death pronouncement on 12/20/2026. 5.Review of the agency on-call report revealed family of P4 called the agency on 03/20/2026, at 8:26 PM regarding the medication for throat gurgling noises. The patient’s spouse called the agency again on 3/20/2026, at 9:38 PM, to report that P4 is experiencing worsening of gurgling noises, the caller is concerned about the severity of the symptoms and P4’s comfort. The patient’s spouse called again on 3/20/26, at 10:07 PM to report the death of P4. Record review revealed that the nurse arrived at the home of P4 at 11:44 PM on 3/20/2026. 6.Review of the agency on-call report revealed that on 06/02/2026, at 7:30 PM, the family of P6 called to report P6 is hallucinating. Review of clinical record for P6 failed to reveal a follow up phone call or home visit was made on 06/2/26. On 06/04/2026, at 6:17 PM, the family of P6 called and reported that P6 is having redness and swelling on arm and feeling very hot. P6 is uncontrollable. Family of P6 reported the agency failed to send a nurse out to the home to access P6. Review of clinical record of P6 revealed patient discharged per CG request. 7.Review of the agency on-call report revealed that on 05/02/2026, at 5:30 AM, family of P7 called and reported that P7 is unresponsive, blood sugar is 46. Family called the agency on 05/02/2026 at 8:52 PM reporting that P7 is unresponsive. The on-call note revealed the facility called Emergency Medical Service (EMS), and IV (intravenous) fluids were given, and labs were drawn on P7. Review of P7’s clinical records failed to reveal a nurse visit on 5/2/2026. Record review for P7 revealed that a nurse made a visit on 05/05/2026. 8.Review of the agency on-call report revealed that on 05/07/2026, at 8:10 PM family called to say that P8 is having left side chest pain. Record review for P8 revealed that nurse made a visit on 5/7/2026 at 9:55 PM. On 07/06/2026 at 1:30PM, an office interview was conducted with the Administrator who stated that all notes are given as requested.On 07/07/2026 at 10:50 AM, a phone interview was conducted with the on-call RN AA. RNAA stated that he did on-call weekends and weekdays. He stated that he did not have an official backup person. He stated he would call the manager if he needed backup. He stated that he did on-call for both offices and he lived in Alpharetta and was not able to reach the patients on the far end of Cartersville (branch office) if need be. He stated that he did triage after he received a call from the triage company and he would determine if the patient needed a visit. He stated he does not recall any specifics about any of the patients (P1, P2, P3, P4, P5, P6, P7, P8). He stated that he normally would put in a note in the coordination notes.Further review failed to reveal any notes found for any of the patients mentioned above.”

“Based on clinical record reviews, agency policy reviews, and staff interviews, it was determined that the agency failed to comply with the State Regulation of the nursing services’ one-hour response time when there is notification by a patient or family member of a patient experiencing a crisis or change in condition, and failed to ensure patient’s rights were maintained by effectively managing pain and controlling symptoms for conditions related to the terminal illness and at the end of life for eight patients (P1, P2, P3, P4, P5, P6, P7, P8) of eight sampled patients. Findings include: RESPONSIBILITIES13. Additional activities to the Governing Body include:Provision of care and services that optimize comfort and dignity and that is consistent with family and family needs and goals as priority.Review of the agency policy undated, titled, “Patient Rights and Responsibilities”, revealed the following:Quality of care-Receive effective pain management and symptom control from the hospice for conditions related to your terminal illnesses. Review of agency policy undated titled, “After Hours Accessibility” revealed the following:Procedure:5. For reported falls, change in condition, uncontrolled symptoms, or other concerns requiring a physical assessment, the Registered Nurse (RN) will arrange a follow-up visit within 1 hour, unless the patient or family declines or emergency services are required. 1. Review of the agency on-call report revealed that on 06/28/2026, at 7:13 AM, the family of P2 called to report change in patient’s condition. Family reported that P2 appears to be in a stupor and is difficult to arouse. The on-call note revealed that the Triage Nurse will notify the care team about the change in the patient’s condition and request a nurse to come to assess P2. The on-call log revealed that the triage nurse made numerous calls to the care team with no response. Review of P2’s record reveal that no visit was made on 06/28/2026. 