Citizens Memorial Hospice

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 12/30/2025 with a terminal diagnosis of pressure ulcer of the sacral region, stage 4 (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a family caregiver.Observation and interview on 03/31/2026 at 10:30 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile:-The provider’s profile showed zinc (a supplement) by mouth, take one tablet daily. The patient’s caregiver (cg) stated that the patient no longer took this medication;-The provider’s profile showed vitamin C (a supplement) 500 mg by mouth, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed Azo Cranberry (a supplement) 250 mg by mouth, take two tablets daily. The patient’s cg stated that she no longer took this medication;-The provider’s profile showed calcium carbonate (a supplement) 500 mg, take one tablet twice daily. The patent’s cg stated that the patient no longer took this medication;-The provider’s profile showed melatonin (a supplement) 1 mg, take one tablet at bedtime. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed cranberry fruit (a supplement) 500 mg, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed diclofenac sodium 1% gel (used for pain relief), use one application two times a day. The patient’s cg stated that the patient no longer used this medication;-The provider’s profile showed tizanidine (used to treat spasms, cramping, and tightness caused by spinal cord injuries or multiple sclerosis) 4 mg, take one tablet three times daily. The patient’s cg stated that the patient took this medication every four hours; and-The patient took vitamin D3 (a supplement) 50 micrograms (mcg) once daily. This provider’s profile failed to contain this medication.During an interview on 03/01/2026 at 2:45 PM, the hospice administrator stated that he/she would expect all medications that the patient is taking to match what is on the medication profile.RECORD/PATIENT #5:Review of the clinical record showed that the patient was admitted to hospice services on 03/13/2026 with a terminal diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (uncontrolled growth of abnormal cells in the lung tissue, often causing symptoms like a persistent cough, chest pain, and weight loss). The patient lived at home with family caregivers.Observation and interview of 03/31/2026 at 12:30 PM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile:-The provider’s profile showed Tarpeyo (a prescription-strength corticosteroid used to reduce proteinuria (protein in urine)) 4 mg capsule, take two capsules daily. The patient no longer took this medication;-The provider’s profile showed Aleve (used for pain) 220 mg tablet, take one tablet every 8-12 hours as needed. The patient no longer took this medication; and-The provider’s profile showed acetaminophen (used to treat fever/pain) 650 mg suppositories, use one suppository every four hours as needed. The patient no longer used this medication.During an interview on 03/01/2026 at 2:45 PM, the hospice administrator stated that he/she would expect all medications that the patient is taking to match what is on the medication profile. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/12/2026 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF). Record review of the hospice provider’s medication profile, dated 03/30/2026, and the LTCF’s medication profile, dated 03/31/2026, showed the following discrepancies between the provider’s medication profile and the LTCF’s medication profile:- The provider’s profile showed Women’s 50 Probiotic 4 billion cell (a supplement designed to promote intestinal, vaginal and immune health), take one capsule every evening (PM). The LTCF’s profile did not include this medication;- The provider’s profile showed garlic 1000 milligrams (mg) (a supplement used to support cardiovascular health, healthy blood pressure, and immune health), take one capsule daily. The LTCF’s profile did not include this medication;- The provider’s profile showed atorvastatin 80 mg (a medication used to reduce bad cholesterol and triglycerides while reducing the risk of heart attacks and stroke), take one tablet daily. The LTCF’s profile did not include this medication;- The provider’s profile showed trazodone 50 mg (an antidepressant frequently used off label for insomnia), take one tablet at bedtime. The LTCF’s profile showed trazodone 25 mg, take one at bedtime;- The provider’s profile showed magnesium 250 mg (actual elemental magnesium that is easier for the body to absorb and better for increasing overall magnesium levels), take one tablet daily. The LTCF’s profile showed Mag-ox (magnesium oxide) 400 mg (refers to the weight of the compound, not the elemental magnesium, and is known for having high elemental magnesium, but poor solubility, meaning less is absorbed by the body), take one daily. Magnesium 250 mg and magnesium oxide 400 mg were two different types of medication;- The provider’s profile showed aspirin 81 mg, oral tablet delayed release, take one tablet daily. The LTCF’s profile showed aspirin chewable 81 mg, take one daily;- The LTCF’s profile showed Loratadine 5 mg (an antihistamine used to reduce allergy symptoms like sneezing, runny nose, itchy eyes and hives), take one daily. The provider’s profile failed to include this medication. - The LTCF’s profile showed PRN medications of Tylenol 650 mg every four hours, Dulcolax 10 mg rectal capsule (RC; suppository) (a medication taken to relieve constipation) daily, Senokot-S (a medication to relieve constipation) 86/50 mg two times per day, Isopto Atropine 1% ophthalmic drops (a medication taken for excess oral secretions), take sublingual every 4 hours, Roxanol oral solution (a medication for severe pain) 5 mg every three hours, Tylenol 650 mg RC every six hours, and Imodium (a medication used to treat diarrhea) four mg twice a day, The provider’s profile failed to include all of these PRN medications. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (decrease in the ability of the heart to pump blood). The patient lived at home with a family caregiver. Observation and interview on 04/01/2026 at 10:00 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile: - The provider’s profile showed ergocalciferol (vitamin D2) 1250 mcg (a supplement used to treat severe vitamin D deficiency), take one capsule weekly. The patient’s caregiver (cg) stated that the patient did not take this medication; - The provider’s profile showed gabapentin 300 mg (a medication used to treat nerve pain) by mouth, take one capsule four times daily. The patient’s cg stated that the patient only took this medication three times a day; - The provider’s profile showed amiodarone 200 mg (a medication used to treat heart arrythmias) by mouth, take one tablet daily. The patient’s cg stated this medication was not taken on Mondays, Wednesdays, and Fridays; - The provider’s profile showed fentanyl 12 micrograms (mcg)/hour transdermal patch (used to manage chronic pain), one patch every 72 hours. The patent’s cg stated that the medication patch is changed two times per week, not always every 72 hours; - The patient took Tylenol extra strength, two tablets by mouth as needed. This provider’s profile failed to contain this medication; - The patient took Uqora Defend part 2, one tablet every day to help prevent urinary tract infections. The provider’s profile failed to contain this medication; and - The patient took Uqora Flush Proactive drink mix every three days to help prevent urinary tract infections. The provider’s profile failed to contain this medication. During an interview on 04/01/2026 at 2:45 PM, the hospice administrator stated that he/she would expect all medications that the patient is taking to match what is on the medication profile. Findings Included:Review of the policy titled,” Patient Medication Schedule Worksheet/ Medication Reconciliation HHA 09-16” dated 08/2022 showed in part:The nurse will prepare the medication schedule worksheet and give the original to the patient at the time of completion; andWhen changes with medications occur, the nurse will complete a new medication schedule worksheet for the patient and dispose of the old worksheet for the patient and dispose of the old worksheet to avoid patient confusion about his/her medication schedule. