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“Based on record review and interview the registered nurse failed to ensure the written plan of care for the assigned aide provided specific guidance and care instructions on the needs of the patient for 1 (P-1) of 3 records reviewed (L-625) and registered nurse failed to ensure hospice aide services met the needs of the patient for 1 (P-3) of 3 records reviewed (L-629). The cumulative effect of these systemic problems resulted in the Hospice Agency’s inability to ensure the written plan of care is complete and accurate to meet the needs of the patient for the Condition of Participation: 42 CFR §418.76 Hospice Aide and Homemaker Services.”

“Based on record review and interview, the registered nurse failed to ensure the written plan of care for the assigned aide provided specific guidance and care instructions on the needs of the patient for 1 (P-1) of 3 records reviewed, resulting in the potential for unsafe care needs and poor patient outcomes. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 10/20/25. The Plan of Care (POC) identified a terminal diagnosis of Dementia. During record review on 3/11/26, it was noted that the “Hospice Aide Plan of Care” dated 1/21/26 completed by the registered nurse (RN) stated, “Transfer/Ambulation: Assist with transfers, one person.” The IDG Meeting Review dated 1/13/26 stated, “Activities Permitted: …Transfer assistance 2 person… Clinical Summary: Nursing Narrative: …Patient is fully dependent for all ADLs (Activities of Daily Living), non-ambulatory, chair-bound, and requires two-person transfers…” P-1 sustained a fall confirmed by video on 1/26/26 while receiving care from the lone hospice aide (Staff-E). The Aide Plan of Care failed to reflect the documented requirement of two-person transfers which could result in the potential of unsafe care needs. A review of the agency policy occurred on 3/12/26 titled “Hospice Aide Services” (Revision: 06/25/2025). The policy states, “Procedure: 3. Hospice aide services are assigned to a specific patient by a RN that is a member of the interdisciplinary group. 4. Written patient acer instructions for a hospice aide must be prepared by a hospice RN who is responsible for the supervision of the hospice aide. 5. A hospice aide provides services that are ordered by the interdisciplinary group, included in the plan of care, permitted to be performed under State law by such hospice aide, and consistent with the hospice aide’s training.”The Administrator (Staff-A) and Director of Clinical Services (Staff-B) reviewed and acknowledged the findings listed above in an interview on 3/12/26 at 9:55 am.”

“Based on record review and interview, the registered nurse failed to ensure hospice aide services met the needs of the patient for 1 (P-3) of 3 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #3 (P-3) was admitted to this hospice agency on 11/28/25 with the terminal diagnoses of senile degeneration of the brain and Alzheimer’s disease. During record review on 3/11/25, it was determined hospice aide services were ordered 2 times per week and were to include the personal care tasks of: a shower or chair/commode bath, brush/comb hair, nail care, oral hygiene, brush teeth, lotion skin, assist with dressing, companionship, and pericare.Upon review of the hospice aide visits between 11/30/25 and 1/24/26, it was determined P-3 should have received 16 hospice aide visits during that time. Of the 16 hospice aide visits that should have been completed, it was determined P-3 refused 8 times and therefore did not receive any personal care services on those days, other than companionship. Additionally, there was no documentation of communication with facility staff to ensure P-3 would receive the personal care services later in the day by facility staff or that the visit would be rescheduled to meet the ordered frequency.Upon review of the skilled nursing visit notes during that time, it was determined a skilled nurse performed supervisory visits for the hospice aide on 12/1/25 (prior to the hospice aide starting), 12/8/25, 12/11/25, 12/15/25, 12/18/25, 12/22/25, 12/24/25, 12/27/25, 12/29/25, 12/31/25, 1/8/26, 1/12/26, 1/15/26, and 1/20/26. Each of the supervisory visit notes marked “Yes” next to the to the questions that stated is the hospice aide “Following care plan?” and are “Patient’s needs being met with current care plan?” [sic]Although aide supervisory visits were performed timely per the agency policy below, there was no documentation by the skilled nurse performing the supervision to acknowledge P-3 did not receive personal care services for half of the visits ordered due to refusal. Therefore, the skilled nurse failed to accurately supervise the services provided by the hospice aide to ensure the needs of the patient were being met.A review of agency policy titled “Hospice Aide Supervisory Visits” (Policy 20.13, revised 1/12/23) revealed, “1. A registered nurse makes an on-site visit to the patient’s residence no less frequently than every 14 days, to ensure the quality of care and the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need.”During an interview with the director of nursing services (Staff B) on 3/11/26 at 3:35 PM, Staff B was asked about the findings above. Staff B stated P-3 had facility staff to help with personal care services when refused, however, Staff B acknowledged the documentation did not reflect this. Additionally, Staff B acknowledged the supervisory notes did not reflect accurate supervision of the hospice aide services provided as a result. The administrator (Staff A) was also present and acknowledged the findings at the time of interview.”

“Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs for all patients, and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 418.110(d), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 99 and 101, Life Safety Code (LSC), Chapter 21 Existing Ambulatory Health Care Occupancy, resulting in the potential for negative outcomes, up to and including death for all patients within the facility, in the event of a fire. Findings Include: See tag 827 - Fire Protection”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care for 5 (P-5, 6, 8, 15, and 17) of 27 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #15 (P-15) was admitted to this hospice agency on 8/4/25 with the terminal diagnosis of metastatic colon cancer with metastases to the brain and lungs. During record review on 8/12/25, it was noted the chaplain attempted to visit the patient on 8/5/25, however, he was unable to complete the assessment because P-15 wanted to visit with his grandmother that day. Upon further review of the record, it was determined the chaplain had not returned to complete the spiritual portion of the comprehensive assessment as of 8/13/25 – 9 days after the start of care.Patient #17 (P-17) was admitted to this hospice agency on 5/15/25 with the terminal diagnosis of end stage renal (kidney) disease. During record review on 8/13/25, it was noted the chaplain attempted to visit the patient on 5/19/25, however, he was unable to complete the assessment because P-17 was sleeping. Upon further review of the record, it was determined the chaplain had not returned to complete the spiritual portion of the comprehensive assessment as of 5/26/25 when the patient revoked his hospice benefit – 11 days after the start of care.A review of agency policy 3.13 titled “Chaplain Initial Assessments” (revised 8/11/15) revealed, “1….The chaplain initial assessment must be completed within 5 calendar days of admission.”The hospice residence director (DON-2) reviewed and acknowledged the findings during an interview on 8/13/25 at 3:03 PM. Patient #5 (P-5): This 87-year-old was admitted to the hospice on 8/5/25 with a terminal diagnosis of lung cancer with spread to the bones. The medical record was reviewed on 8/15/25. During review, it was noted that the chaplain entered a “Hospice Comprehensive Spiritual Assessment” on 8/6/25 and documented that P-5 was asleep and failed to wake up when her name was called. There was no follow-up visit to complete the spiritual assessment as of the time of this medical record review (8/15/25- 9 days after the chaplain’s initial visit).Patient #6 (P-6): This 84-year-old was admitted to the hospice on 7/28/25 with a terminal diagnosis of senile degeneration of the brain (progressive cognitive decline). The medical record was reviewed on 8/15/25. During review, it was noted that the Medical Social Worker (MSW) wrote a “Missed Visit” note on 7/31/25 (3 days after start of care) and documented a call stating the following: “MSW spoke with both… AFC staff and son… who report no urgent SW (social work) needs for today and are open to a visit next week…” The “Social Work Assessment” was not completed by the MSW until 8/6/25 (9 days after start of care).Patient #8 (P-8): This 88-year-old was admitted to the hospice on 7/23/25 with a terminal diagnosis of acute myeloblastic leukemia (cancer that affects blood and bone marrow). The medical record was reviewed on 8/13/25. During review, it was noted that the chaplain entered a “Hospice Comprehensive Spiritual Assessment” on 7/25/25 and documented that P-8 had 2 children visiting at the time and “welcomed the chaplain to visit her at a later time as they were engaged in conversation.” Due to the patient request, the spiritual assessment was not completed on 7/25/25 however, there was no follow-up visit to complete the spiritual assessment as of the time of this medical record review (19 days after the chaplain’s initial visit).On 8/15/25, an interview was conducted with the Administrator (Adm-1), the Director of Nursing (DON-1), and the Residence Director (DON-2) at 3:45 PM. During the interview, the above findings were reviewed and acknowledged by all present.”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment identified and evaluated the physical, psychosocial, emotional, and spiritual needs related to the terminal illness in 1 (P-17) of 27 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #17 (P-17) was admitted to this hospice agency on 5/15/25 with the terminal diagnosis of end stage renal (kidney) disease (ESRD). Patients with ESRD have impaired kidney function and often experience difficulty with producing urine due to the kidneys no longer being able to filter waste from the body. During record review on 8/13/25, it was noted the section labeled “Genitourinary” on the comprehensive assessment (dated 5/15/25) was left completely blank. There was no information recorded regarding urinary output, clarity, incontinence, color, odor, or frequency.The hospice residence director (DON-2) reviewed the findings during an interview on 8/13/25 at 3:03 PM. DON-2 was unable to find an assessment of P-17’s genitourinary status and acknowledged the findings at the time of interview.”

