Hospice of Lansing

“Based on record review and interview, the agency failed to ensure that the licensed professional services are delivered only by health care professionals who meet the appropriate qualifications and in accordance with hospice policies in 1 (MSW-1) of 10 personnel files reviewed. Findings include: During personnel record review on 10/23/25, it was noted that MSW-1 had an expired license that stated, “License Type: Masters Social Worker Limited…License Expiration Date: 07/21/2023…” This information was confirmed on the Licensing and Regulatory Affairs (LARA) Professional Licensing webpage. Furthermore, an email from MSW-1 to HR-1 on 3/31/2025 stated, “…and my license last expired in 23 (2023). I am working on my testing for re-instatement. (ED-1) and (DO-1) are aware of this and the “need” for it was removed when I accepted the supervisor position from my job description.” Additionally, it was noted that MSW-1 completed 740 assessment visits, revisits and discharge visits for the agency from 7/22/23 to 10/24/25 with an expired license. The Executive Director/Administrator (ED-1) and Director of Operations (DO-1) reviewed and acknowledged the findings listed above in an interview on 10/24/25 at 10:30 am., and stated, “We are aware that her limited license had expired…We thought that her masters was acceptable according to the conditions of participation…” A review of the agency policy occurred on 10/24/25 titled “Licensure/Certification/Registration Policy No. 1-006” (Reviewed April 2025). The policy states, “Policy: All organization personnel will be properly licensed, certified, and/or trained to meet specific job requirements. Procedure: 1. Personnel must maintain and show proof of licensure, certification, and/or registration as appropriate. 2. Personnel must comply with requirements to maintain such licensure, certification, and/or registration in accordance with applicable state law and regulation.”A review of the agency policy occurred on 10/24/25 titled “Categories/Qualifications of Personnel Policy No. 1-004” (Reviewed April 2025). The policy states, “Minimum Qualifications: Professional Personnel: Individuals must present evidence of required licensure and experience as appropriate. This includes…medical social workers.””

“Based on observation, record review and interview the facility that provides inpatient care directly failed to demonstrate compliance with Life Safety Codes as follows: failed to provide documentation for the monthly 30 second testing of emergency lighting (see K0291); failed to provide documentation for the semi-annual commercial kitchen hood cleaned by an outside vendor (see K0324); failed to provide documentation of the Quarterly Dialer Test (see K0345); failed to provide documentation for the first quarter, second quarter, and third quarter sprinkler flow inspection test (see K0353); failed to maintain the cross-corridor door at the West Hall (see K0363); failed to provide documentation for the 4-year damper inspection throughout the facility (see K0521); failed to provide written records of inspection and testing of fire doors and assemblies (see K0761); failed to provide a letter of reliability from their natural gas supplier (see K0911); failed to provide essential electrical system maintenance and testing as required. (see K0918). The cumulative effect of the above noncompliance presents a potential threat to the health and safety of all of the facility’s patients, staff and visitors.”

“Based on record review and interview, the Agency failed to develop and maintain an Emergency Preparedness program that included the required elements, that must be reviewed and updated at least every 2 years, resulting in the potential for the Agency’s inability to provide safe patient care in the event of an actual emergency. Findings include: On 3/12/25 at 2:30 p.m., the agency’s Emergency Preparedness (EP) plan was reviewed with the Executive Director (ED #1) and the Director of Operations (DO #1). The Life Safety Surveyor was also present during the review. During the review, it was noted that the Plan was dated 2005 with an additional date of 2003. When queried about the outdated plan and what staff were trained on, DO #1 stated, “This is the plan we use.” (Referencing the 2005 plan). Upon further review of the documents, dates including 2018 were noted on some of the pages. This Hospice practices within a Hospice Residence. The Residence Evacuation Plan listed contact information for the former Executive Director, Clinical Director and Operations Supervisor. During the review, ED #1 reported, “I have a newer working copy on my computer.” When asked if staff would have access to the computerized documents in the event of a power outage or disaster, ED #1 responded, “No.” In light of the dates noted on the documents, 2003, 2005, 2018 and the plan within ED #1’s computer to reflect a date of 2024, there was no sufficient evidence to support that the agency’s EP plan had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with ED #1 and DO #1 at the time of discovery.”

“Based on record review and interview, the Agency failed to implement in the Emergency Preparedness policy the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, resulting in the potential for the interruption in needed care and services. Findings included: On 3/11/25, the Director of Operations (DO #1) was asked to provide documented evidence that the agency’s Emergency Preparedness (EP) plan included language that included a process for the integration or use of volunteers or other staffing strategies with local, regional, State and Federal officials to address surge needs during an emergency. On 3/12/25 at 2:30 p.m., DO #1 was asked if she was able to locate the requested information to which she responded, “Our plan doesn’t include that language.” The Agency failed to include information regarding the use of volunteers in its policy, and the integration with the State and Federally designated health care professionals during times of surge needs for the Agency’s patients in the event of an emergency or disaster. These findings were reviewed with and acknowledged by DO #1 during the above interview.”

“Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices and volunteers, as appropriate, that had been reviewed and updated at least every 2 years, resulting in lack of an effective communication plan and the potential for interruption in the provision of needed care and services in the event of an emergency or disaster. Findings include: The agency’s Emergency Preparedness Plan was reviewed on 3/12/25 at 2:30 p.m. with the Executive Director (ED #1) and the Director of Operation (DO #1). The Life Safety Surveyor was also present. During the review, it was noted that there was no language that included contact information for the above entities. The Agency failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the required subject areas as per this requirement. These findings were acknowledged at the time of discovery.”

“Based on record review and interview, the Agency failed to provide documented evidence to ensure that all staff received initial and ongoing training in the Agency’s emergency preparedness program, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially affect staff and all patients currently serviced by this Agency. Findings include: On 3/12/25 at 2:30 p.m., the agency’s Emergency Preparedness binder/documents were reviewed with the Executive Director (ED #1), Director of Operations (DO #1) and the Life Safety Surveyor (LSS #1). At the time of the review, there was no documented evidence that all Agency staff had received initial and ongoing training in emergency preparedness. Further, no additional documentation had been provided by the end of the survey. These findings were reviewed with and acknowledged by ED #1, DO #1 and LSS #1 at the time of discovery. These findings were again reviewed during a subsequent interview on 3/14/25 and during the Exit Conference.”

