Mercyone Genesis

“Based on home visit observations, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 1 of 3 sampled patients with home observation visits in a private home (Patient #1). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency’s policy titled Medication Management/Administration and Medication Regimen Review, dated June 2025, a nurse will perform a medication reconciliation during every home visit to assess the patient’s current medication list and update it with any changes. During an interview on 7/15/26 at 10:00 AM, the Administrator stated a Drug Regimen Review (DRR) is completed on admission, reviewed during every routine skilled nurse visit and discussed at every Interdisciplinary Group (IDG) meeting. Patient #1 had a hospice admission date of 5/7/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 6/24/26 to 8/22/26, identified the patient had diagnoses of Parkinson’s disease and dementia and included physician orders for medication and skilled nursing services. b. The IDG update to the comprehensive assessment and POC, dated 7/8/26, identified a DRR completed and no changes made to the patient’s medication profile. c. During a home observation visit on 7/14/26 at 9:00 AM with Staff C, Registered Nurse (RN), the surveyor reviewed the pre-filled medication packets the patient receives from the pharmacy and identified the following discrepancy: The prefilled medication packets included losartan potassium 50 milligram tablets with instructions to take 1 tablet by mouth every day. The agency medication profile, printed on 7/13/26 failed to include losartan potassium as a medication the patient currently takes. During an interview at the same observation visit, Staff C, RN, confirmed the patient has taken the medication for greater than 3 months and it should have been listed on the patient’s medication profile. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator and the Compliance Specialist.”

“Based on agency policy, staff interview and clinical record reviews, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 2 of 9 sampled patients with a wound (Patients #7 and #21). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients’ wound status and effectiveness of treatments and interventions. Findings include: 2. Patient #21 had a hospice admission date of 5/23/26, and received hospice services from the Illinois office while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 5/23/26 to 8/20/26, included primary diagnosis of Congestive Heart Failure and orders for skilled nursing, social work and chaplain services. b. Skilled nurse visit note, dated 5/26/26, completed by Staff E, RN, included documentation a penile sore had developed, but lacked documentation of a wound assessment and measurements. c. Skilled nurse visit note, dated 6/2/26, completed by Staff E, RN, included documentation of irritation to penile area, but lacked documentation of a wound assessment and measurements. d. Skilled nurse visit notes, dated 6/5/26, 6/9/26, 6/12/26, 6/16/26, 6/19/26, 6/23/26, 6/26/26, 6/30/26, completed by Staff E, RN, included documentation wound from catheter, penile area, but lacked documentation of a wound assessment and measurements. During an interview on 7/21/26 at 4:05 PM, Administrator reported she would expect a wound assessment and/or measurements to be documented for this wound. The clinical record failed to include weekly wound measurements. The above findings were reviewed with the Administrator and Compliance Specialist. According to agency policy titled Hospice Wound Care Documentation, dated 1/18/17, hospice nurses will document wound care once weekly. Documentation will include measurements of length, width and depth, the number and location of wounds, description and wound type (specify pressure ulcer, venous stasis ulcer, abrasion, etc...), staging if possible, and any ordered wound care treatments.During an interview on 7/15/26 at 10:00 AM, the Administrator reported that the expectation for wound assessment is that wounds are assessed and measured every week including the type, description, measurements and then uploaded into the electronic medical record (EMR). 1. Patient #7 had a hospice admission date of 4/17/26, and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care (POC), dated 4/17/26 to 7/15/26, included primary diagnosis of congestive heart failure and orders for skilled nursing, social work and chaplain services and the patient had a wound to the buttocks.b. Skilled nurse visit note, dated 5/12/26, completed by Staff Q, RN, failed to include assessment of the patient’s buttock wounds. c. Skilled nurse visit note, dated 5/27/26, completed by Staff S, RN, failed to include assessment of the patient’s buttock wounds. The clinical record failed to include weekly wound measurements.”

