Kansas City Hospice and Palliative Care

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments in one of three community patient records reviewed (Record/Patient #6). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Care Planning Process,” dated 06/26/2024, showed in part that:- The POC is based on the identified and expressed values, goals and needs of the patient/caregiver and is developed with professional guidance and support from the interdisciplinary team (IDT) while taking into consideration risk versus benefit and best evidence; and- The POC includes, but is not limited to, an initial and comprehensive, interdisciplinary assessment of the patient and caregiver; and the needs and goals expressed or identified by the patient/caregiver and developed with the guidance of the IDT. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 01/08/2026 with a terminal diagnosis of cancer of the pancreas. The patient had secondary diagnoses of anemia , nicotine dependence, and itching. The patient resided in his/her private residence with his/her spouse. Review of the updated POC, dated 02/17/2026, showed in part that:- The patient: * Had steps in his/her home and needed assistance at times with ambulation; * Had difficulty finding his/her words, forming words, when he/she tried to speak, the words made no sense and he/she could not find the correct pronunciation; * Had a decreased appetite and was trying to eat two meals per day; * Needed lots of continuing education on his/her pain medications, specifically when to take them. The nurse had educated the patient at every visit and with every phone call on how to take his/her pain medications; - The POC contained interventions related to pain management including: * Collaboration with attending physician regarding pain medications, treatment, and care needs; * Educate family in nonverbal expressions of pain; * Instruct patient/caregivers on provider’s 24-hour contact numbers; and * Teach medication actions, side effects, and interactions; and- The POC contained, in part, the following medication orders: * Dexamethasone (a medication used to reduce inflammation) daily; * MS (morphine sulfate) Contin (an opioid pain medication) every 12 hours; * Pepcid (used to treat itching) daily; * Hydroxyzine (used to treat itching) as needed for itching; and * Oxycodone (an opioid pain medication) as needed for pain. Observation and interview on 02/24/2026 at 1:00 PM: - This state agent (SA) asked the patient for his/her current medication list. The patient stated that he/she would like to have a list of his/her medications, and he/she had asked for a list on more than one occasion;- This SA then asked to look at the patient’s medication bottles, the patient’s spouse stated that he/she would be very happy to have someone look at the patient’s medications, and that he/she had not seen anyone look at the patient’s medication bottles for a long time; - The patient stated that he/she kept his/her daily medications in the hall closet, escorted this SA to the closet, and showed this SA bottles containing oxycodone, hydroxyzine, and MS Contin. The patient stated that he/she took one pill from each of the three bottles one time per day; - The patient stated that he/she kept all of his/her as needed medications in the bathroom medicine cabinet; - The patient escorted this SA to the bathroom, and this SA observed the medication bottles in the bathroom medicine cabinet, and noted that prescription bottles for Pepcid and Dexamethasone were in the medicine cabinet in the patient’s bathroom; - This SA then asked the patient where he/she kept the comfort kit medications; - The patient stated that he/she kept them in the refrigerator, the patient escorted this SA to the kitchen and retrieved the comfort kit medication bag from the refrigerator;- The patient stated that he/she would like to get a medication list so he/she would know what medications he/she should be taking; and- He/she would be willing to use a medication planner, and no one had offered to assist him/her with one. During an interview on 02/25/2026 at 9:20 AM, registered nurse (RN)-2 stated that:- The patient and his/her spouse were both extremely confused at times; - He/she had taken and left two medication lists to the patient’s home; - He/she physically checked the patient’s medication bottles every visit;- The patient would move the bottles around his/her home between visits; they were never in the same place; - He/she sat with the patient on several occasions and explained the purpose of the medications to the patient; - The patient had a history of noncompliance with his/her medication regimen; - The patient had refused to use a medication planner in the past; - He/she thought they had discussed the patient’s noncompliance with his/her medication regimen at interdisciplinary group (IDG) meetings; - He/she was not worried about the patient’s safety with his/her medications because the patient had an adult child who checked on the patient. Review of the updated POC documentation for the dates of 01/13/2026, 01/20/2026, 01/31/2026, 02/03/2026, and 02/17/2026, showed in part that the POC failed to contain goals and interventions related to the patient’s ongoing noncompliance with his/her medication regimen including, but not limited to, the patient’s:- Refusal to use the medication planner offered by the skilled nurse;- Retain multiple medication lists;- Frequent relocation of his/her medication bottles; and - The adult child providing oversight for the patient’s medications. During an interview on 02/25/2026 at 11:02 AM, governing body appointee-1 and the RN coordinator stated that they would expect clinicians to check the patient’s medications at least weekly, modify the patient’s POC to reflect interventions and goals related to noncompliance, and the patient’s POC failed to contain goals and interventions related to the patient’s noncompliance with his/her medication regimen.