“Based on observation, interview and record review, the agency failed to ensure the initial bereavement assessment identified the social, spiritual and cultural needs of all family members and other individuals that may be affected by the patient’s death in 11 (Patient # P-6, P-7, P-8, P-11, P-16, P-18, P-20, P-24, P-25, P-26, P-27) records, from a total of 27 records reviewed, which included 3 bereavement records, resulting in the potential for unmet needs for bereavement support and grieving during the end of life. Findings include: Patient #24’s (P-24) Start of Care (SOC) was dated 3/28/24. The Plan of Care (POC) identified a terminal diagnosis of Breast Cancer. During record review on 8/13/25, it was noted that the bereavement risk assessment was completed by the Medical Social Worker (MSW) on 3/29/24 for the patient’s cousin. On 8/11/25, the MSW documented a narrative note stating, “…Patient now has more family support. Patient reports her father’s sister now lives in the facility, across the hall from her…” The bereavement risk assessment failed to include the patient’s aunt and other possible family support. Patient #25’s (P-25) Start of Care (SOC) was dated 7/12/25. The Plan of Care (POC) identified a terminal diagnosis of Atrial Fibrillation. During record review on 8/12/25, it was noted that the bereavement risk assessment was completed by the MSW on 7/14/25 for the patient’s adopted daughter. On 7/14/25, the MSW documented a narrative note stating, “…PT (patient) has 6 adopted children PT wants his daughter to make any medical decisions for him…” The bereavement risk assessment failed to include the patient’s other 5 adopted children. Patient #26’s (P-26) Start of Care (SOC) was dated 7/1/25. The Plan of Care (POC) identified a terminal diagnosis of Heart Disease. During record review on 8/12/25, it was noted that the patient refused MSW services “For now.” The Electronic Medical Record (EMR) contained no evidence of a bereavement risk assessment. The agency failed to complete a bereavement risk assessment. Patient #27’s (P-27) Start of Care (SOC) was dated 7/1/25. The Plan of Care (POC) identified a terminal diagnosis of Bone Cancer. During record review on 8/12/25, it was noted that a pre-bereavement assessment was completed by the MSW on 7/10/25 for the patient’s daughter. On 7/9/25, the MSW documented a narrative note stating, “…Reports to having adequate support system (dau(daughter)/friend) …” The bereavement risk assessment failed to include the patient’s friend. The Director of Nursing (DON-1) reviewed and acknowledged the findings listed above in an interview on 8/13/25 at 3:10 pm. P-20: This patient was admitted to hospice on 6/29/25 with terminal diagnoses of colon cancer. During a scheduled joint home visit with social work (SW) and skilled nursing services on 8/13/25 at 12:05 PM, it was observed the patient’s main care giver was his wife, who was the lone individual identified in the BRA completed by SW services on 7/2/25. However, it was noted during the visit that the patient’s mother who had flown in from Nebraska to be with her son and help with care giving needs. After the home visit, additional record review found no evidence that the patient’s mother was included in the bereavement assessment. An additional interview was conducted with the manager of counseling services (CS-1) on 8/13/25 at 2:35 PM to ascertain quickly the number of individual(s) that would be included in a BRA. With the help of CS-1, it was noted of the 40 random records chosen, all included a BRA. However, only 3 of the 40 records had more than one individual identified. Subsequently, these results were reviewed and acknowledged by the agency’s Administrator, Director of Nursing, Quality Control Manager, and Chief Operations Officer during an interview that day at 15:17 PM. All further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “Grief Support Services” Policy 4.15 (Revised 7/16/25) stated, “(Agency) provides an organized Grief Support Program that offers a variety of counseling services to the patient’s designated primary bereaved (and other family members if appropriate) following the death of the patient... These services are designed to... identify and appropriately refer those people who may need additional counseling/resources.” Patient #16 (P-16) was admitted to this hospice agency on 12/29/24 with the terminal diagnoses of end stage heart failure and acute respiratory failure with hypoxia (low oxygen levels). During record review on 8/13/25, it was noted