“Based on staff electronic mail (email), in- service education training documentation, and hospice policy review, the hospice failed to maintain documentation for 2 of 5 sampled hospice aides, hired prior to last survey date 8/23/23, completed a minimum of 12 hours of in-service educational training annually (Staff I and Staff J). The agency employed 14 hospice aides at the time of the survey. Failure to have hospice aides receive 12 hours of in-service training annually increased the potential that hospice aides lacked updated and current information related to the care provided by the hospice aides. Findings include: According to hospice policy, titled Hospice Aide Orientation, dated 6/2025, the aide must receive at least 12 hours of in-service training during each 12 month period. 1. Staff I, Hospice Aide, had a hire date of 6/25/18. Staff I’s personnel file contained documentation of 4.25 in-service hours in 2024 and 9.25 in-service hours in 2025. In an email, dated 7/21/26 at 12:05 PM, the Administrator confirmed that Staff I, Hospice Aide, does not have additional in-service hours. 2. Staff J, Hospice Aide, had a hire date of 8/7/23. Staff J’s personnel file lacked documentation of any in-service hours for 2024 and 2025. In an email, dated 7/20/26 at 3:22 PM, the Administrator confirmed Staff J, Hospice Aide, does not have any documented in-service hours. The above findings were reviewed with the Administrator and Compliance Specialist.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the registered nurse developed hospice aide instructions for patient care that were specific and individualized to the patients’ needs for 6 of 18 patients receiving hospice aide services (Patients #1, #7, #8, #9, #11 and #12). Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task leads to the potential risk that patients may fail to receive necessary services ordered on the plan of care. Findings include: 4.Patient #7 had a hospice admission date of 4/17/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/17/26 to 7/15/26, identified the patient had a diagnosis of vascular dementia, orders for hospice aide services twice a week and the patient was forgetful. b. The aide care plan, dated 4/22/26, included aide instructions to perform a shower per patient request and to shave the patient per patient request.The hospice RN failed to include patient specific instructions with specific frequencies of cares based on the patient’s needs. 5.Patient #11 had a hospice admission date of 11/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/20/26 to 7/18/26, identified the patient had diagnoses of Alzheimer’s disease, orders for hospice aide services twice a week and the patient was forgetful and disoriented. b. The aide care plan, dated 11/24/25, included aide instructions to perform a shower per patient request. The hospice RN failed to include patient specific instructions with specific frequencies of cares based on the patient’s needs. 6.Patient #12 had a hospice admission date of 10/18/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 6/4/26 to 8/2/26, identified the patient had diagnosis of frontotemporal neurocognitive disorder, orders for aide services twice a week and the patient was minimally alert and nonverbal. b. The aide care plan, dated 10/9/25, included aide instructions to perform a shower per patient request and to shave the patient per patient request.The hospice RN failed to include patient specific instructions with specific frequencies of cares based on the patient’s needs. The above findings reviewed with the Administrator and Compliance Specialist. According to the agency policy titled Interdisciplinary Group (IDG), dated August 2024, a registered nurse member of the IDG is designated as the Registered Nurse (RN) Case Manager for each patient and caregiver. The RN Case Manager is responsible for coordinating the care and services provided by the IDG. During an interview on 7/15/26 at 10:00 AM, the Administrator stated the RN seeing the patient and/or the RN case manager is responsible for developing the aide