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 06/26/2025 with a terminal diagnosis of heart failure. The patient resided at home with a spouse. Observation and interview on 03/31/2026 at 11:00 AM, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for cholecalciferol with vitamin D3 (vitamin supplement) 1250 micrograms (mcg) capsule, take one capsule by mouth once each week. The patient’s spouse stated that the patient no longer used the medication;-The medication profile showed an order for spirolactone (used to treat heart failure, and edema (swelling) 25 milligrams (mg) tablet, take one tablet by mouth once each day. The patient’s spouse stated that the patient no longer used the medication;-The patient took the medication trazadone (used to treat major depressive disorders), 50 mg tablet, take one tablet by mouth, once each day. This medication was not included on the provider’s medication profile; -The patient took the medication metoprolol (used treat high blood pressure) 25 mg tablet, take one tablet by mouth, once each day. This medication was not included on the provider’s medication profile; and-The patient took Tylenol (a pain reliever and fever reducer) 650 mg suppository, take one suppository rectally every four hours as needed. This medication was not included on the provider’s medication profile. During an interview on 04/01/2026 at 2:50 PM, the administrator stated that the medication the patient is currently taking in the home should match the hospice provider’s medication profile. The patient’s medications should be reconciled each week. Findings included:Review of the policy titled, “Patient Medication Schedule Worksheet/Medication Reconciliation,” dated 08/2022, showed in part:-The nurse will prepare the medication schedule worksheet and give the original to the patient at the time of completion; and-When changes with medications occur, the nurse will complete a new medication schedule worksheet for the patient and dispose of the old worksheet to avoid patient confusion about his/her medication schedule. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/12/2026 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF).Review of the hospice provider’s medication profile, dated 03/30/2026, and the LTCF’s medication profile, dated 03/31/2026, showed the following discrepancies:- The provider’s profile showed Women’s 50 Probiotic 4 billion cell (a supplement designed to promote intestinal, vaginal and immune health), take one capsule every evening (PM). The LTCF’s profile did not include this medication;- The provider’s profile showed garlic 1000 milligrams (mg) (a supplement used to support cardiovascular health, healthy blood pressure, and immune health), take one capsule daily. The LTCF’s profile did not include this medication;- The provider’s profile showed atorvastatin 80 mg (a medication used to reduce bad cholesterol and triglycerides while reducing the risk of heart attacks and stroke), take one tablet daily. The LTCF’s profile did not include this medication;- The provider’s profile showed trazodone 50 mg (an antidepressant frequently used off label for insomnia), take one tablet at bedtime. The LTCF’s profile showed trazodone 25 mg, take one at bedtime;- The provider’s profile showed magnesium 250 mg (actual elemental magnesium that is easier for the body to absorb and better for increasing overall magnesium levels), take one tablet daily. The LTCF’s profile showed Mag-ox (magnesium oxide) 400 mg (refers to the weight of the compound, not the elemental magnesium, and is known for having high elemental magnesium, but poor solubility, meaning less is absorbed by the body), take one daily. Magnesium 250 mg and magnesium oxide 400 mg were two different types of medication;- The provider’s profile showed aspirin 81 mg, oral tablet delayed release, take one tablet daily. The LTCF’s profile showed aspirin chewable 81 mg, take one daily;- The LTCF’s profile showed loratadine 5 mg (an antihistamine used to reduce allergy symptoms like sneezing, runny nose, itchy eyes and hives), take one daily. The provider’s profile failed to include this medication.- The LTCF’s profile showed PRN (as needed) medications of Tylenol (used to treat mild pain/fever) 650 mg every four hours, Dulcolax 10 mg rectal capsule (RC; suppository) (a medication taken to relieve constipation) daily, Senokot-S (a medication to relieve constipation) 86/50 mg two times per day, Isopto Atropine 1% ophthalmic drops (a medication taken for excess oral secretions), take sublingual every 4 hours, Roxanol oral solution (a medication for severe pain) 5 mg every three hours, Tylenol 650 mg RC every six hours, and Imodium (a medication used to treat diarrhea) four mg twice a day, The provider’s profile failed to include all of these PRN medications. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 12/30/2025 with a terminal diagnosis of pressure ulcer of the sacral region, stage 4 (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a family caregiver (cg).Observation and interview on 03/31/2026 at 10:30 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile:-The provider’s profile showed zinc (a supplement) by mouth, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed vitamin C (a supplement) 500 mg by mouth, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed Azo Cranberry (a supplement) 250 mg by mouth, take two tablets daily. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed calcium carbonate (a supplement) 500 mg, take one tablet twice daily. The patent’s cg stated that the patient no longer took this medication;-The provider’s profile showed melatonin (a supplement) 1 mg, take one tablet at bedtime. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed cranberry fruit (a supplement) 500 mg, take one tablet daily. The patient’s cg stated that the patient no longer took this medication;-The provider’s profile showed diclofenac sodium 1% gel (used for pain relief), use one application two times a day. The patient’s cg stated that the patient no longer used this medication;-The provider’s profile showed tizanidine (used to treat spasms, cramping, and tightness caused by spinal cord injuries or multiple sclerosis) 4 mg, take one tablet three times daily. The patient’s cg stated that the patient took this medication every four hours; and-The patient took vitamin D3 (a supplement) 50 micrograms (mcg) once daily. This provider’s profile failed to contain this medication. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 06/26/2025 with a terminal diagnosis of heart failure (a decrease in the ability of the heart to pump blood). The patient resided at home with a spouse. Observation and interview on 03/31/2026 at 11:00 AM, showed the following medication discrepancies with the provider’s medication profile:-The medication profile showed an order for cholecalciferol with vitamin D3 1250 mcg capsule, take one capsule by mouth once each week. The patient’s spouse stated that the patient no longer used the medication;-The medication profile showed an order for spironolactone (used to treat heart failure, and edema (swelling)) 25 mg tablet, take one tablet by mouth once each day. The patient’s spouse stated that the patient no longer used the medication;-The patient took the medication trazodone 50 mg tablet, take one tablet by mouth, once each day. The provider’s profile failed to include this medication; -The patient took the medication metoprolol (used treat high blood pressure) 25 mg tablet, take one tablet by mouth, once each day. The provider’s profile failed to include this medication; and-The patient took Tylenol 650 mg suppository, take one suppository rectally every four hours as needed. The provider’s profile failed to include this medication. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/15/2025 with a terminal diagnosis of hypertensive heart disease with heart failure. The patient lived at home with a family cg.Observation and interview on 04/01/2026 at 10:00 AM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile:- The provider’s profile showed ergocalciferol (vitamin D2) 1250 mcg (a supplement used to treat severe vitamin D deficiency), take one capsule weekly. The patient’s cg stated that the patient did not take this medication;- The provider’s profile showed gabapentin 300 mg (a medication used to treat nerve pain) by mouth, take one capsule four times daily. The patient’s cg stated that the patient only took this medication three times a day;- The provider’s profile showed amiodarone 200 mg (a medication used to treat heart arrythmias) by mouth, take one tablet daily. The patient’s cg stated that this medication was not taken on Mondays, Wednesdays, and Fridays;- The provider’s profile showed fentanyl 12 mcg/hour transdermal patch (used to manage chronic pain), one patch every 72 hours. The patent’s cg stated that the medication patch is changed two times per week, not always every 72 hours;- The patient took Tylenol extra strength, two tablets by mouth as needed. This provider’s profile failed to contain this medication;- The patient took Uqora Defend part 2, one tablet every day to help prevent urinary tract infections. The provider’s profile failed to contain this medication; and- The patient took Uqora Flush Proactive drink mix every three days to help prevent urinary tract infections. The provider’s profile failed to contain this medication. RECORD/PATIENT #5:Review of the clinical record showed that the patient was admitted to hospice services on 03/13/2026 with a terminal diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (uncontrolled growth of abnormal cells in the lung tissue, often causing symptoms like a persistent cough, chest pain, and weight loss). The patient lived at home with family caregivers.Observation on 03/31/2026 at 12:30 PM, showed the following discrepancies between the patient’s home medications and the provider’s medication profile:-The provider’s profile showed Tarpeyo (a prescription-strength corticosteroid used to reduce proteinuria (protein in urine)) 4 mg capsule, take two capsules daily. The patient no longer took this medication;-The provider’s profile showed Aleve (used for pain) 220 mg tablet, take one tablet every eight to twelve hours as needed. The patient no longer took this medication; and-The provider’s profile showed acetaminophen (used to treat mild pain or fever) 650 mg suppositories, use one suppository every four hours as needed. The patient no longer used this medication.During an interview on 04/01/2026 at 2:50 PM, the hospice administrator stated that the medication the patient is currently taking in the home/LTCF should match the hospice provider’s medication profile. The patient’s medications should be reconciled each week.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure an individualized plan of care was developed for each patient in three of five full records reviewed (Records/Patients #1, #2, and #5). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/12/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF).Review of the plan of care, dated 02/12/2026 to 05/12/2026, showed:- Patient had a secondary diagnosis of Type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with diabetic polyneuropathy (a neurological condition resulting from widespread damage to peripheral nerves, often causing numbness, tingling, pain, and muscle weakness, typically starting in the feet or hands); and- The aide care included trimming the patient’s nails.During an interview on 04/01/2026 at 2:45 PM, the hospice administrator stated that he/she would expect the aide care plan to have only included to clean and file the patient’s nails, not to trim them. Findings included:Review of the provider’s policy titled, “Interdisciplinary Plan of Care,” dated 12/2025, showed the hospice will develop an individualized written plan of care for each patient. The plan of care will reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments Findings included:Review of the provider’s policy titled, “Interdisciplinary Plan of Care,” dated 12/2025, showed the hospice will develop an individualized written plan of care for each patient. The plan of care will reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/12/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF).Review of the plan of care, dated 02/12/2026 to 05/12/2026, showed:- Patient had a secondary diagnosis of Type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with diabetic polyneuropathy (a neurological condition resulting from widespread damage to peripheral nerves, often causing numbness, tingling, pain, and muscle weakness, typically starting in the feet or hands); and- The aide care plan included trimming the patient’s nails. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 12/30/2025 with a terminal diagnosis of pressure ulcer of the sacral region, stage 4 (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a family caregiver.Review of the plan of care, dated 12/30/2025-03/29/2026, showed patient had secondary diagnoses of -Type 1 diabetes mellitus with diabetic autonomic polyneuropathy (a serious, often under-recognized complication involving damage to nerves controlling involuntary body functions), -type 1 diabetes mellitus with diabetic amyotrophy (a rare, severe complication characterized by acute, painful muscle weakness and wasting in the hips, thighs, or buttocks), type 1 diabetes mellitus with hyperglycemia (occurs when insulin deficiency causes blood sugar levels to rise above the target range), and type 1 diabetes mellitus with diabetic polyneuropathy (a common, long-term complication resulting from chronic high blood sugar damaging peripheral nerves).