2.Review of the agency on call report revealed that on 12/26/2025, at 11:14PM, the family of P3 called to report that P3 has passed away. Record review for P3 revealed that no visit was made to pronounce patient’s death. Review of On-call log dated 12/27/26 at 12:17 AM revealed the RN on-call advised the triage nurse to tell the family of P3 to call 911, and have someone pronounce the grandmother and to arrange services for P3. Furthermore, review of the Unattended Death visit note dated 12/29/2025, revealed P3 expired on 12/27/2025, at 2:00 AM.Review of on-call log dated 12/26/2025, revealed family of P3 called local police to come out and pronounce P3 of death. 3. Review of the agency on call report for P5 revealed that on 04/03/26, at 5:34 PM, Caregiver (CG) called agency for assessment and review of medication Lorazepam (It treats anxiety disorders, insomnia, and active seizures). The review of the on-call log revealed that at 5:37PM the on-call nurse stated he would follow up and someone to be sent. At 5:41PM message on the on-call log report reads, “I will follow up and address the patient’s needs.” At 6:00 PM, family of P5 called regarding concerns and questions about the medication lorazepam (medication to treat anxiety). Review of clinical record failed to reveal a phone call, or visit made to address P5’s concerns about medications. Further review of the on-call report revealed that at 7:00PM, message response was “I will follow-up and address the patient’s needs.” Record reviewed for P5 failed to show a follow-up visit on 4/3/2026. 4.Review of the agency on call report revealed family of P1 called the agency on 12/13/2025, at 11:06 AM and requested “a nurse to come help her with the patients new bed sores and wants an evaluation”. Review of P1’s clinical records revealed as RN visit was conducted at 1:44 PM on 12/13/2025. Furthermore, review of the agency on call report revealed that family of P1 called the agency on 12/20/2025, at 3:46 PM and requested a nurse. Review of on call report reveals the family of P1called the agency again on 12/20/2025, at 7:52 PM to report P1 had died. On 07/07/2026 at 2:30 PM, during an office interview, Licensed Practical Nurse (LPN) LPNAA confirmed she could not verify a nurse in home visit time for death pronouncement on 12/20/2026. 5.Review of the agency on-call report revealed family of P4 called the agency on 03/20/2026, at 8:26 PM regarding the medication for throat gurgling noises. The patient’s spouse called the agency again on 3/20/2026, at 9:38 PM, to report that P4 is experiencing worsening of gurgling noises, the caller is concerned about the severity of the symptoms and P4’s comfort. The patient’s spouse called again on 3/20/26, at 10:07 PM to report the death of P4. Record review revealed that the nurse arrived at the home of P4 at 11:44 PM on 3/20/2026. 6.Review of the agency on-call report revealed that on 06/02/2026, at 7:30 PM, the family of P6 called to report P6 is hallucinating. Review of clinical record for P6 failed to reveal a follow up phone call or home visit was made on 06/2/26. On 06/04/2026, at 6:17 PM, the family of P6 called and reported that P6 is having redness and swelling on arm and feeling very hot. P6 is uncontrollable. Family of P6 reported the agency failed to send a nurse out to the home to access P6. Review of clinical record of P6 revealed patient discharged per CG request. 7.Review of the agency on-call report revealed that on 05/02/2026, at 5:30 AM, family of P7 called and reported that P7 is unresponsive, blood sugar is 46. Family called the agency on 05/02/2026 at 8:52 PM reporting that P7 is unresponsive. The on-call note revealed the facility called Emergency Medical Service (EMS), and IV (intravenous) fluids were given, and labs were drawn on P7. Review of P7’s clinical records failed to reveal a nurse visit on 5/2/2026. Record review for P7 revealed that a nurse made a visit on 05/05/2026. 8.Review of the agency on-call report revealed that on 05/07/2026, at 8:10 PM family called to say that P8 is having left side chest pain. Record review for P8 revealed that nurse made a visit on 5/7/2026 at 9:55 PM. On 07/06/2026 at 1:30PM, an office interview was conducted with the Administrator who stated that all notes are given as requested.On 07/07/2026 at 10:50 AM, a phone interview was conducted with the on-call RN AA. RNAA stated that he did on-call weekends and weekdays. He stated that he did not have an official backup person. He stated he would call the manager if he needed backup. He stated that he did on-call for both offices and he lived in Alpharetta and was not able to reach the patients on the far end of Cartersville (branch office) if need be. He stated that he did triage after he received a call from the triage company and he would determine if the patient needed a visit. He stated he does not recall any specifics about any of the patients (P1, P2, P3, P4, P5, P6, P7, P8). He stated that he normally would put in a note in the coordination notes.Further review failed to reveal any notes found for any of the patients mentioned above.”