care plan. 1.Patient #1 had a hospice admission date of 5/7/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 6/24/26 to 8/22/26, identified the patient had diagnoses of Parkinson’s disease and dementia and included orders for aide services twice a week. b. The aide care plan, dated 5/16/25, included aide instructions to perform a shower per patient request. c. The start of care comprehensive assessment, dated 5/7/25, completed by Staff R, RN, identified the patient had dementia due to Alzheimer’s disease, alert, forgetful and confused. The hospice RN failed to include patient specific instructions with specific frequency of care based on the patient’s needs. 2. Patient #8 had a hospice admission date of 6/24/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 6/24/26 to 9/21/26, identified the patient had a diagnosis of Alzheimer’s disease and included orders for aide services twice a week. b. The aide care plan, dated 6/26/26, included aide instructions to perform a shower per patient request. c. The start of care comprehensive assessment, dated 6/24/26, completed by Staff T, RN, identified the patient the patient had Alzheimer’s disease, the patient is forgetful and has nonsensical speech at times. The hospice RN failed to include patient specific instructions with specific frequency of care based on the patient’s needs. 3. Patient #9 had a hospice admission date of 1/16/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 1/16/26 to 4/15/26 and 4/16/26 to 7/14/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for aide services twice a week. b. The aide care plan, dated 4/25/26, included aide instructions to perform a partial/sponge bath 5 times per week. The hospice RN failed to include patient specific instructions with an accurate frequency of care based on the patient’s assessed needs.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure registered nurses performed a hospice aide supervisory visit at least once every 14 days for 2 of 16 sampled patients (Patients #2 and #12) that received hospice aide services for 14 days or longer. Failure to supervise hospice aides at least every 14 days placed patients at risk for a delay in identification of potential problems and/or patient needs and placed patients at risk for not receiving the services needed to meet the assessed patient needs. Findings include: 2. Patient #2 had a hospice admission date of 5/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/18/26 to 7/16/26, identified the patient had a primary diagnosis of multiple sclerosis and included orders for skilled nurse and hospice aide services. b. The skilled nurse visit note, dated 6/8/26, signed completed on 6/8/26 by Staff O, RN, included hospice aide supervision. c. The skilled nurse visit note, dated 6/23/26, signed completed on 6/23/26 by Staff U, RN, included hospice aide supervision (1 day late per regulation). The RN failed to supervise hospice aide services every 14 days. The above findings were reviewed with the Administrator and Compliance Specialist. According to the hospice policy titled Clinical Supervision, dated 10/1/02, an RN, or Therapist, must make an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the aide. During an interview on 7/15/26 at 9:16 AM, Staff V, Registered Nurse (RN), reported that hospice aide supervision is usually performed every visit, but is required to be performed at least every 2 weeks. 1. Patient #12 had a hospice admission date of 10/18/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The plan of cares (POC), dated 4/5/26 to 6/3/26 and 6/4/26 to 8/2/26, identified the patient had a primary diagnosis of frontotemporal neurocognitive disorder and included orders for skilled nurse and hospice aide services. b. The skilled nurse visit note, dated 5/27/26, signed completed on 5/27/26 by Staff E, RN, included hospice aide supervision. c. The skilled nurse visit note, dated 6/17/26, signed completed on 6/17/26 by Staff T, RN, included hospice aide supervision (21 days late per regulation). The RN failed to supervise hospice aide services every 14 days.”

