St Francis Hospice

“Based on record review and interview, the facility failed to ensure that all smoke detectors were maintained and tested for sensitivity in accordance with NFPA 72 (2010): 14.4.5.3 as indicated by NFPA 101: 9.6.1.3. The deficient practice had the potential to delay or prevent residents of all out of 1 smoke compartments from safely accessing the exit stair enclosure during an emergency. On 02/12/2026 at 10:17 AM, during document review with the Inpatient Unit Manager and the Engineering Construction Manager, the facility was unable to produce documentation demonstrating that the required biannual smoke detector sensitivity testing had been conducted. According to NFPA 72 (2010), Section 14.4.5.3, smoke detector sensitivity must be tested within one year of installation and every alternate year thereafter. While the code permits this testing to be done manually or automatically via a self-testing panel, the facility must maintain records of the results for review during inspection. No records could be provided at the time of review. This finding was acknowledged by the Inpatient Unit Manager and the Engineering Construction Manager during the document review and confirmed at the exit conference.”

“Deficient Practice Statement: Based on observation and interview, the facility failed to ensure a sidewall sprinkler was positioned far enough away from an obstruction to allow its discharge pattern to fully develop in accordance with NFPA 13 (2010), Section 8.7.5.2.1.3, as required by NFPA 101 (2012), Sections 19.3.5.1 and 9.7.1.1(1). This deficient practice could affect any residents, staff, or visitors utilizing Room 105. Findings: On 02/18/2026 at 1:04 PM, during a facility tour with the Inpatient Unit Manager and the Engineering Construction Manager, the surveyor observed a standard spray sidewall sprinkler in Room 105 located approximately 4 inches horizontally from the side edge of a wall-mounted flat panel TV. The TV projected 3 inches from the adjacent wall. According to NFPA 13, sprinklers must be positioned away from obstructions a minimum distance of three times the maximum dimension of the obstruction to prevent blocking the spray pattern. A 3-inch deep obstruction requires a minimum horizontal clearance of 9 inches. This finding was verified with the Inpatient Unit Manager and the Engineering Construction Manager at the time of observation and acknowledged during the exit conference.”

“Based on observation, record review, and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25 (2011) by failing to conduct a 5-year internal inspection of piping (Section 14.2.1) and failing to maintain sprinklers free of foreign materials (Section 5.2.1.1.1), as required by NFPA 101 (2012), Sections 19.3.5.1 and 9.7.5. This deficient practice could affect all 11 residents, staff, and visitors. 1. On 02/18/2026 at approximately 10:30 AM, during a document review, the facility was unable to produce documentation demonstrating that a 5-year internal inspection of the sprinkler system piping had been conducted. NFPA 25 requires this inspection every 5 years to check for the presence of pipe blockages. 2. On 02/18/2026 at 12:56 PM, during a facility tour, the surveyor observed one sprinkler head located in the main corridor near the skylight by the nursing station that was heavily loaded with dust. NFPA 25 requires sprinklers to be free of foreign materials to ensure proper operation. These findings were acknowledged by the Inpatient Unit Manager and the Engineering Construction Manager at the times of discovery and confirmed during the exit conference.”

“Based on observation and interview, the facility failed to ensure that 2 of 11 resident room corridor doors and 1 of 1 corridor doors serving the soiled linen room were maintained to provide positive latching and were free from impediments to closing in accordance with NFPA 101: 19.3.6.3.5 as indicated by NFPA 101: 19.2.2.2.1. The deficient practice had the potential to delay or prevent residents of all out of 1 smoke compartments from safely accessing the exit stair enclosure during an emergency. 1. On 02/12/2026 at 1:16 PM, during a facility tour with the Inpatient Unit Manager and the Engineering Construction Manager, a privacy curtain was observed obstructing the corridor door to Room 110. The resident room door was propped open. When attempting to close the door, the curtain fabric became caught between the door and the frame, preventing the door from closing and latching. The curtain had to be manually repositioned in order for the door to fully close and latch. 2. On 02/12/2026 at 1:22 PM, during the same facility tour, the surveyor observed that the corridor door to a single-occupancy resident room was obstructed by a mobile overbed table. The table extended into the door’s swing path, preventing the door from fully closing and latching unless the table was manually repositioned by staff. 3. On 02/12/2026 at 1:31 PM, during the same facility tour, the surveyor observed that the corridor door to the soiled linen room would not latch. A paper towel had been intentionally stuffed into the strike plate in the door frame, preventing the latch bolt from engaging. Upon interview at the time of observation, staff stated that they intentionally placed the paper towel in the strike plate “so it can be pushed open easily.” These findings were acknowledged by the Inpatient Unit Manager and the Engineering Construction Manager at the times of discovery and confirmed during the exit conference.”