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) contained measurable outcomes in three of three community patient records reviewed (Records/Patients #5, #6, and #7). This deficient practice has the potential to affect all the patients served by the provider.Findings included: Review of the provider’s policy titled, “Care Planning Process,” dated 06/26/2024, showed that goals for immediate needs will be identified and individualized. The policy failed to contain the verbiage that the patient goals would be measurable. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 05/06/2024 with a terminal diagnosis of sequelae (aftereffects) of cerebral infarction (stroke). The patient had secondary diagnoses of dementia (decline in mental capacity), severe malnutrition, and abnormal weight loss. The patient resided in the private residence of his/her adult child. Review of the POC last updated 02/18/2026 showed in part the following patient goals: - For patient and family, primary caregiver, maintain safe home environment, the goal failed to identify what elements evidenced a safe home environment; - For patient and family, increase quality of life, the goal failed to identify what elements evidenced quality of life; and- For the patient and family, primary caregiver, adjust to changing nutritional needs, the goal failed to identify what elements evidenced adjustment to changing nutritional needs. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 01/08/2026 with a terminal diagnosis of cancer of the pancreas. The patient had secondary diagnoses of anemia , nicotine dependence, and itching. The patient resided in his/her private residence with his/her spouse. Review of the POC last updated 02/17/2026 showed in part the following patient goals: - For minor child, patient, and family, increase quality of life, the goal failed to identify what elements evidenced increased quality of life; and - For patient and family, maintain desired nutrition/hydration level, the goal failed to identify what elements to evidenced the patient’s desired nutrition/hydration level. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2023 with a terminal diagnosis of Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient had secondary diagnoses of dementia (decline in mental capacity), history of falling. The patient resided in a skilled nursing facility (SNF). Review of the POC last updated 02/10/2026, showed in part the following patient goals: - For patient and family, facility staff, maintain optimal airway patency, the goal failed to identify what elements evidenced optimal airway patency; - For patient and family, facility staff achieve optimal fluid/electrolyte balance, the goal failed to identify what elements evidenced optimal fluid/electrolyte balance; and- Mental function will be managed effectively while on hospice, the goal failed to identify what elements evidenced effective management. During an interview on 02/25/2026 at 11:39 AM, governing body appointee-1 and the registered nurse coordinator stated that the software allows for numerical rating of progress toward goals, and they were unable to locate measurable elements in the identified goals.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the drugs and treatments necessary to meet the needs of the patient in two of three community patient records reviewed (Records/Patients #6 and #7). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Care Planning Process,” dated 06/26/2024, showed that the POC would include the scope and frequency of services, medical equipment, supplies, medications and treatments needed to meet the patient/caregiver needs. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 01/08/2026 with a terminal diagnosis of cancer of the pancreas. The patient had secondary diagnoses of anemia , nicotine dependence, and itching. The patient resided in his/her private residence with his/her spouse. Review of the interdisciplinary group (IDG) notes, dated 02/03/2026, showed that the registered dietician (RD) had made recommendations for the patient’s care and gave the skilled nurse written literature for the patient. Review of the updated POC and IDG notes, dated 02/17/2026, showed the document failed to contain information on the RD’s information and treatment recommendations for the patient’s care. During an interview on 02/25/2026 at 11:02 AM, governing body appointee (GBA)-1 and the registered nurse coordinator (RNC) stated that they would expect the POC to contain the drugs and treatments necessary to meet the needs of the patient, and they were unable to locate the RD’s recommendations in the patient’s POC.RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2023 with a terminal diagnosis of Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient had secondary diagnoses of dementia (decline in mental capacity), history of falling. The patient resided in a skilled nursing facility (SNF). Observation on 02/24/2026 at 1:00 PM, review of the facility POC