P-16’s son was the only individual listed in the initial bereavement assessment. Upon further review of the record, it was noted the social work evaluation dated 12/30/24 indicated, “Patient son lives with her, also has two daughters that live near by to provide assistance and support.” [sic] Additionally, during a joint home visit with the chaplain on 8/13/25 at 12:30 PM, P-16 talked about her 2 daughters who visited her often and were very involved in her care.During an interview with the director of nursing (DON-1) on 8/14/25 at 1:00 PM, DON-1 reported she was unsure why P-16’s daughters were not included in the initial bereavement assessment and acknowledged the findings.Patient #18 (P-18) was admitted to this hospice agency on 7/24/25 with the terminal diagnoses of heart failure and chronic obstructive pulmonary disease (COPD). During record review on 8/13/25, it was determined there was no initial bereavement assessment completed for this patient.During an interview with DON-1 on 8/14/25 at 1:00 PM, DON-1 stated the initial bereavement assessment was typically completed by the social worker during the initial assessment. Upon further review of the record, it was determined the social worker had not seen P-18 for an initial assessment, therefore, there was no initial bereavement assessment completed. DON-1 was not sure why the social worker had not evaluated this patient and acknowledged the findings at the time of interview. Patient #6 (P-6): This 84-year-old was admitted to the hospice on 7/28/25 with a terminal diagnosis of senile degeneration of the brain (progressive cognitive decline). The medical record was reviewed on 8/15/25. During review, it was noted that the Medical Social Worker (MSW) entered an initial bereavement assessment into the medical record on 8/6/25 (9 days after start of care) for P-6’s son, however, did not complete the assessment and documented “MSW…unable to get in contact for this initial assessment.” There were no additional MSW notes for review at the time of medical record review (19 days after start of care) and no evidence of follow-up to complete the initial bereavement assessment.Patient #7 (P-7): This 66-year-old was admitted to the hospice on 8/5/25 with a terminal diagnosis of lung cancer with spread to the brain. The medical record was reviewed on 8/15/25. During review, it was noted that the MSW completed the “Hospice Comprehensive Psychosocial Assessment” on 8/6/25. The MSW included documentation in the “Shift Narrative” that P-7 reported getting his support from his 3 sisters who are all involved in his care. Additionally, in the “IDG Summary”, the MSW documented that P-7’s daughter and sisters were supportive, involved, and attentive in P-7’s care. The MSW provided an initial bereavement assessment for only 1 sister sitting at bedside the day of the assessment. No other initial bereavement assessments were completed for P-7’s family members who were identified as being attentive in the care and support for P-7.Patient #8 (P-8): This 88-year-old was admitted to the hospice on 7/23/25 with a terminal diagnosis of acute myeloblastic leukemia (cancer that affects blood and bone marrow). The medical record was reviewed on 8/13/25. During review, it was noted that the MSW completed the “Hospice Comprehensive Psychosocial Assessment” on 7/24/25. P-8’s son was at the bedside while the MSW completed the assessment and included the documentation, “Initial MSW visit to patient and her son in patient’s room… Patient and son grieving her decline… Son and daughters are all medical DPOA (durable power of attorney)”. An initial bereavement assessment was provided for only one of P-8’s three children. P-8’s son and another daughter were not included in initial bereavement assessments even though they were identified as active in P-8’s life and care.Patient #11 (P-11): This 93-year-old was admitted to the hospice on 7/30/25 with a terminal diagnosis of chronic obstructive pulmonary disease. The medical record was reviewed on 8/14/25. During review, it was noted that there was no MSW assessment completed for this patient at the time of review (15 days after start of care) including an initial bereavement assessment for family members or others who would be most impacted by the death of this patient.On 8/15/25, an interview was conducted with the Administrator (Adm-1), the Director of Nursing (DON-1), and the Residence Director (DON-2) at 3:45 PM. During the interview, the above findings were reviewed and acknowledged by all parties present.”