“Based on record review and interview, it was determined the Agency failed to provide documented evidence for the required tabletop, community based full-scale exercises or any documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff not being properly prepared for an actual emergency in the event of a disaster. This deficiency has the potential to affect staff and all patients currently serviced by this agency. Findings include: On 3/12/25 at 2:30 p.m., the agency’s Emergency Preparedness documents were reviewed with the Executive Director (ED #1), Director of Operations (DO #1) and the Life Safety Surveyor. During the review, this writer requested documented evidence of Community/Facility based drills including documentation of participants and actions taken during the actual drills, in addition to any tabletop exercises available for review, along with documentation of the agency’s after-action plans. DO #1 responded, “We don’t have documentation of what happened during the actual drills, but we did have a Tornado drill, which was an actual event.” The Director of Operations (DO #1) provided an email dated 4/18/24, titled, “Tornado “drill” which documented, “As DO #1 said in her email yesterday, the team responded with much grace, care and compassion to the weather situation on Wednesday. I’m sending out our Tornado Warning procedure for review.” The email contained the procedures to be followed in the event of a Tornado. There was no documentation of the events that transpired during the reported event and no evidence of what parts either of the participants played. During an interview on 3/14/25, ED #1 stated, “We also have a Fire Drill”, and instructed DO #1 to provide documentation for review. Upon review, the provided document was noted to be a policy titled, “Fire Safety-Office, 6-020.1, 1/2019. A signature sheet was attached which documented, “1 min 11 seconds to complete.” There was no information on who activated the emergency system or any information on what part the participants played in the reported drill. Additionally, there was no after-action plan associated with either drill that analyzed the response with suggested improvements. The Agency failed to provide documented evidence to support the required drills had been conducted as per this requirement. The above findings were reviewed with and acknowledged by ED #1 and DO #1 at the time of discovery.”

“Based on record review and interview, the agency failed to ensure the comprehensive assessment included a drug profile that identified potential drug interactions or duplicate therapies in 6 (P-10, 11, 12, 13, 14, 19) of 19 records reviewed; and failed to ensure findings were reported and documented per agency policy in 2 (P-11, 6) of 19 records reviewed, resulting in the potential for dangerous drug interactions and poor patient outcomes. Findings include: P-6: This 69-year-old was admitted to hospice on 12/9/24 with a diagnosis of senile degeneration of the brain. During record review on 3/11/25 it was noted that the comprehensive assessment completed by the nurse indicates that no issues were identified regarding the medication profile review. However, the drug interaction feature on the agency’s electronic medical record system, indicates there is 1 severe interaction and 12 major interactions. The findings were reviewed with DO #1 during an interview on 3/13/25 at 1:00 p.m. DO #1 explained that the medications are reviewed by the contracted pharmacy. The pharmacy flags interactions and notifies the physician or the nurse. DO #1 ran an Active Medication Profile Report through the contracted pharmacy. The report notes the following comment: Drug-drug interactions – QT prolonging agents – (Haldol + Pletal) – concomitant use may increase risk of QT interval prolongation. Monitor patient for cardiac complaints, dizziness and shortness of breath. There was no documentation to indicate the physician or nurse were informed of this drug-drug interaction. DO #1 acknowledged the finding. P-19: This 90-year-old was admitted to hospice on 2/3/25 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease with recurrent pneumothorax (abnormal collection of air between the lung and the chest wall). On 3/12/25 at 1:00 p.m., a joint visit was conducted with the Registered Nurse (RN). During the visit the RN brought a list of medications for this patient which were on file with the hospice agency from the start of care (comprehensive) assessment. The RN was observed while giving the list of medications brought to P-19s Power of Attorney (POA) to review for accuracy. The POA stated that the list had a medication which P-19 was not taking (Lisinopril- a blood pressure medication) and was missing 2 migraine medications which P-19 was actively using when needed. The RN reviewed the 2 migraine medications for interactions and duplication at the time of the visit. These medications were not identified or reviewed until 40 days after the comprehensive assessment was completed. On 3/14/25 at 1:20 p.m., this finding was reviewed and acknowledged during interview with the Director of Operations (DO #1). **Policy 4-050.1 titled “;Medication Profile” (revised December 2024) stated, “;2. A drug review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify:...B. Actual or potential side effects;...I. Actual and potential drug interactions; J. Duplicate drug therapy...”. It also stated, “;6. Any conclusions and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians.” During record review from 3/11/25 to 3/13/25, it was noted the comprehensive assessments for P-10, P-11, P-12, P-13, and P-14 all indicated “;No issues identified” under the section labeled “;Medication Profile Review.” However, upon using the drug interaction feature on the agency’s electronic medical record system, it was noted each record had interactions that were labeled “;severe” or “;major”. The agency failed to identify potential drug interactions or duplicate therapies on the comprehensive assessment. During an interview with the Director of Operations (DO #1) on 3/13/25 at 2:00 PM, DO #1 was asked about the agencys policy for medication reconciliation. DO #1 stated the agency used their contracted pharmacy to review the medications and to report harmful interactions. DO # 1 was asked about a policy regarding what level interaction is considered harmful by the agency. DO #1 stated she was unsure what the pharmacy reported, but they “;trusted them” based on their professional judgement. DO #1 stated she did not have a specific agency policy on what level interaction to report. When queried about the records above all stating, “;No issues found” on the comprehensive assessment, DO #1 stated it meant that any issues found did not require any changes. However, DO #1 agreed that could be confusing or conflicting and acknowledged the findings. Additionally, DO #1 was asked to show an example of a drug interaction identified by the contracted pharmacy. DO #1 ran the report for P-11, which indicated a drug-to-drug interaction between the medications Cirpoflaxin and Trazadone on 3/3/25. The report indicated the pharmacist reviewed the interaction with “;RN Jenny.” DO #1 was asked to provide evidence of that conversation in the patients record and the steps the nurse followed after learning of the interaction. DO #1 was unable to locate any documentation in the record. Additionally, DO #1 stated the nurse typically wrote an order to discontinue the medication after an interaction is identified and the doctor would sign off on it. However, it was noted that an order to discontinue Cirpoflaxin was not sent until 3/5/25 – 2 days after the interaction was reported by the pharmacy. DO #1 acknowledged the findings.”