showed the patient had orders for: - Heat to right shoulder PRN (as needed) for pain; - A regular diet, thin consistency, fruit with all meals, a Super Donut (a donut that provides meaningful amounts of vitamins, minerals and protein) with breakfast, Vanilla Thrive ice cream (a complete nutritional supplement) with lunch, and a house supplement (a dietary supplement) three times per day; - Elevate the head of bed/chair 30-45 degrees; and- TED (thrombo-embolic deterrent; support hose used to reduce the occurrence of blood clots) hose on bilateral lower extremities PRN. Review of the updated POC IDG notes, dated 02/10/2026, showed that the documentation failed to contain drugs and interventions to address the patient’s facility orders for heat to the right shoulder, fruit with all meals, Super Donut with breakfast, Vanilla Thrive ice cream with lunch, house supplement three times per day, elevation of the head of bed/chair 30-45 degrees, and the use of TED hose PRN. During an interview on 02/25/2026 at 11:30 AM, GBA-1 and the RNC stated that they would expect the hospice POC to reflect the drugs and treatments used at the SNF, and they were unable to locate the identified items on the hospice POC.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that care and services were provided in accordance with the plan of care (POC) when they failed to administer medication timely, in one of seven full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process,” revised 06/26/2024, showed in part: - The interdisciplinary team (IDT) establishes and maintains an individualized POC for each patient/caregiver admitted;- The POC includes but is not limited to medications needed to meet the patient/caregiver needs; and- Care Is provided in accordance with the POC. Review of the provider’s policy titled, “Medication Administration,” revised 08/23/2011, showed in part, medications must be given within one hour before or after the designated time. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 10/25/2025 with a terminal diagnosis of extranodal marginal zone B-cell lymphoma of mucosa associated with lymphoid tissue also known as MALT lymphoma (a rare, slow growing type of non-Hodgkin lymphoma (a blood cancer of the lymphatic system) that originates in B cells within mucosal tissues most commonly of the stomach but also in the lungs, thyroid or skin). The patient was admitted to inpatient hospice house B under general inpatient care (GIP- short term, Medicare covered level of care for managing acute pain or severe symptoms that cannot be treated at home or in other settings) care on 02/15/2026. Review of the physician’s POC signed by the physician 01/29/2026 showed:- Assess medication effectiveness, duplication, interactions, side effects and regimen adherence; and- Collaborate with the attending physician regarding pain medications, treatment and care needs. Review of the current medication profile showed methadone (an opioid used to treat chronic pain) 15 milligrams (mg) every eight hours at 5:00 AM, 1:00 PM, and 9:00 PM. Observation on 02/23/2026 at 5:48 PM, showed registered nurse (RN)-1 administered methadone 15 mg (more than three hours before it was scheduled to be administered). Per interview conducted during observation, RN-1 stated that:- The methadone should not have been given until 9:00 PM;- He/she had to notify the attending physician, the supervisor, and the patient’s power of attorney of the error; and- He/she had to write up an incident report. During an interview on 02/25/2026 at 9:25 AM, inpatient manager (IM)-1 stated that medications were to be given within one hour either before or after the time the medication was ordered to be given.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the written agreement specified how the skilled nursing facility/nursing facility (SNF/NF) or intermediate care facility of individuals with intellectual disabilities (ICF/IID) and the hospice would communicate with each other, and document such communications, to meet patient needs 24 hours a day. Findings included: Review of the provider’s policy titled, “Written Agreements for Contracted Services,” updated 10/18/2024, showed the written agreement would address the following:- The role, if any, of the organization and the contracted individual in coordination, supervision, and evaluation of patient care provided; and - What documentation the provider required and the time frame for completing and submitting the documentation to the provider. Review of the hospice contract titled, “Agreement for the Provision of Hospice Home Health Care Services to Residents of Nursing Home,” dated 06/28/2024, showed:- The facility would promptly notify the hospice in the event of changes in the patient’s condition; and- The facility would communicate with the hospice to ensure the needs of the patient are addressed and met 24 hours a day.The hospice contract failed to indicate how the facility and the Hospice would communicate with each other regarding patient care to ensure prompt communication. During an interview, on 02/25/2026 at 1:30 PM, the hospice governing body appointee (GBA)-2 stated that the way they communicate with the nursing facilities had never been specified. It was assumed the nursing facility would call the phone numbers in the patient’s hospice files. GBA-2 stated the nursing facility also utilizes a documentation sheet in the patient file to let the hospice nurse know about the patient’s needs.”