“Based on record review and interview, the Hospice agency failed to ensure the plan of care (POC) included patient specific measurable goals in 3 (Patients/P-2, P-3, P-4) of 26 records reviewed for POC content, from a total sample of 26 records reviewed, resulting in the potential for unmet patient care needs and goals for all 899 patients currently receiving services. Findings include: P-2 through P-4: During record review from 8/13/25 through 8/15/25, it was noted that the POC’s were generic and not measurable as required. Subsequently, progress made (or lack of) could not be tracked and trended to enable Hospice staff to accurately perform an objective evaluation of the patient’s progress concerning the specified goal. Examples include: “Goals/Pre-bereavement; Patient/Family/Caregiver will identify and mobilize support systems/networks... Goals/Pain: Evaluated effectiveness of pain measures and pain will not interfere with: Sleep, Activities, Appetite, Mood... Goals/Activities: Patient will remain safe in environment.”These findings were reviewed with and acknowledged by the Administrator (Adm-1) during an interview on 8/15/25 at 3:12 PM.”

“Based on record review and interview, the agency failed to ensure services were provided as ordered in the plan of care for 2 (P-8, and P-25) of 27 records reviewed, resulting in the patient not receiving services as ordered in the plan of care. Findings include: Patient #25’s (P-25) Start of Care (SOC) was dated 7/12/25. The Plan of Care (POC) identified a terminal diagnosis of Atrial Fibrillation. During record review on 8/12/25, it was noted that the POC ordered Home Health Aide (HHA) to provide visits at the frequency of 2w12 (2 times a week for 12 weeks). The HHA completed a visit on 7/14/25 and a missed visit on 7/16/25. There were no further visits or documentation of refusal completed by the HHA for the last 4 weeks. Additionally, on 7/29/25, the Registered Nurse (RN) stated, “…RN plan for next two weeks: weekly RN visits. Two time weekly HHA visits…” The agency failed to complete HHA visits as ordered.The Director of Nursing (DON-1) reviewed and acknowledged the findings listed above in an interview on 8/13/25 at 3:30 pm. Patient #8 (P-8): This 88-year-old was admitted to the hospice on 7/23/25 with a terminal diagnosis of acute myeloblastic leukemia (cancer that affects blood and bone marrow). The medical record was reviewed on 8/13/25. During review, it was noted that the Medical Social Worker (MSW) made an initial visit on 7/24/25 and included the following documentation regarding the MSW plan of care, “SW (social work) plan is to make weekly visits…”. The MSW made one routine visit the next week on 7/30/25. There were no MSW visits entered for the week of 8/3/25 through 8/9/25, and no visits between 8/10/25 and the date of medical record review (8/13/25). Additionally, the chaplain made an initial visit on 7/25/25 and included the following documentation regarding the chaplain plan of care, “The chaplain will visit this patient weekly to provide spiritual care.” There were no additional chaplain visits made by the time of this medical record review (19 days after the chaplain’s initial visit).On 8/15/25, an interview was conducted with the Administrator (Adm-1), the Director of Nursing (DON-1), and the Residence Director (DON-2) at 3:45 PM. During the interview, the above findings were reviewed and acknowledged by all parties present.”