-Activities permitted: Complete bedrest;-The aide was care planned to trim the patient’s nails; and-The plan of care failed to include interventions related the possibility of skin breakdown. RECORD/PATIENT #5:Review of the clinical record showed that the patient was admitted to hospice services on 03/13/2026 with a terminal diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (uncontrolled growth of abnormal cells in the lung tissue, often causing symptoms like a persistent cough, chest pain, and weight loss). The patient lived at home with family caregivers.Review of the skilled nurse admission visit, dated 03/13/2026, showed-The patient verbalized no needs for chaplain services as he/she was agnostic (the view that the existence of God or the supernatural is unknown or inherently unknowable); and-The patient had an implanted port in the right chest.Review of the plan of care, dated 03/13/2026-06/10/2026, showed:-A care goal that the patient will be at peace with God, others, and self;-A care step for spiritual concerns;-A care step to provide spiritual care directly;-A care step to provide spiritual care indirectly;-A care step to offer spiritual care: directly;-A care step to offer spiritual care: indirectly;-A care step to facilitate spiritual care for spiritual community involvement;-A care step to facilitate individual spiritual care;-A care step to discuss spiritual care strengths;-A care step to discuss spiritual care concerns; and-A care goal that states the patient’s port is not in use at the present time and patient will tolerate infusion therapy without complications throughout the course of care. The patient did not have any infusion orders. During an interview on 03/01/2026 at 2:45 PM, the hospice administrator stated that he/she would expect the aide care plan to have only included to clean and file the patient #1’s nails, not to trim them. Additionally, hospice administrator stated that he/she would expect the patient #2’s potential for skin breakdown to be on the care plan and the aide should have only been care planned to clean and file the patient’s nails, not to trim them, and patient #5’s plan of care should have been individualized to remove any spiritual care needs and infusion therapy. Findings included:Review of the provider’s policy titled, “Interdisciplinary Plan of Care,” dated 12/2025, showed the hospice will develop an individualized written plan of care for each patient. The plan of care will reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/12/2025 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF).Review of the hospice POC, dated 02/12/2026 to 05/12/2026, showed:- Patient had a secondary diagnosis of Type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with diabetic polyneuropathy (a neurological condition resulting from widespread damage to peripheral nerves, often causing numbness, tingling, pain, and muscle weakness, typically starting in the feet or hands); and- The hospice aide care plan included trimming the patient’s nails. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 12/30/2025 with a terminal diagnosis of pressure ulcer of the sacral region, stage 4 (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a family caregiver.Review of the hospice POC, dated 12/30/2025-03/29/2026, showed:-Patient had secondary diagnoses of:*Type 1 diabetes mellitus with diabetic autonomic polyneuropathy (a serious, often under-recognized complication involving damage to nerves controlling involuntary body functions); *Type 1 diabetes mellitus with diabetic amyotrophy (a rare, severe complication characterized by acute, painful muscle weakness and wasting in the hips, thighs, or buttocks); *Type 1 diabetes mellitus with hyperglycemia (occurs when insulin deficiency causes blood sugar levels to rise above the target range); *Type 1 diabetes mellitus with diabetic polyneuropathy (a common, long-term complication resulting from chronic high blood sugar damaging peripheral nerves);-Activities permitted: Complete bedrest;-The hospice aide care plan included trimming the patient’s nails; and-The hospice POC failed to include interventions related to the patient’s possibility of skin breakdown. RECORD/PATIENT #5:Review of the clinical record showed that the patient was admitted to hospice services on 03/13/2026 with a terminal diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (uncontrolled growth of abnormal cells in the lung tissue, often causing symptoms like a persistent cough, chest pain, and weight loss). The patient lived at home with family caregivers.Review of the skilled nurse admission visit, dated 03/13/2026, showed:-The patient verbalized no needs for chaplain services as he/she was agnostic (the view that the existence of God or the supernatural is unknown or inherently unknowable); and-The patient had an implanted port in the right chest.Review of the plan of care, dated 03/13/2026 - 06/10/2026, showed:-A care goal that the patient will be at peace with God, others, and self;-A care step for spiritual concerns;-A care step to provide spiritual care directly;-A care step to provide spiritual care indirectly;-A care step to offer spiritual care directly;-A care step to offer spiritual care indirectly;-A care step to facilitate spiritual care for spiritual community involvement;-A care step to facilitate individual spiritual care;-A care step to discuss spiritual care strengths;-A care step to discuss spiritual care concerns; and-A care goal that states the patient’s port was not in use at the present time and the patient would tolerate infusion therapy without complications throughout the course of care. The patient did not have any infusion orders. During an interview on 04/01/2026 at 2:45 PM, the administrator stated that he/she would expect the hospice aide care plan to have only included to clean and file the patient #1’s nails, not to trim them. Additionally, the administrator stated that he/she would expect the patient #2’s potential for skin breakdown to be on the POC and the hospice aide should have only been care planned to clean and file the patient’s nails, not to trim them. Patient #5’s plan of care should have been individualized to remove any spiritual care needs and infusion therapy.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure standing orders were individualized to the patient in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included:RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 12/30/2025 with a terminal diagnosis of pressure ulcer of the sacral region, stage 4 (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The patient lived at home with a family caregiver.Review of the plan of care, dated 12/30/2025-03/29/2026, showed the patient had an allergy to hydrocodone and oxycodone.Review of the physician’s orders, dated 12/30/2026, showed a standing order for:-A general comfort pack including oxycodone 20 milligrams (mg)/milliliter (mL). Take 0.25 mL sublingual or by mouth every three hours as needed.During an interview on 04/01/2026 at 12:40 PM, the hospice administrator stated that oxycodone is part of the comfort pack medications in case they are needed for patients. Oxycodone should have been taken off the patient’s orders since the patient had an allergy to the medication. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (decrease in the ability of the heart to pump blood). The patient lived at home with a family caregiver. Review of the skilled nurse recertification visit note, dated 01/05/2026, showed the patient had a size 20 French foley catheter. Review of the physician’s orders, dated 01/07/2026, showed in part the following standing order: As needed (PRN), per sterile technique, insert 16 French foley catheter with five cubic centimeters (cc) balloon inflated with 10 cc of sterile water. May change PRN if occluded or leaking. During an interview on 04/01/2026 at 12:40 PM, the hospice administrator stated that the foley catheter should have been removed from the standing orders since the patient already had a catheter.