“Based on record review and interview, the Hospice failed to ensure the comprehensive assessment included an initial bereavement assessment that identified all who would be affected by the patient’s death in 1(P-2) record, from a total of 19 records reviewed resulting in the potential for unmet bereavement care needs. Findings included: Policy: Bereavement Assessment, 4-049.1, 4/2022 stated, “On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment..., At a minimum, it will include Survivor needs, Grief risk factors, The bereavement counselor will review the risk assessment to determine potential needs of the survivors...” P-2: The patient was admitted to Hospice on 12/6/24 with a terminal diagnosis of congestive Heart Failure. During the clinical record review on 3/12/25 at 12:55 p.m., it was noted that the patient’s Contacts listed the patient’s 2 sons and a daughter-in-law. The Initial Bereavement Assessment conducted by the Social Worker failed to include one of the patient’s sons and daughter-in-law. The Social Worker failed to evaluate the bereavement needs of the patient’s family and failed to include all who would be affected by the patient’s death. These findings were reviewed with and acknowledged by the Executive Director, the Director of Operations and the Social Worker, who was present during the review. No response was offered.”

“Based on record review and interview, the Hospice agency failed to ensure the interdisciplinary group supervised the care and services provided by the agencies 26 volunteers resulting in the potential for unidentified issues with patient care. Findings include: Agency policy titled “;Volunteer Services”; Policy No. 4-007.1, was reviewed on 3/14/25. On page 2., it stated “;2. The Volunteer Coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care.” On 3/13/25 at 2:40 p.m., interview was conducted with the Bereavement Coordinator (BC #1) and the Volunteer Coordinator (VC #1). During the interview, VC #1 stated that the hospice currently had 26 volunteers providing care and services for the agency. VC #1 was asked how the hospice ensured volunteers are following the plan of care and how supervision of volunteer services was accomplished. VC #1 stated that she would email or call the volunteers to see how they were doing but that currently, the hospice does not perform supervision calls or visits with the volunteers.”

“Based on record review and interview, it was determined the Hospice failed to develop a patient specific plan of care that included interventions for pain and symptom management for 4 (P-1, P-2, P-4, P-5) records, from a total of 19 sampled records reviewed, resulting in the potential for unrelieved pain and symptom management and unmet care needs. Findings include: P-1: This patient was admitted to Hospice on 11/21/24. The benefit period of review was 2/19/25 through 3/14/25 with a terminal diagnosis of Neurocognitive Disorder. During the clinical record review on 3/11/25 at 12:15 p.m., it was noted that the Plan of Care (POC) was void of any measures/interventions to address pain or symptom management. These findings were reviewed with and acknowledged by the Executive Director (ED #1) and Director of Operations (DO #1) during an interview on 3/14/25 at 2:44 p.m. P-2: This patient was admitted to Hospice on 12/6/24 with a terminal diagnosis of Congestive Heart Failure. During the clinical record review on 3/12/25 at 12:55 p.m., it was noted that the POC did not include any measures to address pain or symptom management. These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:04 p.m. P-4: This patient was admitted to Hospice on 7/22/23. The benefit period of review was 2/11/25 through 3/14/25 with a terminal diagnosis of Alzheimer’s Disease. During the clinical record review on 3/13/25 at 2:20 p.m., it was noted that the POC was void of any measures that addressed pain or symptom management. These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:14 p.m. P-5: This patient was admitted to Hospice on 3/6/25 with a terminal diagnosis of Senile Degeneration of the Brain. During the clinical record review on 3/13/25 at 3:45 p.m., it was noted that the POC was void of any measures to address potential pain and symptom management. These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:20 p.m.”

“Based on record review and interview, the Hospice failed to ensure the plans of care included patient specific goals/outcomes for the Hospice patient, for 8 (P-1, P-2, P-4, P-6, P-7, P-11, P-13, P-14) records, from a total sample of 19 sampled records reviewed, resulting in the potential for lack of progress towards needed goals and unmet care needs. Findings include: P-1: This patient was admitted to Hospice on 11/21/24. The benefit period of review was 2/19/25 through 3/14/25 with a terminal diagnosis of Neurocognitive Disorder. During the clinical record review on 3/11/25 at 12:15 p.m., it was noted that the patient had a Foley Catheter (indwelling urinary collection) and resided in an Assisted Living Facility. Upon review of the Plan of Care (POC), it was noted that the goals were vague in nature and not measurable such as, “Neurological status within realm of end stage disease process...” There was no clear indication as to how this goal would be attained. Additionally, there were no measurable goals that addressed the patient’s indwelling catheter. These findings were reviewed with and acknowledged by the Executive Director (ED #1) and Director of Operations (DO #1) during an interview on 3/14/25 at 2:44 p.m. P-2: This patient was admitted to Hospice on 12/6/24 with a terminal diagnosis of Congestive Heart Failure. During the clinical record review on 3/12/25 at 12:55 p.m., it was noted that the POC goals were not patient centered or measurable such as, “Staff will be able to demonstrate improved safety awareness as evidenced by...” These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:04 p.m. P-4: This patient was admitted to Hospice on 7/22/23. The benefit period of review was 2/11/25 through 3/14/25 with a terminal diagnosis of Alzheimer’s Disease. During the clinical record review on 3/13/25 at 2:20 p.m., it was noted that the POC was void of measurable goals that addressed the patient’s terminal diagnosis. These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:14 p.m. P-11: This 73-year-old patient was admitted to hospice on 12/26/24 with the terminal diagnosis of a malignant neoplasm of the main bronchus (lung cancer). During record review on 3/12/25, it was determined the plan of care did not list any goals for this patient. P-13: This 84-year-old patient was admitted to hospice on 1/10/25 with the terminal diagnoses of moderate protein-calorie malnutrition and vascular dementia. During record review on 3/13/25, the following skilled nursing goals were noted on the plan of care: “;Staff at Brookdale will demonstrate ways to achieve/maintain adequate nutrition and fluid intake in the next 2 week.” “;[P-13’s] nutrition will remain at his current baseline in the next 2 weeks.” “;Skin integrity will be maintained and problems managed as disease process will allow in the next 2 weeks. These goals are generic, not individualized and not quantifiable. P-14: This 82-year-old patient was admitted to hospice on 2/24/25 with the terminal diagnoses of senile degeneration of the brain and moderate protein-calorie malnutrition. During record review on 3/13/25, the following skilled nursing goals were noted on the plan of care: “;[P-14] will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury in the next 2 weeks.” “;[P-14] and staff at Willows can verbalize understanding/demonstrate how to reduce risk and avoid urinary tract infection in the next 2 weeks.” These goals are generic, not individualized and not quantifiable. Findings were reviewed with and acknowledged by the Director of Operations (DO #1) during an interview on 3/14/25 at 10:20 AM. P-6: This patient was admitted to hospice on 12/9/24 with a terminal diagnosis of senile degeneration of the brain. During record review on 3/11/25, it was noted that the 12/9/24 plan of care failed to include measurable outcomes for this patient. The following are a sample of the goals/outcome: [P-6] will feel needs are being met as she defined during this certification period; and Medical Social Worker will educate [P-6] to access services needed during this certification period. There was no indication of which “needs are being met” as defined by the patient and no indication how the social worker was going to educate this patient with senile degeneration of the brain to access services. It was unclear how these goals were to be measured. The findings were reviewed with and acknowledged by DO #1 during an interview on 3/13/25 at 1:00 p.m. P-7: This patient was admitted to hospice on 3/10/25 with diagnoses of chronic kidney disease, heart disease, and dementia. During record review on 3/12/25, it was noted that the 3/10/25 plan of care failed to include a measurable pain outcome for this patient. The goal states, [P-7] will be pain free or verbalize an acceptable pain level with current pain management regimen. There was no indication of what constitutes an acceptable pain level for this patient. It was unclear how this goal was to be measured. The findings were reviewed with and acknowledged by DO #1 during an interview on 3/13/25 at 1:00 p.m.”