“Based on staff electronic mail (email), personnel record review and agency policy review, the hospice failed to document annual direct supervision of hospice aides for 6 of 6 sampled hospice aides hired prior to 2026 (Staff I, Staff J, Staff K, Staff L, Staff M and Staff N). Failure of the hospice to maintain documentation of the annual supervision of hospice aides by registered nurses increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: According to the hospice policy, titled Hospice Aide Orientation, dated 06/2025, the aide must be supervised by a registered nurse and the hospice must maintain documentation that demonstrates regulatory requirements are met. According to the hospice policy, titled Evaluation of Field Staff, dated 09/2024, home evaluation visits of hospice aides will be conducted at a minimum of annually by the appropriate supervisor, registered nurse, therapist or designee. In an email, dated 7/21/26 at 12:52 PM, the Administrator reported the hospice does not have annual direct supervision documented for the requested hospice aides for 2024 and 2025. Hospice had leadership turnover and are unable to locate the files. 1. Staff I, Hospice Aide, had a hire date of 6/25/18. Staff I’s personnel file lacked documentation of annual direct supervision for 2024 and 2025. 2. Staff J, Hospice Aide, had a hire date of 8/7/23. Staff J’s personnel file lacked documentation of annual direct supervision for 2024 and 2025. 3. Staff K, Hospice Aide, had a hire date of 11/27/17. Staff K’s personnel file lacked documentation of annual direct supervision for 2024 and 2025. 4. Staff L, Hospice Aide, had a hire date of 5/18/25. Staff L’s personnel file lacked documentation of annual direct supervision for 2025. 5. Staff M, Hospice Aide, had a hire date of 4/22/24. Staff M’s personnel file lacked documentation of annual direct supervision for 2024 and 2025. 6. Staff N, Hospice Aide, had a hire date of 1/9/23. Staff N’s personnel file lacked documentation of annual direct supervision for 2024 and 2025. The hospice failed to document annual direct supervision for requested hospice aides. The above findings were reviewed with the Administrator and Compliance Specialist.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained accurate, up-to-date and complete information for 2 of 9 sampled patients requiring an indwelling catheter (Patients #13 and #21). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without accurate information related to the patient’s condition and needs. Findings include: 2. Patient #21 had a hospice admission date of 5/23/26, and received hospice services from the Illinois office while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 5/23/26 to 8/20/26, included primary diagnosis Congestive Heart Failure and orders for skilled nursing, social work and chaplain services. b. Skilled nurse visit note, dated 6/23/26, completed by Staff E, RN, included documentation foley catheter: yes, last inserted: 5/18/26, next planned replacement: 6/18/26, catheter due to be changed tonight. c. Skilled nurse visit note, dated 6/26/26, completed by Staff E, RN, included documentation foley catheter: yes, last inserted: 5/18/26, next planned replacement: 6/18/26. d. Skilled nurse visit note, dated 6/30/26, completed by Staff E, RN, included documentation foley catheter: yes, last inserted: 6/23/26, next planned replacement: 7/23/26. Skilled nurse visit note, dated 6/26/26, failed to identify the updated insertion date of foley catheter and next planned replacement date. The clinical records failed to include accurate and up-to-date patient information. The above findings were reviewed with the Administrator and Compliance Specialist. According to the agency policy titled Documentation Timeframe, dated September 2024, all staff are required to complete clinical documentation in the patient’s electronic health record in a timely, accurate and complete manner. 1.Patient #13 had a hospice admission date of 4/26/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 4/26/26 to 7/24/26, identified the patient had a primary diagnosis of Parkinson’s disease and included orders for skilled nursing, social work and chaplain services. b. The clinical record included a physician order for the skilled nurse to insert a standard indwelling catheter, size 16 French (Fr) with 10 milliliters (ml) sterile water balloon) per request of the patient or caregiver. c. The skilled nurse visit note, dated 6/8/26, completed by Staff H, Registered Nurse (RN), included documentation a size 16 Fr with 10 ml balloon was inserted per the patient and caregiver request. d. The skilled nurse visit notes, dated 6/11/26, 6/18/26, 6/22/26, 6/25/26, 6/29/26 and 7/2/26, included documentation the patient had a foley catheter size 20 Fr with 10 ml balloon inserted on 6/8/26. e. The skilled nurse visit note, dated 7/6/26, completed by Staff H, RN, included documentation the catheter replaced using a foley catheter size 22 French 10 ml balloon. During an interview on 7/22/26 at 9:15 AM, the Administrator identified the RN who inserted the foley catheter on 6/8/26 and changed the catheter on 7/6/26 was not available for interview due to being scheduled off work. The clinical records failed to include accurate information related to catheter size.”