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure updated wound assessments were performed in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients with wounds served by the provider. Review of the provider’s policy titled, “Pressure Ulcer/Wound Assessment and Treatment,” revised 06/2025, showed in part the following:- Measure pressure ulcer wound in centimeters (cm), including length, width and depth at greatest points;- Wounds should be assessed and measured weekly; and- Obtain exact dressing change orders from physician with materials to be used and frequency to be changed. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (decrease in the ability of the heart to pump blood). The patient lived at home with a family caregiver. Review of the skilled nurse (SN) visit note, dated 01/22/2026, showed the following:- 2 cm x 2 cm x 0.5 cm “injury” to left calf;- 1 cm x 0.5 cm “spot” on left calf; and- The SN failed to describe appearance of the wounds including color or drainage. Review of the SN visit note, dated 01/26/2026, failed to show an assessment of the patient’s wounds on left calf. Review of the SN visit note, dated 01/29/2026, showed the wound assessment of the left calf, stage two, newly acquired, covered with Mepilex AG (antimicrobial foam dressing designed for treating low-to-moderately exuding chronic and acute wounds). The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/01/2026, showed “left ankle has a bandage on it due to a dime sized wound”. The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/04/2026, failed to show any assessment of the patient’s wounds on left calf. Review of the SN visit note, dated 02/09/2026, showed a stage 3 ulcer back R (right) leg, size “nipple”, skin dry, thin, weak texture, color WNL (within normal limits), moisture and turgor WNL. The SN failed to measure the wound, describe the appearance of the wound, and document the correct location of the wound (documented right instead of left leg wound). Review of the SN visit note, dated 02/12/2026, showed “Stage 3 the size of a nickel to the left calf, Mepilex AG covering wound”. The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/16/2026, showed “Wound noted to left leg. Area cleaned with Telfa (non-adherent dressing) and Kerlix (absorbent gauze roll) and T.A.O. (triple antibiotic ointment) applied. Photo of wound sent to (named physician) for review.” The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/19/2026, showed the following:- Wound noted to left leg, T.A.O. applied with Maxorb (high-absorption, calcium alginate dressings designed for moderate to heavily draining, partial-to-full thickness wounds), Telfa, and Tegaderm (sterile, transparent, and waterproof film dressing used to protect skin and cover wound) dressing in place; - Dressing clean, dry, and intact;- (Named physician) aware of wound status;- No new drainage noted at time of assessment; and- The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/23/2026, showed the following:- Wound left calf stage 3, 1 inch x 0.5 inches; and- Clean wound bed with wound wash, apply Maxorb AG, Telfa and cover with Tegaderm weekly. Review of SN visit note, dated 02/26/2026, showed “wound care scheduled to be completed Monday per plan of care”. The SN failed to measure the wound or describe the appearance of the wound. Review of the physician’s orders, date 01/22/2026 through 03/01/2026, failed to show treatment or wound care orders for patient’s left calf wound. Review of physician’s order, dated 03/02/2026, showed the following order for patient’s wound care to left calf:- Effective 03/02/2026, every week for five weeks, end date 04/04/2026;- Cleanse with wound wash, apply Maxorb to wound bed, cover with Telfa, secure with Kerlex and tape. Review of the SN visit notes, dated 03/02/2026, 03/05/2026 and 03/13/2026, showed wound care as ordered and measurements of wound, but failed to assess wound appearance. Review of SN visit notes, dated 03/12/2026 and 03/23/2026, failed to show an assessment of the patient’s wounds on left calf. Review of the SN visit notes, dated 03/16/2026, showed wound care as ordered, but failed to measure wound or assess wound appearance. During an interview on 04/01/2026 at 1:30 PM, the hospice administrator stated that the expectation when a patient had a wound, was to assess the wound, including measuring the wound, once per week. Findings included: Findings included:Review of the provider’s policy titled, “Pressure Ulcer/Wound Assessment and Treatment,” revised 06/2025, showed in part the following:- Measure pressure ulcer wound in centimeters (cm), including length, width and depth at greatest points;- Wounds should be assessed and measured weekly; and- Obtain exact dressing change orders from physician with materials to be used and frequency to be changed. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (decrease in the ability of the heart to pump blood). The patient lived at home with a family caregiver. Review of the skilled nurse (SN) visit note, dated 01/22/2026, showed the following:- 2 cm x 2 cm x 0.5 cm “injury” to left calf;- 1 cm x 0.5 cm “spot” on left calf; and- The SN failed to describe appearance of the wounds including color or drainage. Review of the SN visit note, dated 01/26/2026, failed to show an assessment of the patient’s wounds on left calf. Review of the SN visit note, dated 01/29/2026, showed the wound assessment of the left calf, stage two, newly acquired, covered with Mepilex AG (brand; antimicrobial foam dressing designed for treating low-to-moderately exuding chronic and acute wounds). The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/01/2026, showed “left ankle has a bandage on it due to a dime sized wound”. The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/04/2026, failed to show any assessment of the patient’s wounds on left calf. Review of the SN visit note, dated 02/09/2026, showed a stage 3 ulcer back R (right) leg, size: “nipple”, skin dry, thin, weak texture, color WNL (within normal limits), moisture and turgor WNL. The SN failed to measure the wound, describe the appearance of the wound, and document the correct location of the wound (documented right instead of left leg wound). Review of the SN visit note, dated 02/12/2026, showed “Stage 3 the size of a nickel to the left calf, Mepilex AG covering wound”. The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/16/2026, showed “Wound noted to left leg. Area cleaned with Telfa (brand; non-adherent dressing) and Kerlix (absorbent gauze roll) and T.A.O. (triple antibiotic ointment) applied. Photo of wound sent to (named physician) for review.” The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/19/2026, showed the following:- Wound noted to left leg, T.A.O. applied with Maxorb (brand; high-absorption, calcium alginate dressings designed for moderate to heavily draining, partial-to-full thickness wounds), Telfa, and Tegaderm (brand; sterile, transparent, and waterproof film dressing used to protect skin and cover wound) dressing in place; - Dressing clean, dry, and intact;- (Named