“Based on review of agency policy, clinical record reviews, and staff interview, it was determined the agency’s interdisciplinary group (IDG) failed to ensure comprehensive assessments were completed no later than five calendar days after the election of hospice for two patients (P) (P9, P11) of 16 sampled patients. Specifically, the agency failed to ensure two patients (P) (P9 P11) received an initial assessment by a Social Worker (SW) within the required five Calander days of patient’s election of hospice care.Findings include: Review of agency policy titled, “Initial Assessment/Comprehensive Assessment”, revised February 2022, reveals the following:Procedure4. The Hospice IDG, in consultation with the patient’s attending physician (if any), must complete the comprehensive assessment no later than five (5) calendar days after patient’s election of Hospice care. Review of clinical records of P9 revealed P9, with a start of care (SOC) date of 06/02/2026, failed to reveal an initial assessment was completed by a Social Worker (SW) within five calendar days of P9’s SOC date.Review of clinical records of P11 revealed P11, with a start of care (SOC) date of 06/16/2026, failed to reveal an initial assessment was completed by a SW within five calendar days of P11’s SOC date.During an office interview on 07/08/2026, at 12:30 PM, the Director of Nursing (DON) confirmed P9 and P11 did not receive an initial assessment by a SW within the required five calendar days of the patient’s election of hospice care.The agency’s SW was unavailable for interview.”

“Based on review of agency policy, clinical record reviews, patient family interviews, and staff interview, it was determined the agency failed to ensure medications were reconciled during home visits for all drugs and treatments necessary to meet the needs for four patients (P) (P18 P19 P20 P21) of four patients sampled. Findings include: 3. On 07/07/2026 at 11:00 AM, during a home visit observation with P20, the surveyor observed the following medications listed on the hospice agency’s medication profile but were not present in the home during the home visit observation: Ativan 1 mg (used to treat anxiety), Morphine 0.25 ml (used to treat pain and shortness of breath), and Ondansetron 4 mg (used to prevent nausea and vomiting). Furthermore, surveyor observed the following medications present in the home that were not listed on the hospice agency’s medication profile: Sertraline HCL 25 mg (used to treat depression), Carbidopa Levo ER 25-100 mg (used to treat Parkinson’s Disease), and Carbidopa Levodopa 25-100 mg (used to treat Parkinson’s Disease). On 07/07/2026 at 11:15 AM, an in-person interview was conducted with the caregiver of P20, who confirmed that the following medications had not yet been provided by the hospice agency: Ativan 1 mg (used to treat anxiety), Morphine 0.25 ml (used to treat pain and shortness of breath), and Ondansetron 4 mg (used to prevent nausea and vomiting). Furthermore, the caregiver confirmed that P20 was currently taking the following meds: Sertraline HCL 25 mg (used to treat depression), Carbidopa Levo ER 25-100 mg (used to treat Parkinson’s Disease), and Carbidopa Levodopa 25-100 mg (used to treat Parkinson’s Disease). 4. On 07/07/2026 at 10:15 AM, during a home visit observation with P21, the surveyor compared the hospice agency’s medication profile to the assisted living facility’ (ALF) medication profile. Comparison of the hospice agency’s medication profile to the ALF’s medication profile revealed that the ALF’s medication profile contained medications that did not match the hospice’s medication profile. Review of hospice POC document titled “Patient Information Report” signed and dated by a physician on 05/20/2026 failed to reveal an order for Hyoscyamine Sulfate 0.125 mg (used to treat excessive