“Based on staff interview and clinical record review the hospice failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards for 2 of 8 sampled patients with music therapy services (Patients #11 and #12). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: During an interview 7/21 at 4:11 PM, the Administrator reported that Staff P, Music Therapist, is the owner of the music therapy company the agency is contracted with and likely wrote 3rd party as a title because of that. The Administrator reported that it is unknown as to why Staff P did not use an appropriate discipline title when the visit note was signed. 1.Patient #11 had a hospice admission date of 11/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The Plan of Care (POC) dated 5/20/26 to 7/18/26 identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, hospice aide, chaplain, volunteer, social work and music therapy services. b. The music therapy visit note, dated 6/1/26, completed by Staff P, Music Therapist, lacked an accurate title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation. 2.Patient #12 had a hospice admission date of 10/18/23 and received hospice services while residing in a private residence. Clinical record review revealed: a.The POC dated 4/5/26 to 6/3/26 identified the patient had a primary diagnosis of frontotemporal neurocognitive disorder and included orders for skilled nurse, hospice aide, chaplain, volunteer, social work and music therapy services. b. The music therapy visit note, dated 6/3/26, completed by Staff P, Music Therapist, lacked an accurate title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation. The above findings reviewed with the Administrator and Compliance Specialist.”

“Based on staff interview, clinical record review and agency policy review, the hospice failed to ensure the hospice staff sent a copy of the patient’s discharge summary to the receiving facility for 1 of 1 sampled patients transferred to a facility at the time of discharge (Patient #25). Failure to ensure the hospice staff included the receiving facility in the process of discharge placed the patient at risk for not receiving ongoing medical care and services necessary to meet the needs of the patient. Findings include: According to the agency policy titled Documentation Timeframe, dated September 2024, agency discharge and transfer assessments and summaries should be completed as soon as possible. Patient #8 had a hospice admission date of 6/6/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 6/6/26 to 9/3/26, identified the patient had a primary diagnosis of atrial fibrillation and included orders for skilled nurse, social work and chaplain services. b. The skilled nurse coordination note, dated 6/9/26, completed by Staff G, Registered Nurse (RN), identified the patient went to the hospital last night/early this morning due to a fall and was admitted to the hospital. Hospice team was not contacted at the time of the fall. Caregiver chose to revoke hospice care to seek treatment. c. The clinical record failed to include documentation a discharge summary was completed and forwarded to the receiving facility. During an interview on 7/22/26 at 9:16 AM, the Administrator stated the discharge summary was sent to the patient’s primary care physician, not to the receiving facility. The above findings were reviewed with the Administrator and Compliance Specialist.”

“Based on staff interview, clinical record reviews, review of nursing home plans of care and agency policy review, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patients treatments/interventions for 1 of 2 sampled patients with nursing home observation visits (Patient #2). Failure to ensure the hospice staff provided overall coordination of the patient’s treatments/interventions with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: According to the hospice agency policy titled Hospice Care in a Nursing Facility, dated December 2024, hospice assumes full responsibility for the professional management of the patient’s hospice care. Hospice designates a member of each Interdisciplinary Group (IDG) that is responsible for providing overall coordination of hospice care for the facility resident. During an interview on 7/15/26 at 9:16 AM, Staff V, Registered Nurse (RN), stated the hospice provides nursing facilities with plans of care and updated plans of care and they are placed in a binder in the nursing home. The hospice team communicates with nursing home staff by phone call in between visits and in person during visits. Patient #2 had a hospice admission date of 5/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 5/18/26 to 7/16/26, identified the patient had a primary diagnosis of multiple sclerosis and included IDG orders for skilled nurse to change the patient’s suprapubic catheter, size 16 French (Fr), 10 milliliters (ml) balloon monthly and as needed for occlusion. b. Review of the nursing home plan of care, dated 7/14/26, included orders to change the suprapubic catheter with an 18 Fr 10 ml balloon 2 times a month and as needed, order start date 11/15/23. Hospice staff failed to ensure the overall coordination of the patient’s treatments/interventions with the nursing home. The above findings were reviewed with the Administrator and Compliance Specialist.”

“Based on observation and staff interview, the hospice failed to ensure food and drink items were stored properly to ensure expired foods were not prepared and served to hospice patients at the hospice house. The hospice reported 6 current patients residing at the hospice house at the time of the survey. Failure to ensure food and drink items stored were not expired placed hospice patients at risk of potentially receiving and consuming expired food and drink items which were not palatable and attractive. Findings include: On 7/16/26 beginning at 8:20 AM, during an observational tour of the facility with the Hospice Administrator, the surveyor observed a liter bottle of cranberry juice that was half empty and lacked an opened date, a liter bottle of prune juice that was less than half empty and lacked an opened date, and 3 Ziploc baggies of cheese slices that lacked identification of what the food was and an expiration date. In an interview during the same observational tour, the Administrator reported hospice staff are to label and date all foods in the refrigerator. The hospice has color coded dated stickers for staff use. During an interview on 7/22/26 at 8:05 AM, Staff K, Hospice Aide, reported hospice staff are to date multi use containers when opened, that way they know when to dispose of the contents. The above findings were reviewed with the Administrator and Compliance Specialist.”