“Based on nationally recognized standards, observation, and interview the hospice inpatient provider failed to maintain a safe physical environment free of hazards. This deficient practice has the potential to affect all patients, staff, and visitors. Findings included:Review of the National Fire Protection Association (NFPA) 1 Fire Code, 2012 edition showed 11.1.2: All electrical appliances, fixtures, equipment, or wiring shall be installed and maintained in accordance with NFPA 70, National Electrical Code. Review of the NFPA 70, 2011 edition showed 210.8 (B): Other Than Dwelling Units. All 125-volt, single phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.(1) Bathrooms(2) Kitchens(3) Rooftops(4) Outdoors(5) Sinks - where receptacles are installed within 1.8 meters (6 ft) of the outside edge of the sink.(6) Indoor wet locations(7) Locker rooms with associated showering facilities(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used.*NFPA 70, 2011 edition - Definition of Dwelling Unit: Dwelling Unit. A single unit, providing complete and independent living facilities for one or more persons, including permanent provisions for living, sleeping, cooking, and sanitation. Observation on 02/24/2026 beginning at 9:30 AM, at inpatient house-A, showed the following:- The manager’s office contained a small fish tank full of water plugged into a wall outlet that failed to be a ground fault circuit interrupter (GFCI) outlet (a GFCI outlet must be installed within six feet of water sources to prevent shock hazards);- The kitchen hallway contained a water and ice machine plugged into a wall outlet that failed to be a GFCI outlet;- The pod C nurse’s station contained an apartment sized refrigerator that was plugged into a power strip (power strips are not allowed for heavy electrical use items in patient care areas due to fire hazards); and- The pod D storage room contained a blanket warmer plugged into an extension cord (extension cords are not allowed for heavy electrical use items due to fire hazards). During an interview on 02/24/2026 at 10:08 AM, the maintenance supervisor confirmed that the fish tank and water and ice machine were not on GFCI outlets. During an interview on 02/25/2026 beginning at 9:45 AM, the maintenance supervisor stated that he/she would expect any electrical items with water to be on GFCI outlets and that power strips and extension cords should not be used for refrigerators and towel warmers.”