“Based on record reviews and interviews, the facility failed to ensure patients were followed up on, informed of, and/or provided with written information regarding, its policies on advance health care directive for two of 26 patients (Patient (P) 4 and P28) reviewed. As a result, patients were not assured of being fully informed of their rights regarding advance health care directives (AHCD). Findings Include: Review of the facility’s policy and procedure “Advance Directives” date issued 03/22/24, documented “During the referral visit and during the state of care visit (the admission visit)...explain the patient’s right to make healthcare decisions...If a patient lacks capacity at the time of admission or state of care, advance directive information will be provided to the patient’s surrogate...B. Each patient will be asked at the point of admission to hospice if he/she has executed an advance directive and his/her response documented in the medical record . If a patient does not have an Advance Directive, general information will be provided to the patient or surrogate...D. If a patient does not have an advance directive and is interested in pursuing the matter further, he/she will be provided a bank copy with written instructions, or he/she can complete the document. A referral to the Social Worker will be made if a patient has questions or concerns related to the Advance Directive...” 1) P4’s election of hospice care was 11/28/25 for routine inpatient care and was discharged due to death on 12/04/25. A review of P4’s Electronic Health Record (EHR) found no documentation that P4 was informed of, or provided with written information regarding AHCD. Review of the facility’s AHCD assessment form, signed and dated by P4 and the hospice liaison nurse on 11/25/25, showed the sections indicating whether the patient had an AHCD, whether it was reviewed, or whether written information was provided was left blank. On 12/12/25 at 09:33 AM, an interview was conducted with Social Worker Manager (SWM). SWM confirmed P4’s AHCD assessment form did not document whether P4 had an AHCD, or whether the patient was informed of and provided written information regarding AHCDs. SWM further confirmed this omission was not followed up and should have been addressed.2) P28’s election of hospice care was 05/23/25. A review of P28’s EHR revealed P28 did not have an AHCD.Review of the facility’s AHCD assessment form, signed and dated by P28 and the hospice liaison nurse on 05/22/25, showed that under “SECTION 2: Does Not Have An Advance Health Care Directive and/or POLST,” P28 selected the option, “I have been given written materials about my right to make decisions about my medical treatments, and I would like to speak more fully with someone regarding this topic.” On 12/12/25 at 09:33 AM, an interview was conducted with Social Worker Manager (SWM). SWM confirmed there was no documentation that the facility followed up with P28’s as requested regarding the AHCDs.”

“Based on record review and interview with staff, the facility failed to ensure patient’s care plan was reviewed, revised and documented no less frequently than every 15 calendar days for one of 26 patients (Patient (P) 18) in the sample.Findings Include: P18 was an 80-year-old patient, elected for hospice on 07/10/25 and discharged on 08/22/25 to pursue more aggressive treatment. Diagnoses included but not limited to vascular dementia and dysphagia. Review of P18’s Electronic Health Record (EHR) for certification period of 07/10/25 to 10/07/25 revealed that the interdisciplinary group (IDG) met on 07/10/25 and 08/05/25 to review the P18’s plan of care. No other IDG meetings were documented in the EHR.On 12/12/25 at 12:08 PM, an interview with Hospice Manager (HM) 1 was conducted in the conference room. HM1 confirmed that an IDG meeting was missed for P18 when the case was reassigned to a different team. As a result, the plan of care was not reviewed within 15 days of the initial one. Review of facility policy titled “Assessment, Patient/Family” dated 01/16/19 stated, “. . . IDG meetings shall be conducted to reassess and prioritize patient’s needs with the plan of care reviewed at least every fifteen (15) days. . .””