“Based on record review and interview, the facility did not maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition, 14.6.2.4, 14.3.1, and 14.4.5, by not ensuring the fire alarm system is inspected on a semiannual basis, and by failing to provide inspection, testing, and maintenance records that include all required information for the fire alarm system. The deficient practice of not conducting semiannual inspections of the fire alarm system and ensuring all required information is available does not ensure proper operation and prompt repair, affecting all occupants. This facility had a capacity of 16 and a census of 6 residents at the time of the survey. Findings include:1. Record review on 7/13/2026 between 10:50 a.m. and 11:04 a.m., of the fire alarm inspection and testing forms conducted by Xenotronics revealed the fire alarm system was not inspected on a semiannual basis as required. The facility provided documentation of inspection by Xenotronics dated June 2026, 5/14/2025, and 12/19/2023, these were the last available documentation for the inspection of the fire alarm system. The inspection tags left on the fire alarm panel by Xenotronics also aligned with these inspection dates. 2. Record review and interview on 7/13/2026 between 10:50 a.m. and 11:04 a.m. of the facility’s fire alarm inspection records, revealed the inspection reports provided to the facility by Xenotronics dated June 2026 and 5/14/2025 did not list 100% of devices connected to the fire alarm system per NFPA standards for a full itemized device list. These items should include a device test results sheets that individually list all alarm notification appliances (audible/visual devices, visual devices, fire detectors, CO detectors), devices connected to the fire alarm system (door holders, smoke dampers, locks), hood suppression system, elevator system, and tampers/flows devices, or interface relays and include the device type, address, location, and test results for each device. The report from June 2026 only consisted of a cover page indicating when the inspection occurred, but no other information or detailed report was available. The report from 5/14/2025 listed some of the required devices (strobes and hornstobes) as well as a sensitivity list that listed zones and locations such as laundry and L/L electrical, etc. but did not list what the devices being tested were. The June 2026 report was missing all device list items and the 5/14/2025 report was missing:1. Smoke detectors2. Heat detectors3. Manual pulls4. Duct detectors5. Water flow devices6. High/low pressure switches, including the PIV valve on the sprinkler system7. Tamper switches8. Door hold opens9. Elevator10. Hood suppression system in the KitchenFurther record review revealed the report provided by Xenotronics on 12/19/2023 did include a fully itemized device list which individually listed all items connected to the fire alarm and all items listed above which were absent from the 5/14/2025 report, but the 2023 report was the last available report with all required information. Each time the fire alarm company performs an inspection, a complete itemized list of devices needs to be included which individually lists out all devices connected to the fire alarm system regardless of if the fire alarm company specifically tests them (i.e. waterflow, tampers, etc.). If a device is connected to the fire alarm system it is required to be listed.The Maintenance Staff and Administrator verified the documentation during the survey and exit interview.”

“Based on record review, observation, and interview, the facility failed to inspect, test, and maintain the automatic sprinkler system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1 and 13.4.4.2.2.2, by not ensuring the three-year trip test is performed and by not ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. These deficient practices could affect all occupants within the facility. The facility had a capacity of 16 and a census of 6 residents at the time of the survey. Findings include:1. Record review and observation on 7/13/2026 between 11:10 a.m. and 11:50 a.m., revealed the facility failed to have the three-year trip test for the Dry pipe sprinkler system performed as required. The annual report provided to the facility by Tri-State on 4/8/2026 listed the three-year trip test date as 5/19/2023. During the walk of the facility, the inspection tags on the sprinkler system riser also confirmed the last three-year full trip test of the Dry sprinkler system as 5/19/2023 and is currently due.2. Observation on 7/13/2026 at 12:53 p.m., revealed two dirty sprinkler heads covered in dust located in the front lobby seating area and next to the elevator. Both of these sprinkler heads were located next to vents.3. Observation on 7/13/2026 at 1:02 p.m., revealed a dirty sprinkler head covered in dust located in the laundry room down the Rooms 109-117 Hall.4. Observation on 7/13/2026 at 1:05 p.m., revealed a dirty sprinkler head covered in dust located next to Room 112 in the hall. This sprinkler was located next to a vent. The Administrator verified these findings during the exit interview.”