physician) aware of wound status;- No new drainage noted at time of assessment; and- The SN failed to measure the wound or describe the appearance of the wound. Review of the SN visit note, dated 02/23/2026, showed the following:- Wound left calf stage 3, 1 inch x 0.5 inches; and- Clean wound bed with wound wash, apply Maxorb AG, Telfa and cover with Tegaderm weekly. Review of SN visit note, dated 02/26/2026, showed “wound care scheduled to be completed Monday per plan of care”. The SN failed to measure the wound or describe the appearance of the wound. Review of the physician’s orders, date 01/22/2026 through 03/01/2026, failed to show treatment or wound care orders for the patient’s left calf wound. Review of physician’s order, dated 03/02/2026, showed the following order for the patient’s wound care to left calf:- Effective 03/02/2026, every week for five weeks, end date 04/04/2026;- Cleanse with wound wash, apply Maxorb to wound bed, cover with Telfa, secure with Kerlex and tape. Review of the SN visit notes, dated 03/02/2026, 03/05/2026 and 03/13/2026, showed wound care as ordered and measurements of the wound, but failed to assess the wound’s appearance. Review of SN visit notes, dated 03/12/2026 and 03/23/2026, failed to show an assessment of the patient’s wounds on left calf. Review of the SN visit notes, dated 03/16/2026, showed wound care as ordered, but failed to measure the wound or assess the wound’s appearance. During an interview on 04/01/2026 at 1:30 PM, the hospice administrator stated that the expectation, when a patient had a wound, was to assess the wound, including measuring the wound, once per week.”

“Based on policy review, record review, and interview, the hospice provider failed to obtain physician’s orders for wound treatment in one out of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients with wounds served by the provider. Review of the provider’s policy titled, “Pressure Ulcer/Wound Assessment and Treatment,” revised 06/2025, showed in part, the hospice provider will obtain exact dressing change orders from the physician with materials to be used and frequency to be changed. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (decrease in the ability of the heart to pump blood). The patient lived at home with a family caregiver. Review of the physician’s orders, dated 01/22/2026 through 03/01/2026, failed to show treatment or wound care orders for patient’s left calf wound identified on 01/22/2026. Review of the skilled nurses’ notes dated 01/29/2026, 2/12/2026, 2/16/2026, 2/19/2026, and 02/23/2026, showed the SN provided wound care and applied dressings to patient’s left calf wound without a physician’s order. Review of physician’s order, dated 03/02/2026, showed the following for patient’s wound care to left calf:- Effective 03/02/2026, every week for five weeks, end date 04/04/2026;- Cleanse with wound wash, apply Maxorb to wound bed, cover with Telfa, secure with Kerlex and tape. During an interview on 04/01/2026 at 1:30 PM, the hospice administrator stated that the nurses should not be doing wound treatments and dressing changes without a physician’s order and should have obtained an order prior to providing wound care. Findings included:”

“Based on policy review, record review, and interview, the provider failed to ensure the designated registered nurse (RN) coordinated care, to include the ongoing assessment of the patient’s and family’s needs, updates to the interdisciplinary group (IDG) and updates to the plan of care (POC) in one of three records reviewed (Record/Patient #1). The cumulative effect of these deficient practices has the potential to affect the provision of care and services to all the patients. Findings included:Review of the provider’s policy titled, “Reassessment, HHA-14,” dated April 2021, showed in part:- The purpose; to ensure that the patient’s current problems/needs are continuously evaluated and that care/services are adjusted accordingly;- Hospice patients will be fully assessed on admission to service and reassessed at the skilled nursing visit;- Symptoms/problems will be discussed with interdisciplinary members and documented on the ongoing POC at a minimum of two-week intervals; and- Symptoms/problems will be discussed with interdisciplinary members and documented on the ongoing POC at a minimum of two-week intervals. Review of the provider’s policy titled, “Interdisciplinary Plan of Care, HHA23-06,” dated July 2022, showed in part:- The registered nurse and/or medical social worker will make an initial visit to assess the patient/family needs and will document them on the interdisciplinary plan of care;- The hospice will develop an individualized written POC for each patient;- The POC is developed by the admission nurse or primary RN providing hospice care to the patient, the medical social worker, the counselor/chaplain, the medical director, and the attending physician; and- Subsequent changes to the initial POC are done via physician interim orders and documented in the ongoing POC. Review of the policy titled, “Pressure Ulcer/Wound Assessment and Treatment NUR05-02,” last revised 01/2025, showed in part the following:- Reassessment will be done according to the patient’s individual needs;- Nursing personnel will continually strive to maintain the skin integrity, tone, turgor, and circulation to prevent skin breakdown, injury, and infection;- Hospice will document skin assessments and treatment administration on home health skilled nursing assessment and visit report; and- Document assessment in patient’s medical record. RECORD/PATIENT #1:Review of the medical record showed the patient was admitted to hospice services on 02/17/2025. The patient’s terminal diagnosis was chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Other comorbidities included type two diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with diabetic polyneuropathy (a complication that affects multiple nerves throughout the body. It is caused by chronic high blood sugar), and congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided at home with his/her spouse. The patient expired on 04/03/2025 at the emergency department. Review of the initial assessment, dated 02/17/2025, showed in part the following:- A new foot wound, “side of left foot”, that was difficult to stage/unstageable (a full thickness tissue loss where the extent of tissue damage is obscured by slough [a layer of yellowish, tan, gray, green, or brown tissue that may be moist or dry] or eschar [a thick, leathery, dry, and dark layer of dead tissue]), the open area had dark red/brown coloration, and no drainage or odor. The note failed to include further wound assessment of the surrounding tissue, the tissue of the wound bed, or measurements of the wound; - The patient reported pain in his/her foot and may need to pad for comfort. Cellulitis (bacterial skin infection) on bilateral lower extremities and blisters (an area of skin covered by a raised, fluid-filled bubble) were noted. The assessment failed to include the size, shape and location of the blisters; and- The initial assessment failed to show the RN notified the physician of the new unstageable wound, cellulitis, and blisters to the lower extremities.Review of the IDG report dated 02/20/2025, showed edema (swelling of the tissues) and blisters to the lower extremities and antibiotics. The IDG report failed to show the unstageable