“Based on record review and interview, the interdisciplinary group failed to coordinate care to ensure delivery of all services ordered in 2 (P-14 and P-19) of 19 records reviewed resulting in the potential for unmet care needs. Findings include: P-19: This 90-year-old was admitted to hospice on 2/3/25 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease with recurrent pneumothorax (abnormal collection of air between the lung and the chest wall). The medical record was reviewed on 3/11/25. During review of the comprehensive assessment dated 2/3/25, it was noted that the patient requested to have volunteer services as part of the hospice care. There was no record of volunteer services being provided between admission and the date of this medical record review (over 5 weeks). Two Interdisciplinary Team (IDT) meeting notes by the Volunteer Coordinator were entered, one on 2/12/25 and another on 3/4/25. Both notes stated that the volunteer coordinator would continue to monitor the patients needs every 2 weeks at IDT and adjust care plan accordingly. On 3/14/25 at 1:20 p.m., interview was conducted with the Director of Operations (DO #1) and the Bereavement Coordinator (BC #1). When asked if efforts had been made to provide volunteer services to this patient, BC #1 stated sometimes they (the hospice) had a hard time finding a volunteer willing to travel to certain locations but in this case, could not provide evidence of attempts made to place a volunteer with this patient. **Policy 1-010.1 titled “;Scope of Assessments/Qualifications” (revised January 2025) stated, “;Clinicians will use organization policies and procedures to guide their activities regarding assessments, documentation, and the communication of findings with the physician, organization personnel, and appropriate others.” P-14: This 82-year-old patient was admitted to hospice on 2/24/25 with the terminal diagnoses of senile degeneration of the brain and moderate protein-calorie malnutrition. During record review on 3/13/25, it was noted music therapy and volunteer services were requested by the patient according to referral forms both dated 2/26/25. It was also noted on interdisciplinary “;prep” notes by the volunteer coordinator (VC #1, dated 2/25/25 and 3/11/25) that, “;...requested vol services at admission. VC will continue to monitor [P-14’s] vol needs every two weeks at IDT and adjust care plan accordingly.” Upon further review of the record, it was determined that as of 3/14/25, the patient had not been seen by music therapy or volunteer services. During an interview on 3/14/25 at 10:20 AM, the Director of Operations (DO #1) was asked about the agency expectation for volunteer, massage, and music therapy to start services after referral. DO #1 stated the agency expectation is 2 weeks to initiate care or contact of some kind. DO #1 stated if contact was made to schedule the patient or care is delayed for any reason, it should be documented in the record. DO #1 was unable to provide evidence the patient had been seen or contacted by either service at the time of interview and acknowledged the findings.”

“Based on record review and interview, the agency failed to ensure services were provided in accordance with the plan of care in 2 (P-11, 13) of 19 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: **Policy 4-101.1 titled “;Missed Visit” (revised December 2024) stated, “;1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for the missed visit; B. Document in the patients clinical record the following information:...2. Date and type of visit that was missed; 3. Reason for the missed visit; 4. Description of any unmet needs and how the patients needs were met; 5. Any other follow-up needed; 6. Other person(s) that were notified of the missed visit...”. The policy also stated, “;3. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above.” **Policy 4-027.3 titled “;Provision of Care and Record Management” (reviewed December 2024) stated, “;14. Care/Care Plans provided to the patient will be in accordance with the plan of care.” P-11: This 73-year-old patient was admitted to hospice on 12/26/24 with the terminal diagnosis of a malignant neoplasm of the main bronchus (lung cancer). During record review on 3/12/25, it was determined the plan of care ordered social work 1 time per month. Upon further review of the record, it was noted the social work evaluation was completed on 12/30/24 and a follow-up visit was made on 1/27/25. It was then noted the patient refused his visit from social work on 2/18/25 according to a missed visit note written by the social worker. As of 3/10/25 (the patients date of death), there had been no follow-up visit documented by the social worker. Additionally, there was no documentation of attempts made to reschedule the missed visit per the agency policy. A description of how unmet needs were met, any follow-up needed, and other people notified was also not documented. During an interview with the social worker (BC #1) on 3/14/25 at 10:45 AM, BC #1 was asked about the missed visit. BC #1 stated sometimes the patient is overwhelmed and may need a break from the visits, so she may wait until the next scheduled visit to see the patient. However, BC # 1 agreed this is not documented in the record and is not in accordance with the agencys policy to ensure the frequency in the plan of care is met. The Director of Operations (DO #1) was also present during the interview and acknowledged the findings. P-13: This 84-year-old patient was admitted to hospice on 1/10/25 with the terminal diagnoses of moderate protein-calorie malnutrition and vascular dementia. During record review on 3/13/25, it was determined the plan of care ordered hospice aide services 2 times a week for 14 weeks and 3 PRN (as needed) visits. Upon further review of the record, it was noted the aide documented missed visits on 1/15/25 and 1/16/25 due to patient refusal. The patient did not have any aide visits that week. There was also a missed visit documented for 1/24/25 due to patient refusal. The patient only had 1 aide visit that week. There was no documentation of attempts made to reschedule the missed visits per the agency policy above. Additionally, there was no documentation the aide contacted the case manager or clinical supervisor to follow-up on the additional measures required per agency policy. Findings were reviewed with and acknowledged by DO #1 during an interview on 3/14/25 at 10:45 AM.”