“Based on record review the facility failed to provide an adequate fire safety plan and evacuation and relocation plan and procedure in case of fire for the evacuation of the building’s smoke zones directly affected by fire in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1 and 19.7.2. This deficient practice affects all residents, staff, and visitors. The facility had a capacity of 16 and a census of 6 residents at the time of the survey. Findings include:Record review on 7/13/2026 at 12:28 p.m. of the facility’s fire safety plan within the Maintenance Binder and Emergency Preparedness Plan, revealed the plan did not include training or procedures for the use of the Ansul hood suppression system in the Kitchen and where the specific pull station for the hood system is located. All staff need to be trained how to activate the Kitchen hood suppression system and the use thereafter of the Type K fire extinguisher, in the event of a fire in the Kitchen when Kitchen staff are not present. The plan also did not list the different types of fire extinguishers located throughout the facility to include: Type ABC and the Type K located specifically within the Kitchen.The Administrator acknowledged the documentation during the exit interview.”

“Based on record review, the facility failed to conduct fire drills under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 16 and a census of 6 residents at the time of survey. Findings include:Record review on 7/13/2026 at 10:25 a.m. of the facility’s fire drill documentation, revealed first, second, and third shift drills were conducted at approximately the same time of day.Three first shift drills were conducted between 11:15 a.m. and 12:00 p.m.: on 3/30/2026 at 11:15 a.m., on 12/30/2025 at 11:30 a.m., and on 6/16/2026 at 12:00 p.m..Four second shift drills were conducted between 3:00 p.m. and 3:30 p.m.: on 12/30/2025 at 3:00 p.m., on 9/25/2025 at 3:30 p.m., on 3/26/2026 at 3:30 p.m., and on 6/18/2026 at 3:30 p.m..Four third shift drills were conducted between 6:00 a.m. and 6:25 a.m.: on 9/25/2025 at 6:00 a.m., on 12/31/2025 at 6:00 a.m., on 3/31/2026 at 6:00 a.m., and on 6/23/2026 at 6:25 a.m.. The Administrator and Maintenance Staff verified the documentation during the survey and exit interview.”

“Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice could affect all smoke compartments and all residents, staff, and visitors. The facility had a capacity of 16 and a census of 6 residents at the time of the survey. Findings include:Record review on 7/13/2026 at 1:27 p.m., revealed the facility was unable to provide the minimum required documentation of non-hospital-grade receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview with the Maintenance Staff and Administrator revealed they were unsure if the receptacles within the rooms were hospital-grade or not, but upon walking the facility, the receptacles located throughout the rooms were not listed as hospital-grade. In either case, no record of testing for non-hospital-grade or initial installation of hospital-grade receptacles was available.NFPA 99 Health Care Facilities Code, 2012 edition, 6.3.4.2 Record Keeping.6.3.4.2.1.2 At a minimum, the record shall contain the date,the rooms or areas tested, and an indication of which itemshave met, or have failed to meet, the performance requirementsof this chapter.The Administrator verified the finding at the time of the survey and exit interview.”

“Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments to meet the needs of the patient for 2 of 5 sampled patients (Patients #1 and #5). Failure to ensure the plan of care included physician orders for all necessary medications, treatments and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to the hospice policy, titled Interdisciplinary Plan of Care, dated 8/2025, identified the plan of care will include drugs and treatment necessary to meet the needs of the patient. 1. Patient #1 had a hospice admission date of 9/30/25 and received services from the hospice while residing in an assisted living facility. Clinical record review revealed: a. Plan of Care, dated 9/30/25 to 12/28/25, included primary diagnosis of atrial fibrillation and interim physician orders for Eliquis 2.5 mg (milligrams) twice daily, levetiracetam (Keppra) 250 mg twice daily, melatonin and pantoprazole (Protonix). b. Interim physician order, dated 10/1/25, identified to discontinue melatonin. c. Interim physician order, dated 10/13/25, identified to discontinue Protonix. d. IDG (Interdisciplinary Group) update to the plan of care, dated 10/15/25, included physician orders for Melatonin and pantoprazole with start dates of 9/14/25. e. Interim physician order, dated 10/23/25, identified to discontinue Eliquis 2.5 mg twice a day and start Eliquis 2.5 mg daily, and to discontinue Keppra 250 mg twice a day and to start Keppra ER (extended release) 500 mg daily. f. IDG updates to the plan of care, dated 10/29/25 and 11/12/25, included physician orders for melatonin, pantoprazole, Eliquis 2.5 mg twice a day with a start date of 9/14/25, Eliquis 2.5 mg daily with a start date of 10/23/25, levetiracetam (Keppra) 250 mg twice a day and Keppra XR (extended release) 500 mg daily. The hospice RN (registered nurse) failed to identify the incorrect medication orders and duplicate medication orders on the IDG update/s to the plan of care and correct them. During an interview on 11/25/25 at 1:50 PM, Administrator/Clinical Manager reported the incorrect medication order dates might be related to staff entering the medications into the pharmacy provider site before entering the physician order in the electronic medical record. 2. Patient #5 had a hospice admission date of 8/7/24, a death date of 9/11/25 and received services from the hospice while residing in a long-term care facility. Clinical record review revealed: a. Interim physician order, dated 8/20/25, identified to discontinue alprazolam 0.25 mg tablet give 1 tablet twice a day every morning and at bedtime, discontinue alprazolam 0.25 mg tablet give 1/2 tablet daily at 1200, and start alprazolam 0.25 mg tablet give 1 tablet three times a day (every morning, 1200 and bedtime). b. IDG update to the plan of care, dated 9/3/25, included physician orders for alprazolam 0.25 mg tablet give 1 tablet three times a day (every morning, 1200 and bedtime) with a start date of 8/20/25, and alprazolam 0.25 mg 1 tablet three times a day with a start date of 8/30/24. The hospice RN failed to identify the duplicate medication order on the IDG update to the plan of care and correct the orders. The above findings were reviewed with the Administrator/Clinical Manager.”

“Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 5 sampled patients (Patient #5). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: According to the hospice policy, titled Interdisciplinary Group, dated 8/2024, the IDG is responsible for documenting all care and services provided in a timely manner in accordance with the Hospice’s documentation requirements. According to the hospice policy, titled Interdisciplinary Plan of Care, dated 8/2025, the Plan of Care will include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Reviews of and changes to the plan of care are documented and communicated to members of the IDG. Patient #5 had a hospice admission date of 8/7/24, a death date of 9/11/25 and received services from the hospice while residing in a long-term care facility. Clinical record review revealed: a. IDG update to the Plan of Care, dated 7/16/25, included physician orders to provide volunteer services one time a week. b. Volunteer visit notes were completed, dated 7/15/25, 7/29/25 and 8/5/25. c. IDG update to the Plan of Care, dated 7/30/25, lacked documentation the IDG was notified of the missed volunteer visit for the week 7/20/25 through 7/26/25. d. IDG updates to the Plan of Care, dated 8/13/25, 8/20/25 and 9/3/25, lacked documentation the IDG was notified of missed volunteer visits after 8/5/25. During an interview on 11/25/25 at 2:15 PM, Administrator/Clinical Manager reported she had contacted the volunteer coordinator and the hospice had no other volunteer visit notes. The hospice failed to provide volunteer visits as ordered per the IDG updates to the Plan of Care. The above findings were reviewed with the Administrator/Clinical Manager.”