“Based on record reviews and interview with staff members, the facility failed to ensure that care and services were provided in accordance with the patients’ plan of care for four of 26 patients (Patient (P) 14, P27, P26, and P28) sampled. The facility did not meet the frequency of visits ordered and as indicated in the plan of care. Findings Include: 1) P14 was a 78-year-old patient that elected for hospice care on 09/23/25. Diagnoses included but not limited to Parkinson’s disease, dyskinesia and dysphagia. Review of P18’s Electronic Health Record (EHR) conducted. For the certification period of 09/23/25 to 12/21/25, physician’s orders on 09/25/25 and patient’s care plan included Hospice Aide (HA) visits twice a week. Review of tab for “Clinical Charting” revealed that the HA missed visits on 11/11/25, 11/21/25, 11/25/25 and 11/27/25. 2) P27 was a 95-year-old patient that elected for hospice care on 06/05/25. Diagnoses include but not limited to senile degeneration of the brain, dementia, adult failure to thrive and protein-calorie malnutrition. Review of P27’s EHR conducted. For the certification period of 09/03/25 to 12/01/25, physician’s orders on 10/06/25 and patient’s care plan stated HA visits to be provided twice a week. Review of the “Clinical Charting” tab revealed that the HA missed visits on 11/11/25, 11/21/25, 11/26/25 and 11/28/25. On 12/12/25 at 09:15 AM, an interview was conducted with Clinical Director (CD) in his office. CD confirmed that the visits from the HA for both P14 and P27 were missed due to the lack of staff available to cover when the HA was on vacation. Review of facility policy titled “Interdisciplinary Plan of Care” stated, “. . . The Hospice Aide visit frequency will be determined by the Plan of Care . . .” 3) On 12/11/25 at 01:30 PM, record review of P26’s EHR was completed. P26’s start of care was 04/12/23, with a diagnosis of dysphagia and cerebral infarction. The certification period of 10/12/25 to 01/12/26 was reviewed. On 11/19/25, services were to include a once-a-month Chaplain visit. Review of the clinical notes found that there was no Chaplain visit completed for the month of November or any documentation of a missed visit.On 12/12/25 at 09:30 AM, interview with CD confirmed that the Chaplain visit was not completed and there was none scheduled for November. CD also confirmed that there was no documentation of why the visit was missed.On 12/12/25 at 12:00 PM, review of the facility’s “Interdisciplinary Plan of Care” policy, dated 03/22/24, in the “Interdisciplinary Group Expectations” section, it reads “C. Spiritual Care 2. At minimum, Chaplain should visit the patient/family at least 2 times a month...” 4) P28’s election of hospice care was 05/23/25. The certification period of 08/21/25 to 11/18/25 was reviewed. A review of P28’s plan of care and physician’s order indicated that P28 was to receive hospice aide visits two times per week, effective 11/12/25.Review of P28’s EHR found between 11/09/25 to 11/15/25 the hospice aide visited the patient once, on 11/10/25, with no additional visit documented for that week. Review of missed visit documentation showed the visit scheduled on 11/14/25 wad missed due to hospice aide being “out sick” and “holiday.” On 12/12/25 at 08:53 AM, an interview was conducted with Hospice Manager (HM) 1. HM1 confirmed the hospice aide visited P28 once between 11/09/25 and 11/15/25 and confirmed the patient should have received two hospice aide visits during that week.”

“Based on observation, interview and record review, the facility failed to ensure staff were following professional standards of practice to prevent the transmission of infections and other disease-causing pathogens. The staff was using gloves that were kept in his pocket and did not perform hand hygiene between glove changes.Findings Include: Patient (P) 25 elected for hospice care on 06/07/24 and lives at a foster home. Diagnoses included but not limited to Pick’s disease (progressive brain disorder causing nerve cell loss leading to behavioral changes and language problems), dementia, and dysphagia.On 12/10/25 from 08:35 AM to 09:32 AM, observed Hospice Aide (HA) 12 provide care to P25. The list of tasks for HA12 to perform included bed bath with peri care, shaving, applying lotion to skin, nail care, oral care, and change bed linens and clothes. Observed HA12 change gloves appropriately between tasks three times but was getting the gloves from his pocket and was not performing hand hygiene between glove changes.On 12/12/25 at 11:10 AM, an interview with Hospice Manager (HM)1 was conducted in the conference room. HM1 confirmed that staff are not to keep gloves to be used in their pockets to prevent contaminating them before use. HM1 added that staff are expected to perform hand hygiene immediately after removing their gloves.Review of facility policy with subject “Infection Control for Hospice Associates, Patients/Families, and Caregivers” dated 03/22/24 stated, “. . . Associates shall store personal protective equipment (gloves, goggles, mask, gown or apron) in the bag or car stock at all times. . .”Review of facility policy with subject “Hand Hygiene” dated 02/15/23 stated, “. . . Use an Alcohol Based Sanitizer . . . Immediately after glove removal . . .””

“Based on observation and interviews, the facility failed to ensure the inpatient kitchen stored food for patients under sanitary conditions, places the patients at risk for illness.Findings Include: During observations and concurrent interview with Dietary Aide (DA) on 12/09/25 at 02:30 pm in the inpatient kitchen, the following was observed:The patient refrigerator #1 door had a sign that was posted on 11/08/2017 by head nurse indicating the following:1) All foods MUST be labeled with name of patient and family2) All foods MUST be dated3) All food WILL be discarded after 48 hours4) Ice cream and other less perishable food MUST be labeled & dated5) The above WILL be discarded per label expiration date6) Patient Food Only in kitchen refrigerator In the patient refrigerator #1, there was a beef base container used for soup preparation without an open and discard date. The DA noted that he would discard the beef base when the rest of the soup bases are expired. There was also a pink dessert covered with clear wrap without a discard date. The DA stated that it was not labeled as he was going to serve it to a patient that day. In the patient freezer #2, there were multiple ice cream containers labeled with patient’s names, but no receive or discard date. The DA acknowledged that the staff forgets to date the food they receive from family members.On 12/10/25 at 03:00 PM, interview with Hospice Manager (HM) 1 noted that staff should have been labeling each food items with an open and discard date. HM1 further noted that she already spoke with DA and undated and unlabeled items were immediately discarded. HM1 stated that the staff will be educated on the proper labeling of food items moving forward.On 12/12/25 at 10:00 AM, review of the facility’s “Dietary Sanitation” policy, with an issue date of 04/24/24, in the “Dietary Aide Responsibilities” section, it reads “6b. Ensure that all nutritional products and supplies are stored appropriately: i.e. canned goods and other supplies are to be dated...””