“Based on record review and interview, the agency failed to ensure the ongoing sharing of information between the Physician, and all disciplines providing care for 1 (P-4) patient who experienced a significant change in condition, from a total of 19 records reviewed, resulting in the potential for worsening of health condition and unmet care needs near the end of life. Findings include: P-4: This patient was admitted to Hospice on 7/22/23. The benefit period of review was 2/11/25 through 3/14/25 with a terminal diagnosis of Alzheimer’s Disease. During the review, it was noted that on 3/9/25 the patient experienced a significant change in condition (TIA/Transient Ischemic Attack/Resembles a Stroke). Upon further review, there was no documented evidence that the Physician had been notified. These findings were reviewed with and confirmed by the Executive Director and Director of Operations during an interview on 3/14/25 at 3:14 p.m.”

“Based on observation and interview, the agency failed to ensure the Home Health Aide followed Infection Control standards of practice during the provision of care for 1 (P-1) patient observed during a home visit, with an indwelling urinary catheter, from a total of 19 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-1: The patient was admitted to Hospice on 11/21/24. The benefit period of review was 2/19/25 through 3/14/25 with a terminal diagnosis of Frontotemporal Neurocognitive Disorder. During the clinical record review on 3/11/25 at 12:15 p.m., it was noted that the patient had an indwelling urinary catheter. The Plan of Care (POC) ordered Hospice Aide Services at a frequency of 2x/wk. x 14 wks. to provide the following services: Catheter care, Incontinent care, Nail care, Oral care, Shampoo, Standard precautions, Universal precautions. On 3/11/25 at 1:00 p.m., a scheduled survey home visit was conducted with the Hospice Aide (HHa #1). During the visit, HHa #1 asked another staff member to assist with showering, transferring and dressing the patient. During the visit, HHa #1 was noted to unhook the patient’s catheter from his wheelchair and placed it on the floor. There was no barrier between the catheter bag and the floor. HHa #1, along with her assistant, was observed placing the catheter bag on the bare floor 3 additional times prior to concluding the visit. Additionally, prior to the shower, the assistant emptied the contents of the catheter into the toilet. Upon completion, HHa #1 instructed the assist to wipe the catheter tubing with a “wet wipe” and not the required alcohol pad used to wipe the tubing, in accordance with professional standards of practice. The Hospice Aide failed to utilize infection control standards of practice during the provision of care. The above findings were reviewed with and acknowledged by the Executive Director and Director of Operations during an interview on 3/14/25 at 2:44 p.m. who offered no response.”

“Based on record review and interview, the agency failed to ensure bereavement services were made available to all individuals in the bereavement plan of care and failed to ensure frequencies of the services to be provided were included in the bereavement plan of care in 1 (P-10) of 3 records reviewed for bereavement services, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings include: **Policy 4-006.1 titled “;Bereavement Services” (revised December 2024) stated, “;6. Bereavement interventions will be reflective of the family/caregivers choices to participate in the bereavement program.” P-10: This 79-year-old patient was admitted to hospice on 3/29/24 with the terminal diagnoses of Parkinsons disease and senile degeneration of the brain. During record review on 3/11/25, it was noted social work evaluation (dated 4/2/24) identified the patients 3 children in the initial bereavement section. Additionally, it was noted the form labeled “;Roster of Family, Caregivers, and Significant Others” (not dated) indicated all 3 children requested bereavement services. Upon review of the bereavement care plan following the patients death on 4/18/24, it was determined only 2 of the children were listed under the bereaved section. The plan of care also noted the mailings were only sent to 1 daughter; however, the bereavement notes in the electronic medical records indicated mailings were sent to 1 daughter and the son. There was no indication of mailings sent to the other daughter who was also identified in the initial bereavement assessment. Additionally, it was noted the bereavement plan of care did not include frequencies of when or how often phone contact was to occur. During an interview with the bereavement coordinator (BC #1) on 3/13/25 at 12:30 PM, BC #1 was asked about the mailings not being sent to one of the daughters. BC #1 stated she typically sends the information to the first person listed and they are to share with the others, however, she agreed the plan of care does not reflect this. BC #1 also acknowledged the bereavement plan does not include frequencies of phone contact to be made and to whom. The findings were again reviewed with BC #1 and the Director of Operations (DO #1) during an interview on 3/14/25 at 10:20 AM. During the interview, the policy above was also reviewed and BC #1 and DO #1 agreed the policy stated interventions are to be provided to all who chose to participate in the bereavement program and acknowledged the findings.”

“Based on record review and interview, the Agency failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a Registered Nurse who observed the Aide’s performance of the required tasks with a patient/pseudo-patient in 2 (HHa #1, HHa #3) of 3 Home Health Aide personnel records reviewed, resulting in the potential for the provision of substandard care and unmet care needs Findings include: HHa #1: Date of Hire was 2/24/22. There was no Initial Competency Evaluation available for review. During an interview on 3/13/25 at 10:05 a.m. with the Human Resources Director (HR #1) and the Director of Operations (DO #1), DO #1 was queried as to the whereabouts of HHa #1’s Competency Evaluation and reported, “I’ll have to look in the computer for hers.” No competency evaluation had been provided by the survey’s end. HHa #3: Date of Hire: 2/7/23. There was no Initial Competency Evaluation available for review. During the same above interview DO #1 was queried as to the whereabouts of HHa #3’s Competency Evaluation and reported, “I have to look for hers as well.” No competency evaluation had been provided by the survey’s end. The agency failed to ensure the Aides were deemed competent prior to the provision of care. The above findings were reviewed with and acknowledged by HR #1 and DO #1 at the time of discovery.”