“Based on observation, record review, and interview, the hospice agency failed to ensure the hospice aide followed accepted standards of practice to prevent the transmission of infection in 1 (P-8) of 1 observation in which a joint home visit was conducted with a hospice aide, potentially resulting in the spread of infectious agents from a dirty area to a clean area. Findings include: The agency policy titled “Infection Control-Hand Hygiene”, policy 9.05 (revised 4/4/2025) was provided for surveyor review on 8/14/25. On page 1., it stated “…staff must use an alcohol-based hand rub or wash hands with soap and water… Before and after wearing gloves…”.Patient #8 (P-8): This 88-year-old was admitted to the hospice on 7/23/25 with a terminal diagnosis of acute myeloblastic leukemia (cancer that affects blood and bone marrow). On 8/12/25 at 11:45 AM, a joint visit was conducted with a hospice aide (HA-1) to observe a bed bath being performed for P-8 who resided in the hospice residence (P-8’s home). During the observation, HA-1 was noted to put on a clean pair of gloves prior to beginning the bed bath. During the multi-step bed bath procedure, HA-1 was observed 3 separate times between various tasks taking one (dirty) glove off the right hand and putting a new (clean) glove on the right hand without first performing hand hygiene between glove changes. HA-1 used the dirty gloved left hand to remove the glove on the right hand and replace with a clean glove each of the 3 times. Additionally, HA-1 did not remove the original left-hand glove for the entire procedure. On 8/15/25, an interview was conducted with the Administrator (Adm-1), the Director of Nursing (DON-1), and the Residence Director (DON-2) at 3:45 PM. During the interview, the above findings were reviewed and acknowledged by all present. DON-2 stated that HA-1 should have removed both gloves and performed hand hygiene prior to putting a new clean pair on each time a glove change was necessary.”

“Based on record review and interview, the agency failed to ensure medical social services were provided by the social worker in 2 (P-11 and 18) of 27 records, resulting in the potential for unmet care needs. Findings include: Patient #18 (P-18) was admitted to this hospice agency on 7/24/25 with the terminal diagnoses of heart failure and chronic obstructive pulmonary disease (COPD). During record review on 8/13/25, it was noted there was no documentation of a social work assessment or follow-up visits for this patient.A review of agency policy 4.12 titled “Medical Social Services” (revised 9/26/22) revealed, “2. A Social Worker is assigned to each patient/family and participates as a member of the hospice IDG in the development and implementation of the patient’s plan of care.” Additionally, a review of agency policy 3.01 titled “Comprehensive Assessment of the Patient” (revised 9/26/22) revealed, “2. The comprehensive assessment is completed by the designated members of the IDG, in consultation with the patient’s attending physician, no later than five calendar days after the patient elects the hospice benefit.”Upon further review of the record, it was noted there was no documentation to indicate any missed or attempted visits by the social worker. It was also noted the interdisciplinary group (IDG) meeting notes dated 8/7/25 indicated, “Patient needs being met by current SW (social work) plan of care” although this patient had not been seen by social work.The director of nursing (DON-1) reviewed and acknowledged the findings during an interview on 8/14/25 at 1:00 PM. DON-1 was unsure why P-18 had not received services from social work. Patient #11 (P-11): This 93-year-old was admitted to the hospice on 7/30/25 with a terminal diagnosis of chronic obstructive pulmonary disease. The medical record was reviewed on 8/14/25. During review, there was no social worker assessment found in the medical record (15 days after the start of care). Additionally, there was an interdisciplinary group note entered by the Medical Social Worker (MSW) on 8/7/25 which stated, “Patient needs being met by current SW (social work) plan of care.”, however, there was no plan of care developed by the MSW.On 8/15/25, an interview was conducted with the Administrator (Adm-1), the Director of Nursing (DON-1), and the Residence Director (DON-2) at 3:45 PM. During the interview, the above findings were reviewed and acknowledged by all present.”