“Based on nationally-recognized standards, observation, record review, and interview the inpatient hospice provider failed to ensure that the sprinkler system was maintained according to National Fire Protection Association (NFPA) standards, that minimum clearance for sprinklers was maintained, and that the fire alarm system was tested semi-annually. This deficient practice has the potential to affect all patients, staff, and visitors. Findings included: Review of the NFPA 25, 2011 edition, showed 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (a sprinkler head that has experienced degradation due to a chemical reaction with the environment) (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (a sprinkler head that has an accumulation of dust, debris, paint, or other foreign materials on its surface) (6) Painting unless painted by the sprinkler manufacturer. Review of the NFPA 25, 2011 edition, showed 5.2.1.2 The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.Review of the NFPA 72, 2002 edition, showed 10.4 Testing. 10.4.2 Test Methods. 10.4.3 Testing Frequency. Testing shall be performed in accordance with the schedules in Table 10.4.3, except as modified in other paragraphs of 10.4.3, or more often if required by the authority having jurisdiction. 10.5 Maintenance. 10.5.1 Fire alarm system equipment shall be maintained in accordance with the manufacturer’s instructions. 10.6.2 Maintenance, Inspection, and Testing Records. 10.6.2.1 Records shall be retained until the next test and for 1 year thereafter. Review of NFPA 72, 2010 edition, showed 14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter. Observation on 02/24/2026, beginning at 9:30 AM, at inpatient house-A, showed the following:- Room number six had a ¼-inch opening around the sprinkler head escutcheon creating an opening into the ceiling in the closet;- The outdoor seating area off B pod had one corroded sprinkler head and one sprinkler cover with rust that had water damage marks in the wood surrounding the sprinkler;- The supply closet on B pod had a sprinkler cover hanging down out of the ceiling tile;- The A pod courtyard (across from room number one) had two sprinkler covers hanging down one-inch on one side;- Room 17 had a missing escutcheon on one sprinkler head that created a 2-inch opening into the ceiling around the sprinkler;- The C pod hallway had a missing escutcheon on one sprinkler head outside of the manager’s office;- The manager’s office had a missing escutcheon on a sprinkler head;- Room 20 had a sprinkler head cover hanging down ¼-inch creating a 1/8-inch opening into the ceiling;- The closet between rooms 23 and 24 had a missing escutcheon on one sprinkler;- The C pod courtyard was missing three escutcheons from sprinkler heads;- The oxygen storage area had a loaded sprinkler head cover;- The D pod locker room had one missing escutcheon from a sprinkler head;- The D pod courtyard had one missing escutcheon from a sprinkler head;- Room 28 had 10 pillows in the closet shelf obstructing the sprinkler head;- Outside the front door was missing an escutcheon on one sprinkler head;- Between rooms seven and eight on the outside of the building the sprinkler head was loaded;- Between rooms nine and 10 on the outside of the building the sprinkler head was loaded;- Between rooms 11 and 12 on the outside of the building the sprinkler head was loaded;- Between rooms 14 and 15 on the outside of the building the sprinkler head was loaded;- Between rooms 16 and 17 on the outside of the building the sprinkler head was loaded;- Between rooms 22 and 23 on the outside of the building the escutcheon was missing from the sprinkler head; and- Between rooms 24 and 25 on the outside of the building the sprinkler head was loaded. Record review showed that a fire alarm inspection was completed on 05/08/2025 and no other inspections had been completed in 2025 or 2026 (fire alarm inspections are to be completed semi-annually). During an interview on 02/25/2026 beginning at 9:45 AM, the maintenance supervisor stated that he/she would expect sprinkler heads to be clean, covered, and in good working order. Also stated that the sprinkler heads should not be blocked and that a minimum of 18-inches of clearance for the sprinkler head should be maintained at all times. He/she would expect that the fire alarm system would be inspected twice per year.”