“Based on record review and interview, the Registered Nurse failed to establish a written plan of care for the assigned Hospice Aide that provided specific guidance and care instructions on the needs of the patient and safety precautions, for 9 (P-1, P-2, P-3, P-4, P-7, P-11, P-12, P-13, P-18) of 14 records with Hospice Aide services ordered, from a total of 19 records reviewed resulting in the potential for the rendering of unsafe care and unmet care needs. Findings include: P-7: This 84-year-old patient was admitted to hospice on 3/10/25 with diagnoses of chronic kidney disease, heart disease, and dementia. The 3/10/25 plan of care listed the following safety measures: Safety Measures: Safe transfers; Fall precautions; Oxygen Precaution; Skin breakdown prevention; No ambulation w/o Assist; Weight Bearing Precautions; Transfer Precautions; Ambulation Precautions; and Universal Precautions. During record review on 3/12/25, it was noted that the aide care plan failed to include safety precautions to alert the aide to the safety needs of this patient. The findings were reviewed with and acknowledged by DO #1 during an interview on 3/13/25 at 1:00 p.m. P-1: The patient was admitted to Hospice on 11/21/24. The benefit period of review was 2/19/25 through 3/14/25 with a terminal diagnosis of Frontotemporal Neurocognitive Disorder. During the clinical record review on 3/11/25 at 12:15 p.m., it was noted that the patient had an indwelling urinary catheter. The Plan of Care (POC) ordered Hospice Aide Services at a frequency of 2x/wk. x 14 wks. and indicated the patient had fall precautions, hand railings, bathtub, wheelchair and shower chair. Upon review of the Aide Care Plan, it was noted the plan was void of the above durable medical equipment. Additionally, there was no visit frequency that instructed the Aide on the number of visits to make per week and no frequencies in which the ordered tasks were to be performed. On 3/11/25 at 12:30 p.m., a survey home visit was conducted with the Home Health Aide (HHa #1). The Aide Care Plan included the task of shaving the patient. During the visit, an electric shaver was observed on the patient’s bathroom sink. As HHa #1 proceeded to shave the patient, she stated, “His (patient) wife prefers to use the electric shaver, but I like to use the razor because it gives a closer shave.” The Aide Care Plan was not clear as to whether the razor or electric shaver was to be used. These findings were reviewed with and acknowledged by the Executive Director (ED #1) and Director of Operations (DO #1) during an interview on 3/14/25 at 2:44 p.m. to which DO #1 responded, “The nurse didn’t specify which one to use. We’ll have to update the plan of care.” P-2: The patient was admitted to Hospice on 12/6/25 with a terminal diagnosis of Congestive Heart Failure. The POC ordered HHa services to be provided at a frequency of 2x/wk. x 2 months. During the clinical record review on 3/12/25 at 12:55 p.m., it was noted that the Aide Care Plan was void of the frequency in which visits were to be made, and void of the frequencies in which the ordered tasks would be performed. These findings were reviewed with and confirmed by ED #1 and DO #1 during an interview on 3/14/25 at 3:04 p.m. P-3: The patient was admitted to Hospice on 1/7/25 with a terminal diagnosis of Senile Degeneration of the Brain. The POC ordered HHa services to be provided at a frequency of 2x/wk. x 13 wks. During a review of the Aide Care Plan on 3/13/25 at 12:15 p.m., it was noted that there was no frequency in which the visits would be made and no frequencies in which the ordered tasks would be performed. These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:09 p.m. P-4: The patient was admitted to Hospice on 7/22/23. The benefit period of review was 2/11/25 through 3/14/25 with a terminal diagnosis of Alzheimer’s Disease. During the record review on 3/13/25 at 2:20 p.m., it was noted that the POC indicated the patient had bleeding precautions. The Aide Care Plan, however, failed to include this precaution. Additionally, there was no frequency indicated on the Aide Care Plan of when and how often visits would be made and no frequencies in which the ordered tasks would be performed. These findings were reviewed with and acknowledged by ED #1 and DO #1 during an interview on 3/14/25 at 3:14 p.m. P-18: This 84-year-old was admitted to hospice on 5/31/24 with a terminal diagnosis of skin and lymph node cancer. The medical record was reviewed on 3/12/25. During review, it was noted that Hospice Aide (HA) services were ordered on 6/24/24. The HA made a visit on 6/25/24 and documented the following on an Aide Visit Note “;Care plan documentation not available for 6/25”. The HA care plan was developed by the Registered Nurse (RN) on 6/26/25 (the day after the HA visit). The HA provided care to the patient without the written patient care instructions prepared by the RN. On 3/14/25 at 1:20 p.m., this finding was reviewed and acknowledged during interview with the Director of Operations (DO #1). P-11: This 73-year-old patient was admitted to hospice on 12/26/24 with the terminal diagnosis of a malignant neoplasm of the main bronchus (lung cancer). During record review on 3/12/25, it was determined the plan of care (dated 12/26/24) identified fall precautions, 24-hour supervision, oxygen precautions, and skin breakdown precautions. Upon review of the aide care plan dated 12/26/24, it was noted it did not include the safety precautions mentioned above. P-12: This 89-year-old patient was admitted to hospice on 11/18/24 with the terminal diagnoses of congestive heart failure and malignant neoplasm of the kidney (kidney cancer). During record review on 3/12/25, it was noted the plan of care dated 2/16/25 indicated ambulation precautions and 24-hour supervision. It also indicted the patient used oxygen and a walker. Upon review of the current aide care plan, it was noted it did not include safety precautions or equipment. P-13: This 84-year-old patient was admitted to hospice on 1/10/25 with the terminal diagnoses of moderate protein-calorie malnutrition and vascular dementia. During record review on 3/13/25, it was noted the aide care plan interventions did not include frequencies for each task to be performed. Findings were reviewed with and acknowledged by DO #1 during an interview on 3/14/25 at 10:20 AM.”