wound was discussed. The POC, dated 02/17/2025, failed to include cellulitis, blisters, and the unstageable foot wound.Review of the nursing routine skilled nurse visit dated on 02/25/2025, showed that the patient had a diabetic ulcer (slow healing open sore or wound on the foot of someone with diabetes) on his/her left plantar foot on the lateral side that was unstageable. The bandaging was just changed. The patient had cellulitis of the bilateral lower legs with two plus pitting edema, “but compression is in place and is clean, dry, and intact as well”. The assessment failed to include a description and measurements of the diabetic ulcer. The medical record failed to show physician notification/orders for the cellulitis and diabetic ulcer. The nurse failed to update the POC.Review of the non-visit documentation note dated 02/26/2025, showed that the patient called to report increased pain in his/her legs, eyes and left foot, muscle cramping and difficulty sleeping last night through the pain. The patient reported that he/she was currently taking Oxycodone (used to treat moderate to severe pain) 15 milligrams (mg) four times a day. The RN provided education that the patient could take as prescribed every four hours and continue to take on schedule throughout rest of the day and night and the nurse would follow up tomorrow (02/27/2025) to report effectiveness. The nurse failed to document a pain assessment. The medical record failed to show the RN followed up the next day on 02/27/2025.Review of the skilled nurse routine visit note dated 02/28/2025, showed the patient continued to have a diabetic ulcer on the left plantar side of his/her foot which was covered with a border dressing. One plus bilateral lower extremity edema which was controlled by Tubigrip (tubular support bandage) socks. The note failed to include a wound assessment or measurements. The note failed to show that the nurse notified the physician. The medical record failed to include orders for the treatment of the diabetic ulcer and lower extremity edema.Review of the skilled nurse routine visit dated 03/04/2025, showed the patient had a recent humeral fracture (a break in the upper arm bone) secondary to a recent fall. The patient had a wound on his/her left plantar foot that was being wrapped with TLC wraps (two-layer compression, used to treat venous leg ulcers and other related conditions) and Mepilex (brand) border dressing (used for low to medium draining wounds). His/her wound had mild serous drainage (clear watery drainage) with mild odor. The documentation failed to show the wound measurement and the assessment of the cellulitis and/or blisters. The documentation failed to show physician notification of the fall and humeral fracture. Review of the physician order dated 03/04/2025, showed to cleanse the wound with wound cleanser, pat dry with sterile gauze, then a Mepilex AG (containing silver) border dressing to be applied to the open wound. After (the dressing), the lower extremities would be wrapped with TLC wraps below the knee. The hospice nurse was to measure the wound once a week and monitor for signs and symptoms of infection.Review of the skilled nurse routine visit dated 03/07/2025, showed the patient’s blood pressure was omitted because the blood pressure cuff was too small and the patient had a left humeral fracture. The documentation failed to show the physician was notified of the left humeral fracture. The nurse failed to update the POC. Review of the skilled nurse routine visit note, dated 03/11/2025, showed in part that he/she continued to have confusion and was at risk for falls. He/she had an appointment with a physician on 03/12/2025 with the possibility of casting his/her left arm. The family requested a low bed. The nurse failed to update the POC.Review of the skilled nurse routine visit note dated 03/14/2025, showed in part the patient was extremely confused and had pain in his/her groin and had a dime sized ulcer on the left labia (the nurse failed to assess or measure the ulcer). The “patient tore (his/her) cast off (his/her) left arm that was broken and (a) soft cast (was) reapplied”. The patient had disorganized thinking. The RN failed to notify the physician of the dimed sized ulcer on the left labia, the fall, fracture, and soft cast. The RN failed to update the POC.Review of the IDG report dated 03/20/2025, showed a soft cast to left arm, “bright red under breast and skin folds” (the previous assessments did not address an assessment of “bright red under the breast and skin folds”). The IDG failed to show discussion of the family’s request for a low bed, the dimed size ulcer on the left labia, the recent fall sustaining a humeral fracture, the wound to the left plantar foot, the cellulitis or the blisters. The IDG failed to update the POC.Review of the physician order dated 03/23/2025, showed nursing visits were increased to three times a week.Review of the skilled nurse routine visit note dated 03/24/2025, showed in part, the hospice nurse was to measure the wound once a week and monitor for signs and symptoms of infection. The patient had a wound to the left plantar foot. The note failed to show wound measurements and an assessment of the wound. Review of the skilled nurse routine visit note dated 03/28/2025, showed in part that a discussion took place regarding the patent’s hallucinations, weakness, lethargy and his/her “wounds”. It was more suitable for the patient to be in bed for his/her safety along with the opportunity for improved provision of care to the patient. The bed would be delivered Friday (the family requested a low bed on 03/11/2025) and the patient would be helped to get into bed. Review of the skilled nurse routine visit note dated 03/31/2025, showed in part the following:- The patient had a wound on bilateral feet on the plantar portion (indicated a new ulcer was present on the right foot) and “both” were covered with Mepilex AG and TLC wraps on both (lower extremities) and the patient tolerated the wraps well;- The ulcer was now a stage IV (four) (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments). The note failed to indicate the location of the stage IV wound and failed to contain any assessment or measurements of an additional wound;- The patient’s spouse was educated on trying “to stay off of it”, keeping it wrapped, and keeping his/her pain under control;- The patient also declined hospital beds in the past because he/she had back pain which was exacerbated by lying down too long;- Today he/she appeared to be weaker and was not able to stand to transfer to the commode;- The documentation failed to include an assessment of the abdomen, breast, and ulcer on the labia (the IDG note on 03/20/2025 showed “bright red under breast and skin folds”);- The documentation failed to show physician notification of the new ulcer and the stage IV ulcer; and- The RN failed to educate the spouse on how to care for the patient, provide incontinent care, since he/she was not able to stand to transfer to the commode and would not lay down and wound care. The RN failed to update the POC. Review of the skilled nurse routine visit note dated 04/02/2025, showed in part the following:- There continued to be a reddened region under the pannus (excess skin of the abdomen) and right breast that was being treated with an antifungal tablet because the nystatin powder was not adequately producing positive results