“Based on observation, record review, and interview the inpatient hospice provider failed to ensure that water temperatures were maintained at a safe level. This deficient practice has the potential to affect all patients, staff, and visitors. Findings included: Observation on 02/24/2026 beginning at 9:30 AM, at inpatient house-A, showed the following:- The water temperature in the bathroom sink in room four (Pod A) was 115 degrees Fahrenheit after running the hot water for three minutes;- The water temperature in the bathroom sink in room 11 (Pod B) was 113 degrees Fahrenheit after running the hot water for three minutes;- The water temperature in the bathroom sink in room 17 (Pod C) was 112.5 degrees Fahrenheit after running the hot water for three minutes;- The water temperature in the bathroom sink in room 27 (Pod D) was 113.5 degrees Fahrenheit after running the hot water for three minutes;- The water mixer for the facility was located in the mechanical room and was observed to be set to 118 degrees Fahrenheit at 11 AM; and- The recommended water temperature at plumbing fixtures should be maintained at or below 110 degrees Fahrenheit. Record review showed that water temperatures were tested weekly in various rooms in the facility and that the water temperatures for 2026 were as follows:- The water temperature on 01/08/2026 in room number one was 114.5 degrees Fahrenheit;- The water temperature on 01/15/2026 in room number 14 was 115.5 degrees Fahrenheit;- The water temperature on 01/23/2026 in room number eight was 115.0 degrees Fahrenheit;- The water temperature on 01/28/2026 in the spa was 117.5 degrees Fahrenheit;- The water temperature on 02/05/2026 in room number 25 was 114.5 degrees Fahrenheit;- The water temperature on 02/13/2026 in the Pod A kitchenette was 115.5 degrees Fahrenheit; and- The water temperature on 02/20/2026 in room number four was 115.5 degrees Fahrenheit. During an interview on 02/24/2026 at 11 AM, the maintenance supervisor stated that the water mixing valve is set to 118 degrees Fahrenheit and that he/she usually checks water temperatures in the afternoon. He/she stated that he/she was unaware that water temperatures should be 110 degrees Fahrenheit or lower.”

“Based on policy review, observation, and interview the inpatient hospice provider failed to ensure that infection control standards were met while giving medications, that all intake and exhaust air ducts were maintained to prevent the entrance of dust, dirt, and other contaminating material into the facility, that all ceiling tiles were free of stains, and that all floors were free of dust. This deficient practice has the potential to affect all patients, staff, and visitors. Findings included: Review of the provider’s policy titled, “Infusion,” revised 07/01/2011, showed in part,:- The named provider will follow the procedures that are recommended by the Infusion Nursing Society;- All other infusion procedures are referenced in the “Policies and Procedure for Infusion Nursing 3rd Edition” which is available in all office locations; and- Nursing staff are to review and follow these procedures when caring for patients with infusion therapy. Observation on 02/23/2026 at 5:00 PM, at inpatient house-A, showed the following:- Patient #13 received Haldol (a medication used for anxiety) 1 milligram (mg), diazepam (a medication used for anxiety) 5 mg, and morphine (a medication used for pain) 5 mg by an internal jugular (IJ) intravenous (IV) site (an IV site placed in the right side of the large vein of the neck for administering medications and IV fluids);- Licensed practical nurse (LPN)-C washed his/her hands, donned gloves, cleaned the IJ IV port with an alcohol pad and administered Haldol, administered a normal saline flush (a medication used to maintain the patency of an IJ or SQ (subcutaneous-given under the skin layers) IV catheter), administered morphine, administered a normal saline flush, administered diazepam, and administered a normal saline flush; and- LPN-C failed to clean the IJ IV port before administering the normal saline flushes or the Morphine and Diazepam. Observation on 02/23/2026 at 5:30 PM, at inpatient house-A, showed the following:- Patient #14 received morphine 10 mg by mouth and diazepam 2.5 mg by SQ infusion;- LPN-C washed his/her hands, donned gloves, administered the morphine by mouth, cleaned the SQ port with an alcohol wipe, administered a normal saline flush, administered the diazepam, and then administered a normal saline flush;- During the administration of the medications the patient’s SQ port laid on his/her shirt between medication administrations; and- LPN-C failed to clean the SQ port before administering the diazepam and the second normal saline flush. Observation on 02/24/2026 beginning at 9:30 AM, at inpatient house-A, showed the following:- The electrical closet in pod A had a thick covering of dust on the floor;- The conference room in pod A had two ceiling tiles with three dark colored stained areas;- The vent in the wall of the pod A kitchenette had a build-up of dust;- The family laundry room had a build-up of dust on the ceiling and on the water valves located in the wall behind the washer and dryer;- The electrical closet in pod C had a thick covering of dust on the floor;- The manager’s office had four ceiling tiles with dark colored stained areas;- The mechanical room had a thick covering of dust on the floor;- The public bathroom across from room 18 had a build-up of dust in the vent;- Room 21 had a build-up of dust in the vent in the bathroom;- Room 25 had one ceiling tile with a dark colored stain;- The dirty utility room was missing an electrical receptacle cover;- The staff breakroom had two ceiling tiles with dark colored stained areas and the lights, ceiling, and vent had dust build-up;- The kitchen hallway had two ceiling tiles with dark colored stained areas;- The volunteer office had two ceiling tiles with dark colored stained areas inside the room and two ceiling tiles with dark colored stained areas outside the room in the hallway; and- The paper storage area had one ceiling tile with a dark colored stained area. During an interview on 02/25/2026 beginning at 9:45 AM, the maintenance supervisor stated that he/she would expect that floors, vents, and ceiling tiles would be clean and stain free at all times.During an interview on 02/25/2026 beginning at 1:35 PM, the inpatient house-A director stated that he/she would expect the IJ and SQ ports to be cleaned with alcohol in between each medication and if the port touched the patient’s shirt.”