“Based on observation, record review and interview, the Hospice failed to ensure the Hospice Aide provided care and services in accordance with the Plan of Care for 2 (P-1 and P-15) of 14 records in which aide services were provided, from a total of 19 sampled records reviewed, resulting in the potential for the provision of unsafe care, poor hygiene and unmet care needs. Findings include: P-1: This patient was admitted to Hospice on 11/21/24. The period of review was 2/19/25 through 3/14/25 with a terminal diagnosis of Frontotemporal Neurocognitive Disorder. During the clinical record review on 3/11/25 at 12:15 p.m., it was noted that the Plan of Care ordered Hospice Aide services at a frequency of 2x/wk. x 14 wks. The Aide Care Plan instructed the Aide to perform the following tasks: Catheter Care, Incontinent Care, Nail Care, Oral Care, Shampoo, and Perineal Care. On 3/11/25 at 1:00 p.m., a survey home visit was conducted with the Hospice Aide (HHa #1). During the visit, HHa #1 failed to perform oral care and nail care as instructed in the Aide Care Plan. Additionally, HHa #1 performed wound care to the patient’s left heel during the visit. This was not one of HHa #1’s assigned/ordered tasks. The Hospice Aide failed to provide care and services only as indicated in the Plan of Care. These findings were reviewed with and acknowledged by the Executive Director and Director of Operations during an interview on 3/14/25 at 2:44 p.m. P-15: This 92-year-old was admitted to hospice on 6/4/24 with a terminal diagnosis of senile dementia. The medical record was reviewed on 3/14/25. During review, it was noted that the Plan of Care (POC) for the certification period of 1/30/25 through 3/30/25 included orders for the Hospice Aide (HA) to provide services to the patient 2 times per week. The written instruction for the HA in the HA care plan included the following tasks to be completed during the visits: shampoo hair and provide either a shower or bed bath. During the period reviewed, the following were noted: The HA made 12 visits over 6 weeks (2 per week). In 7 out of 12 visits, the HA did not document that a shower or bed bath was provided. In 8 out of 12 visits, the HA did not document that the patients hair was shampooed. There were no notes indicating why the above tasks were not performed. There were no notes indicating the HA alerted the Registered Nurse (RN) regarding HA services which were not performed according to the HA care plan. On 3/14/25 at 1:20 p.m., interview was conducted with the Director of Operations (DO #1). DO #1 was asked about the expectation of the HA performing the tasks as assigned on the HA care plan. DO #1 stated that the HA is expected to provide all the services as they are written on the HA care plan each visit and that in the event the task was not completed, a note would be entered, and the RN would be informed so that a plan could be developed moving forward that suited the patients (or caregivers) needs.”

“Based on record review and interview, the Agency failed to provide documented evidence to ensure the Registered Nurse made an annual onsite observation visit at the patient’s residence to observe the care being provided, by 2 (HHa #1, HHa #3) of 3 Hospice Aide files reviewed, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: HHa #1: Date of Hire was 2/24/22. On 3/12/25 during a review of the Aide personnel files, it was noted that a document titled, “Review: -Annual” listed topics that included: baths, back rubs, oral hygiene, shampoos (NA) [sic], changing bed linen, assist with dressing/undressing, skin care and assist with toileting (NA) [sic].” Remaining topics indicated NA (not applicable) such as, preparing meals, assist with feeding, taking and recording oral, rectal and auxiliary temperatures, pulse, respiration and blood pressure when ordered, assist with ambulation, range of motion. Upon review, it could not be determined if these tasks were performed on an actual or pseudo-patient. Further, all the required tasks had not been assessed as per this requirement. HHa #3: Date of Hire 2/7/23. On 3/12/25 during a review of the Aide personnel files, it was noted that a document titled, “Review: -Annual” was undated and unsigned. The document listed topics that included: baths, back rubs, oral hygiene, shampoos (NA) [sic], changing bed linen (NA) [sic], assist with dressing/undressing, skin care, and assist with toileting (NA) [sic].” The remaining topics such as, preparing meals, assist with feeding, taking and recording oral, rectal and auxiliary temperatures, pulse, respiration and blood pressure when ordered, assist with ambulation, range of motion were all marked “NA (Not applicable.” Upon further review, it could not be determined if these tasks were performed on an actual or pseudo-patient. Further, all the required tasks had not been assessed as per this requirement.”

“Based on record review and interview, the hospice failed to ensure that volunteers were providing day-to-day services equaling at least 5% of the total patient care hours of all paid hospice and contract staff resulting in a lack of cost-savings for the agency. Findings included: On 3/13/25, documentation for volunteer activity for years 2024 and 2025 were requested and reviewed. A document titled “;Quarterly Volunteer Time Jan 2024- Dec 2024” was provided and gave the values for “;Volunteer Hours in 2024”, “;Employee Hours in 2024”, and the calculated percentage for total patient care hours utilized by the volunteers equaling 3.41% for 2024. Another document titled “;Quarterly Volunteer Time Jan 2025- March 13, 2025, was provided. That document listed the same items and showed that the calculated percentage for total patient care hours utilized by volunteers equaling 2.21% so far in 2025. During interview on 3/14/25 at 1:20 p.m., with the Bereavement Coordinator (BC #1, who also managed the Volunteer Coordinator), BC #1 acknowledged that the hospice was not meeting the 5% goal for volunteer hours in 2024 and so far in 2025.”