secretions) and Tramadol 50 mg (used to treat pain) which were both included on the ALF’s medication profile. During an office interview on 07/07/2026 at 3:00 PM, the agency’s director of nursing (DON) confirmed P18, P19, P20, and P21’s medication orders were not updated to reflect current patient medication and treatment plan. The DON stated the patients’ medications and treatments should be updated and reconciled with every nurse’s home visit. Review of policy titled “IDG (interdisciplinary group) Care Plan Process” revised February 2022 revealed the following:Procedure2. The care of plan specifies the care and services necessary to meet the patient and family­ specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, com prehensive and updated comprehensive assessments. The plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including:Interventions to manage pain and other symptoms.Effective pain and symptom management includes the ongoing assessment of the patient’ s physical, psychosocial, emotional and spiritual needs and reassessing the effectiveness of the current plan of care in order to address those needs.Symptoms such as pain, nausea, vomiting, dehydration, constipation, dyspnea, emotional distress, insomnia, neuropsychiatric symptoms and spiritual needs will be managed using accepted professional standards of practice.Alternative therapies may be utilized, e.g., music, light and pet therapy, message, yoga, etc.. 1.Review of P18’s plan of care (POC) document titled “Patient Information Report” signed by a physician dated 05/28/2026 revealed P18 was ordered Amiodarone (antiarrhythmic for the heart), Aspirin (mild blood thinner), and Haloperidol (for anxiety and agitation). During a home visit observation on 07/07/2026 at 11:30 AM P18’s caregiver (CG) confirmed P18 was not currently taking Amiodarone, Aspirin, or Haloperidaol. P18’s CG further confirmed she was treating P18’s wound with TheraHoney (treatment for wound healing to decrease inflammation) and Normal Saline (wound cleanser). Furthermore, P18’s CG confirmed P18 was taking Hydrocodone (pain reliever) and had been taking it before P18 was admitted to hospice.Review of Records failed to reveal an order for TheraHoney, Normal Saline and Hydrocodone. 2.Review of P19’s plan of care (POC) document titled “patient Information Report” signed by a physician and dated 05/11/2026 failed to reveal an order for oxygen (for shortness of breath), Lactulose (for constipation), and Hydrocodone (pain reliever).During a home visit observation on 07/07/2026 at 12:30 PM P19’s CG confirmed P19 required oxygen (for shortness of breath) and was currently taking Lactulose (for constipation) and Hydrocodone (pain reliever).”

“Based on review of agency policies, clinical record reviews and staff interviews, it was determined that the agency governing body failed to ensure the nursing services were made available within one hour of notification during afterhours (time when agency office is closed) and during regular business hours to meet patients’ needs for eight patients (P) (P1 P2 P3 P4 P5 P6 P7 P8) of eight sampled patients from the agency on-call report; ensure patient received a social worker (SW) comprehensive assessment no later than five calendar days after the election of hospice for two patients (P) (P9 P11) of 16 sampled patients; and ensure medications were reconciled during home visits for all drugs and treatments necessary to meet the needs of the patients for four patients (P) (P18 P19 P20 P21) of four patients sampled. Findings include: Refer to citation L500 for findings related to Patient’s Rights.Refer to citation L648 for findings related to Governing Body’s organization and administration of services.Refer to citation L797 for findings related to Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.”