“Based on policy review, observation, and interview the hospice inpatient houses, A and B, failed to store food under sanitary conditions in the refrigerator in the kitchenettes. The deficient practice has the potential to affect all patients/families/visitors at the inpatient houses. Findings included:Review of the provider’s policy titled, “Hospice House Kitchenette,” dated revised 03/02/2021, showed in part the following:-The hospice house provides kitchenettes which may be used by patients and/or visitors;-A microwave and refrigerator/freezer are provided for the patient and their visitors to use; and-Written instructions are on the refrigerator: *All items placed in the refrigerator or freezer must be labeled and dated; and * Items left in the refrigerator longer than one week or not labeled/dated will be disposed of by staff or volunteers. Review of undated instructions posted on the kitchenette refrigerator showed:- All food must be stored in an enclosed container (such as a to-go box);- Containers must be bagged and tied, or folded closed in grocery or food delivery bag;- Bags must be labeled with the date. Labels are provided in the family kitchen; and- Outdated and unlabeled food will be removed and discarded per the normal routine. Observation on 02/24/2026 at 4:15 PM, at inpatient house-A, showed that the refrigerator in the pod C kitchenette at the hospice house contained a fast-food container labeled room 14 with a date of 02/17/2026 and multiple unlabeled and undated condiments. The freezer contained homemade freezer pops without a label identifying a patient or visitor name or date.Observation on 02/24/2026 at 4:20 PM, at inpatient house-A, showed that the refrigerator in the pod B kitchenette at the hospice house contained a plastic container labeled as ham salad without a label identifying a patient or visitor name or date and a sandwich wrapped in aluminum foil without a label identifying a patient or visitor name or date. The freezer contained a frozen drink without a label identifying a patient or visitor name or date. During an interview on 02/25/2026 beginning at 1:35 PM, the inpatient house-A director stated that:- He/she would expect that all items in the refrigerator and freezer would be labeled with a patient or visitor name as well as the date;- The refrigerator should be checked periodically; and- Items should be thrown away as necessary. Observation on 02/23/26 at 2:20 PM, of the kitchenette located across from the living room area in inpatient house B during facility rounds, showed a clear plastic container containing lettuce and two plastic tubs inside of it with white gel-like substance (similar to ranch salad dressing) in the refrigerator. The container was not labeled with a patient’s or visitor name and was not dated. Observation on 02/24/2026 at 2:00 PM, of the kitchenette located across from the living room area in inpatient house B, showed the same plastic container in the refrigerator without a label identifying patient or visitor name and date. Observation on 02/25/2026 at 9:10 AM, of the kitchenette located across from the living room area in inpatient house B, showed the same plastic container in the refrigerator without a label identifying patient or visitor name and date. During an interview on 02/25/2026 at 9:15 AM, the Inpatient Manager (IM1), stated that:- He/she would have expected the salad to have been labeled and dated;- The families knew they were supposed to date and label their items;- The hospital staff (not the staff of the North inpatient hospice) are who cleaned the family kitchen (kitchenette); and- He/she knew the hospital environmental staff cleaned the kitchenette every day.”