“Based on record review and interview, the Hospice failed to ensure a Discharge Summary was completed that detailed the course of care provided, including symptom and pain management, responses to treatment, Physician’s orders and the patient’s health status at the time of discharge for 1 (P-2) of 2 patients reviewed, who were discharged to the community or revoked Hospice services, from a total of 19 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: Policy: Discharge Summary, 4-077.1, 12/2024 stated, “Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include: status of problems identified at admission and during the provision of care, significant health history, continuing pain and symptom management, overall status of the patient at discharge, summary of the care or services provided and ongoing needs that cannot be met...” P-2: The patient was admitted to hospice on 12/6/24 with a terminal diagnosis of Congestive Heart Failure. During the clinical record review on 3/12/25 at 12:55 p.m., it was noted that the patient was discharged to the community by way of revocation on 1/2/25. The record reflected that the patient became combative and was subsequently sent to the hospital for treatment resulting in revocation of hospice services. The Plan of Care ordered the patient to receive Skilled Nursing (SN), Hospice Aide (HHa), Spiritual Care (SC) and Medical Social work (MSW) services to be provided. During a review of the Discharge Summary dated 1/3/25, it was noted that there was no summary of care which detailed the course of care provided by the ordered services, with responses to treatment, prior to the date of discharge/revocation. These findings were reviewed with and acknowledged by the Executive Director and Director of Operations during an interview on 3/14/25 at 3:04 p.m.”

“Based on observation and interview, the hospice failed to dispose of outdated biologicals, resulting in the potential for poor outcomes for the 76 current patients. Findings include: A tour of the hospice agency and residence was conducted on 3/12/25 at 1:30 p.m. with CS #1 (clinical supervisor - residence). During the tour, it was observed that the following contents of the residence supply storage room were expired: 12 4-ounce bottles of Gel Rite hand sanitizer expired on 04/2022; 10 boxes of 4-pack of Fleet Enemas expired on 11/2024. The findings were acknowledged by CS #1 at the time of discovery. During a tour of the hospice residence on 3/12/25 at 1:00 PM, the following supplies were found to be expired in the storage room located in the back hallway: 7 – Lemon-glycerine swabsticks ( 5 expired 2/2025, 2 expired 10/2023) 1 – Package of Phytoplex Barrier Cream Cloths (expired 10/2022) 3 – Tubes of Secure Denture Adhesive (expired 4/2024) 1 – Container Microdot bleach wipes (expired 4/2022) The items were given to the clinical supervisor (CS #1) for disposal upon discovery. Additionally, small, clear, reusable cups were located on the shelves containing various creams. Four were labeled “;antifungal” and were dated 1/29/25 and 3 were labeled “;zinc + A&D” and were dated 2/17/25. Upon discovery, CS #1 was asked about the agency policy for storing opened creams and what the labeled dates indicated. CS #1 stated the date indicted the date the cream was put into the container; however, she was unsure what the policy was for when to dispose of them. During an interview with the Director of Operations (DO #1) on 3/14/25 at 10:20 AM, DO #1 was made aware of the expires supplies and acknowledged the findings. DO #1 was also asked about the agency policy for supplies stored in other containers. DO #1 did not think there was a policy regarding this and stated they would not be using this practice anymore.”

“Based on record review and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect all occupants in the event of a fire emergency. On 03/12/2025 between the hours of 9:00-11:45 AM, record review revealed the facility failed to provide documentation for the semi-annual commercial kitchen hood cleaned by an outside vendor as required. No documentation was provided by the exit of the survey. This finding was confirmed by interview with the Facility Representative at the time of record review.”

“Based on record review and interview, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72, and records are readily available as required by 19.6.1.3, 9.6.1.5, NFPA 70 and NFPA 72. This deficient practice could affect all occupants in the event of a fire emergency. On 03/12/2025 between the hours of 9:00-11:45 AM, record review revealed the facility failed to provide documentation of the Quarterly Dialer Test. No documentation was provided by the exit of the survey. This finding was confirmed by interview with the Facility Representative at the time of record review.”

“Based on record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect all occupants in the event of a fire emergency. On 03/12/2025 between the hours of 9:00-11:45 AM, record review revealed the facility failed to provide documentation for the first quarter, second quarter, and third quarter sprinkler flow inspection test. No documentation was provided for the quarterly sprinkler flow inspection test by the exit of survey. This finding was confirmed by interview with Facility Representative at the time of record review.”

“Based on observation and interview, the facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas are 1 3/4 inch solid-bonded core wood or capable of resisting the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed as required by 19.3.6.3, and 42 CFR 403, 418, 460, 482, 483 and 485. There is no impediment to the closing of doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. This deficient practice could affect all occupants in the event of a fire emergency. On 03/12/2025 at approximately 1:09 PM, observation revealed the facility failed to maintain the cross-corridor door at the West Hall. The cross-corridor door failed to close to a smoke tight fit when tested. This finding was confirmed by interview with Facility Representative at the time of observation.”

“Based on observation, record review and interview, the facility failed to provide written records of inspection and testing of fire doors and assemblies as required by NFPA 80. The facility also failed to ensure all fire doors are compliant with NFPA 80 fire rated door assembly. This deficient practice has the potential to affect all occupants. On 03/12/2025 between the hours of 9:00-11:45 AM, Record review revealed the facility failed to provide documentation for the current annual fire rated door inspection. No current documentation was provided by the exit of the survey. On 03/12/2025 at approximately 11:57 AM, observation revealed both kitchen doors leading out to the corridors had non-approved door stops at the bottom of the doors. On 03/12/2025 at approximately 12:26 PM, observation revealed all three crawl space fire rated doors in the basement are missing the handles to the doors creating a through penetration in the doors. These findings were confirmed by interview with Facility Representative at the time of record review and observations.”

“Based on observation, record review and interview, the facility failed to provide essential electrical system (EES) maintenance and testing as required. This deficient practice has the potential to affect all occupants. On 03/12/2025 between the hours of 9:00-11:45 AM, record review revealed the facility failed to provide documentation for the weekly generator inspection. No documentation for the missing weekly inspection was provided by the exit of the survey. On 03/12/2025 between the hours of 9:00-11:45 AM, record review revealed the facility failed to provide documentation for the monthly generator load test. No documentation for the missing monthly inspection was provided by the exit of the survey. On 03/12/2025 between the hours of 9:00-11:45 AM, record review revealed the facility failed to record the monthly specific gravity test values of the lead-acid generator batteries or the values for the monthly conductance test of the maintenance free generator batteries. On 03/12/2025 at approximately 12:57 PM, observation revealed in the basement electrical room at the transfer switch there is no battery backup emergency light for the transfer switch. On 03/12/2025 at approximately 1:30 PM, observation revealed the facilitys generator was in power off mode. These findings were confirmed by interview with Facility Representative at the time of observation.”