St Catherine’s Hospice, LLC

“Based on interviews and record reviews, the agency failed to ensure the patients received care and services per their plan of care and physician orders for 2 (Patient #16, Patient #17) of 19 sampled patients reviewed for plan of care implementation. Findings: Patient #16Review of Patient #16’s Hospice Certification and Plan of Care for the period of 02/12/2026 through 05/07/2026 revealed, in part, the medical social worker (MSW) was to provide services once a month for the first month, then three times a month for the second month. Review of Patient #16’s record revealed the only MSW visits completed in March 2026 were on 03/10/2026 and 03/27/2026. Further review revealed no evidence that a third MSW visit was completed or documentation as to why the third ordered MSW visit was not completed. In an interview on 08/13/2026 at 3:24PM, S2Alternate Administrator indicated the agency had no explanation as to why the third MSW visit was not completed in March 2026 per the plan of care. Patient #17Review of Patient #17’s Hospice Certification and Plan of Care for the period of 07/12/2025 through 10/09/2025 revealed, in part, Patient #17 was to receive hospice aide services effective 07/13/2025 for a frequency of once a week for one week, then three times a week for six weeks. Review of Patient #17’s record revealed the following, in part:-No evidence of any hospice aide visits were completed or attempted the week of 07/13/2025 through 07/19/2026;-During the week of 07/27/2025 through 08/02/2025 a hospice aide visit was attempted on 07/29/2025, and a visit was completed on 07/31/2025; however, there was no evidence of a third hospice aide visit being completed or attempted;-During the week of 08/03/2025 through 08/09/2025 a hospice aide visit was completed on 08/05/2025, and a visit was attempted on 08/07/2025; however, there was no evidence of a third hospice aide visit being completed or attempted;-During the week of 08/10/2025 through 08/16/2025 a hospice aide visit was completed on 08/12/2025 and 08/14/2025; however, there was no evidence of a third hospice aide visit being completed or attempted; and,-During the week of 08/17/2025 through 08/23/2025 a hospice aide visit was attempted on 08/19/2025, and a hospice aide visit was made on 08/21/2025; however, there was no evidence of a third hospice aide visit being completed or attempted. In an interview on 08/13/2026 at 3:37PM, S3Consultant indicated the agency had no evidence to to dispute the above mentioned deficient practice. In an interview on 08/13/2026 at 3:38PM, S2Alternate Administrator indicated the agency had no evidence to dispute the above mentioned deficient practice.”

“Based on interviews and record reviews, the agency failed to ensure the skilled nurse communicated with the patient’s physician when a patient had a change in condition for 1 (Patient #9) of 19 sampled patients reviewed for physician notification requirements. Findings: Review of Patient #9’s Hospice Plan of Care for the certification period of 04/22/2026 through 07/20/2026 revealed Patient #9 received hospice services due to a diagnosis of, in part, respiratory failure with hypoxia (condition of compromised respiratory status with decreased oxygen). Review of Patient #9’s Visit Note Report dated 07/03/2026 revealed, in part, an as needed visit was conducted at the request of Patient #9’s facility. Further review revealed Patient #9 had a temperature of 101.2 degrees Fahrenheit prior to the visit, and Patient #9’s facility nurse voiced a concern of possible aspiration (condition in which food enters the airway or lungs instead of the digestive tract). Further review of Patient #9’s 07/03/2026 Visit Note Report revealed no evidence the skilled nurse communicated with Patient #9’s physician concerning the above. Review of Patient #9’s Visit Note Report dated 07/17/2026 revealed, in part, Patient #9 had a temperature of 101.4 degrees Fahrenheit prior to the visit, which decreased to 99.4 degrees Fahrenheit with administration of Tylenol (medication which decreases fever). Further review of Patient #9’s 07/17/2026 Visit Note Report revealed no evidence the skilled nurse communicated with Patient #9’s physician concerning the above. In an interview on 08/13/2026 at 3:00PM, S2Alternate Administrator indicated the agency had no evidence that Patient #9’s physician was notified of Patient #9’s elevated temperature on 07/03/2026 or 07/17/2026, nor any evidence Patient #9’s physician was notified of the facility’s concern regarding possible aspiration. In an interview on 08/13/2026 at 3:05PM, S1Administrator indicated the nurse failed to communicate concerns with Patient #9’s fever and possible aspiration to the physician.”