“Based on record review and interview, the agency failed to ensure the hospice aide provided the services included in the plan of care for 2 (P-6 and P-18) of 27 records reviewed, resulting in the potential for unmet care needs. Findings include: Patient #18 (P-18) was admitted to this hospice agency on 7/24/25 with the terminal diagnoses of heart failure and chronic obstructive pulmonary disease (COPD). During record review on 8/13/25, it was noted the aide care plan (dated 7/24/25) indicated to report to the supervisor or case manager if “No BM (bowel movement) in 3 days.”Upon further review of the record, it was determined 6 of 6 aide visit notes dated between 7/25/25 and 8/12/25 had “Unknown” documented next to “Document Last Bowel Movement.” Therefore, the aide would not know if the patient had not had a bowel movement in 3 days.A review of agency policy 4.27 titled “Hospice Aide Assignments and Duties” (revised 6/27/25) revealed, “2. A Hospice Adie provided services that are:..B. Included in the plan of care.”The director of nursing (DON-1) reviewed and acknowledged the findings during an interview on 8/14/25 at 1:00 PM. Patient #6 (P-6): This 84-year-old was admitted to the hospice on 7/28/25 with a terminal diagnosis of senile degeneration of the brain (progressive cognitive decline). The medical record was reviewed on 8/15/25. During review, it was noted that hospice aide services were added to the plan of care for P-6 on 7/28/25. A “Hospice Aide Plan of Care” was developed by the case manager (registered nurse) with instruction on 7/30/25 and included instructions for the aide to enter the date of the patient’s last bowel movement each visit. The hospice aide made visits on 7/31/25, 8/4/25, 8/7/25, 8/11/25, and 8/14/25. The aide failed to document the last bowel movement on all of the listed visits.On 8/15/25, an interview was conducted with the Administrator (Adm-1), the Director of Nursing (DON-1), and the Residence Director (DON-2) at 3:45 PM. During the interview, the above findings were reviewed and acknowledged by all parties present.”

“Based on record review and interview, it was determined that the agency failed to ensure the clinical record was complete and thorough in the documentation of patient responses to medication and symptom management in 1 (P-27) of 27 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings included: Patient #27’s (P-27) Start of Care (SOC) was dated 7/1/25. The Plan of Care (POC) identified a terminal diagnosis of Bone Cancer. During record review on 8/12/25, it was noted that on 7/15/25, the Registered Nurse (RN) documented a visit note stating, “GI/GU/Nutritional/Endocrine: Summary of Problems: PT (Patient) taking PRN (as needed) narcotic pain medications requiring bowel protocol. Using Senna. PT also incontinent of urine due to mobility issues.” The Electronic Medical Record (EMR) was blank under the section “Gastrointestinal/Nutrition” that contains assessment documentation for last bowel movement, bowel sounds and constipation. The agency failed to assess the patients gastrointestinal/nutrition which could potentially lead to a poor patient outcome. A review of the agency policy occurred on 8/12/25 titled “Entries into Medical Records” (Revised 9/27/22). The policy states, “Policy: …Documentation in the medical record is timely, detailed, and accurate and reflects the care of services provided.”The Director of Nursing (DON-1) reviewed and acknowledged the findings listed above in an interview on 8/13/25 at 3:20 pm.”

“Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs for all patients, and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 418.110(d), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 99 and 101, Life Safety Code (LSC), Chapter 21 Existing Ambulatory Health Care Occupancy, resulting in the potential for negative outcomes, up to and including death for all patients within the facility, in the event of a fire. Findings Include: See corresponding life safety code tag K0353”

“Based on observation, record review and interview, the facility failed to provide sprinkler system maintenance and testing as required by NFPA 25. This deficient practice has the potential to affect all occupants. On August 12, 2025, at approximately 11:03 AM, record review revealed a deficiency noted on the sprinkler system report dated April 29, 2025 and again on July 16, 2025, hydraulic calculations signage missing on the wet and dry system for the facility. Interview with Facility Maintenance when asked by this surveyor if this deficiency has been corrected answer was, no. Observation revealed at 12:15 PM, there was no hydraulic calculations signage at the sprinkler system dry and wet pipe risers. This finding was confirmed by interview with Facility Maintenance at the time of record review and observation.”