“Based on interviews and record reviews, the agency failed to maintain a complete and comprehensive system for the surveillance and investigation of infectious diseases for 7 (Patient #1, Patient #2, Patient #3, Patient #9, Patient #12, Patient #14, Patient #15) of 19 sampled patients reviewed for monitoring of infections. Findings: Review of Patient #1’s Client Medication Report revealed Patient #1 was prescribed Cipro (antibiotic medication used to treat infections) 500 milligrams (mg) one tablet by mouth twice a day to treat a urinary tract infection (UTI) (infection of the bladder) on 02/19/2025. Further review revealed Patient #1 was prescribed Levofloxacin (antibiotic medication used to treat infections) 250 mg one tablet by mouth daily to treat a suspected UTI on 11/06/2025. Review of Patient #2’s Client Medication Report revealed Patient #2 was prescribed Ciprofloxacin 0.3% ophthalmic solution (antibiotic eye drops) one drop to both eyes three times a day to treat conjunctivitis (infection of the eye) on 03/02/2026. Review of Patient #3’s Client Medication Report revealed Patient #3 was prescribed Levofloxacin 500 mg one tablet by mouth daily to treat an upper respiratory infection (URI) (infection of the respiratory tract) on 03/13/2026. Further review revealed Patient #3 was prescribed Macrobid (antibiotic medication used treat infections) 100 mg one capsule by mouth twice a day to treat a UTI on 08/07/2026. Review of Patient #9’s Client Medication Report revealed Patient #9 was prescribed Levofloxacin 250 mg one tablet by mouth twice a day to treat a possible UTI on 03/04/2026. Review of Patient #12’s Client Medication Report revealed Patient #12 was prescribed Amoxicillin (antibiotic medication used to treat infections) 875 mg one tablet by mouth twice a day to treat a possible infection on 07/28/2026. Further review revealed Patient #12 was prescribed Doxycycline Hyclate (antibiotic medication used to treat infections) 100 mg one tablet by mouth twice a day to treat an infection on 07/28/2026. Review of Patient #14’s Client Medication Report revealed Patient #14 was prescribed Amoxicillin Potassium Clavulanate (antibiotic medication used to treat infections) 500 mg/125 mg one tablet by mouth three times a day to treat possible pneumonia (infection of the lungs) on 07/07/2026. Further review revealed Patient #14 was prescribed Cefdinir (antibiotic medication used to treat infections) 300 mg one tablet by mouth every 12 hours to treat a UTI. Review of Patient #15’s Client Medication Report revealed Patient #15 was prescribed Amoxicillin 500 mg one capsule by mouth twice a day to treat a URI on 03/06/2026. Review of the agency’s 2025 and 2026 Quality Improvement (QI) Event Report for Infections revealed the above mentioned patients’ infections were not captured on the agency’s infection control logs. In an interview on 08/13/2026 at 2:35PM, S4Clinical Director indicated she was responsible for the agency’s infection control program. S4Clinical Director further indicated the process for tracking and trending infections was once a clinician identified an infection and the physician prescribed medications to treat the infection, the clinician was to document the signs and symptoms of the infection, initiate an infection plan of care, and notify administration during the agency’s communication software. S4Clinical Director further indicated the clinician during the visit should also complete an infection report, which was incorporated into the agency’s infection control surveillance and investigation system. S4Clinical Director further indicated if the above mentioned patients’ medications were not listed on the agency’s QI Event Report for Infections, then administration was not aware to track the infection. In an interview on 08/13/2026 at 2:37PM, S3Consultant indicated the above-mentioned patients and medications were not captured on the agency’s QI Event Report for Infections in 2025 and 2026; therefore, the agency had not included these patients’ infections in the tracking and trending of infections for the agency.”

“Based on interviews and record reviews, the agency failed to ensure wounds were measured weekly to assess for wound healing progress for 2 (Patient #12, Patient #13) of sampled patients reviewed for weekly wound assessments. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Patient #12Review of Patient #12’s Hospice Certification and Plan of Care dated 07/28/2026 through 10/25/2026 revealed, in part, Patient #12 was to receive skilled nursing services once a week for thirteen weeks. Review of Patient #12’s Wound Record Report dated 07/28/2026 revealed Patient #12 was assessed with a stage II pressure ulcer (open wound to the skin caused by unrelieved pressure) to the coccyx (area around the tailbone) measuring 3 centimeters (cm) in length by 3 cm in width, with no depth. Further review revealed Patient #12 was assessed with a stage III (open wound which extends through the fat tissue caused by unrelieved pressure) to the left heel measuring 6 cm in length, by 6 cm in width, and 1 cm in depth. Review of Patient #12’s Visit Note Report dated 08/08/2026 revealed, in part, Patient #12 had a stage II pressure ulcer to the coccyx, and a stage III to the left heel. Further review revealed Patient #12’s wounds were not documented as being measured during the visit. Review of Patient #12’s record revealed Patient #12’s stage II coccyx pressure ulcer and Patient #12’s stage III left heel pressure ulcer had not been measured the week of 08/02/2026 through 08/08/2026. In an interview on 08/13/2026 at 3:12PM, S2Consultant indicated the agency had no evidence to present that Patient #12’s coccyx and left heel pressure ulcers were measured the week of 08/02/2026 through 08/08/2026. Patient #13Review of Patient #13’s Hospice Certification and Plan of Care dated 07/08/2026 through 07/31/2026 revealed, in part, Patient #13 was to receive skilled nursing services twice a week for one week, and then once a week for three weeks. Review of Patient #13’s Visit Note Report dated 07/08/2026 revealed, in part, Patient #13 was assessed with a traumatic (wound caused by trauma) right anterior medial pretibial (area on the front of the lower leg) wound with no measurements obtained; a left lower buttock wound. Further review revealed no evidence of any wound measurements having been obtained. Review of Patient #13’s Wound Record Report for 07/08/2026 through 08/13/2026 revealed, in part:There was no evidence that Patient #13’s traumatic right anterior medial pretibial wound was measured from 07/08/2026 through 07/21/2026, when the wound was documented as healed.There was no evidence Patient #13’s left lower buttock wound was measured from 07/08/2026 through 07/21/2026, when the wound was documented as healed.There was no evidence Patient #13’s right lower buttock wound was measured from 07/08/2026 through 07/21/2026, when the wound was documented as healed. Review of Patient #13’s Wound Record Report revealed Patient #13 developed a suspected deep tissue injury (wound caused by unrelieved pressure which presents with a bruised appearance at the base of the wound)of the right heel on 07/27/2026. Further review revealed no evidence Patient #13’s right heel wound was measured from 07/27/2026 through 08/10/2026. In an interview on 08/13/2026 at 3:20PM, S3Consultant indicated the agency had no evidence the above mentioned wounds were measured weekly as required.”