toward being healed;- The patient’s spouse stated that the patient fell approximately two (2) days ago and the spouse called the non-emergent ambulatory line to get a lift assist. The patient’s spouse was educated to call hospice when the patient falls (indicated that the provider was aware of the patient’s fall);- The patient had multiple bruises on his/her bilateral upper extremities secondary to the fall;- His/her bilateral foot wounds were covered with Mepilex AG after being washed with wound cleanser;- His/her plantar foot wound was a stage IV (did not specify which foot). It had worsened and continued to close and open multiple times and appeared dark red with necrotic tissue exposed and possible bone. The wound had a moderate amount of dark drainage on the bandage and a mild odor. The nurse failed to obtain measurements of the stage IV ulcer and failed to notify the physician of the deteriorating wound. - The patient was shearing the bandage off, taking it off and stepping on it after each time it was dressed;- The right plantar foot wound was stage II (a partial thickness loss of the skin), which was dressed as previously stated. It was beefy red in nature with some vertical cracking on the right side of the wound when looking at it. No drainage appeared on the bandage of the right foot. The nurse failed to obtain wound measurements and failed to notify the physician of the condition of right foot plantar stage II wound;- The patient’s spouse stated that he/she had some difficulty changing the patient but was able to do it; and- A hospital bed would be ordered and delivered on Friday (04/04/2025, 7 days after the caregiver was told a bed would be delivered) at 1:00 PM, the non-emergent ambulatory line was called and asked to assist at that time so that “we might” get the patient into bed. A Hoyer lift (a mechanical lift used for transferring patients) had been declined in the past by the spouse because they had small living quarters. Review of the IDG report dated 04/03/2025 and completed on 04/15/2025 (during survey) showed the following:- The primary clinician documented that the patient’s wound had gotten worse due to the patient’s noncompliance, shearing, and the patient’s refusal to lay in bed to improve the redness under the right breast and pannus;- Activities of daily living (ADL) continued to be an issue as the patient was unable to bear weight, follow commands, or transfer;- The patient’s spouse agreed to a hospital bed and overbed table. The plan was for the spouse to contact the non-emergent ambulatory staff to help get the patient into bed on Friday (04/04/2025);- The patient would be properly bathed, changed, assessed, wound dressed and measurements taken;- The goal was to improve wound healing, continue to minimize bilateral lower extremity edema, minimize falls and any injuries, and keep the patient safer by utilizing the hospital bed for now and continue caregivers and or facilities. Review of the discharge summary report showed the patient expired on 04/03/2025 at the emergency department. The patient declined very rapidly while on services.Review of a care concern from the emergency medical services (EMS) on 04/04/2025 showed the following:- EMS originally dispatched for a “lift assist” (04/03/2025);- Upon entering the patient’s residence, the patient was found in a semi-upright “slouched” position;- The family reported he/she “fell three days ago and hit (his/her) head on the bathroom wall, and you can see the hole where (he/she) hit the wall. (He’s/She’s) been like this ever since”;- The patient’s spouse reported that the patient “hasn’t eaten or taken her meds in three days and (has) kind of been out of (his/her) mind”;- The patient’s blood pressure was 95/43, an oxygen saturation of 84 percent on his/her prescribed 3 liters of oxygen, blood sugar (the level of sugar in the blood stream) was 398 (levels are typically between 80 and 130 milligrams per deciliter (mg/dL) before meals and less than 180 mg/dL);- There was a pungent odor of urine and necrotic (dead) tissue;- Obvious signs of emesis (vomit) on the side of the patient’s mouth;- EMS noted a pressure wound above the sacrum with purulent drainage (thick drainage with odor or color present commonly associated with infection), black necrotic tissue, and a strong odor. The note showed the patient had “skin pull off” when EMS moved the patient to examine the patient’s back;- Additional breakdown was noted bilaterally down the posterior legs and on the abdomen; and- The emergency medical technician (EMT) was concerned with the potential lack of care related to the depth of the presenting wound.During an interview on 04/14/2025, the hospice aide stated that:- The patient was seen on 04/02/2025 and the patient was unable to stand or move and was too confused;- He/she tried to lean the patient forward by pushing on the patient’s back, and unable to visualize his/her buttocks. He/she was unable to stand the patient up. The patient was “dead weight” and he/she did not notice a pressure ulcer on the patient’s buttocks;- There was an odor coming from under the stomach (pannus) and he/she was also “peeing” in the chair;- He/she had a wound/redness under the breast and his/her lower legs and the wounds were wrapped;- When he/she left the last visit, he/she called the RN about the redness under the breast, the need for more moisture wicking supplies, the patient’s confusion and the spouse wanted to stand the patient up and that was not happening and if they could get the patient a bed;- The patient went to the hospital at one time and sustained a fracture, he/she would not keep the sling on (the medical record failed to mention a sling);- The patient had slid out of his/her chair at one time, and it took three firefighters to put him/her back up in the chair; and- The patient had chronic back pain at one time. During an interview on 04/14/2025 at 2:16 PM, the case manager stated that:- The patient initially was somewhat ambulatory, had diabetic neuropathy, was morbidly obese, impulsive, and occasionally confused;- The patient’s spouse was confused at times and did not always know what medications to give;- The patient had wounds on his/her lower left leg, left lateral foot, and later on the right plantar (sole) of the foot, he/she had bilateral lower extremity edema with weeping;- He/she heard the patient had a sacral wound and he/she had no idea the patient had a sacral wound, and he/she offered a hospital bed to the patient on three occasions;- There were no odors. The patient some pain in his/her back and was chair bound;- He/she was able to assess the patient’s back to the upper buttock to a point due to mentation, the patient could be combative. He/she was unable to see the patient’s buttocks the whole time; and- The patient refused to get up from the chair and walk, the family was given a hospital bed three times and asked to have it removed and the fourth time the spouse agreed (to have the bed).During an interview on 04/15/2025 at 11:39 PM, the director of home care services stated that:- There were no wound measurements in the medical record and he/she expected measurements to be done weekly;- The physician order on 03/04/2025 was specific to the left plantar wound and then the RN had wounds, plural, so he/she did the same order to the new, right plantar, wound and should have gotten a specific order for the new wound;- The IDG note, dated 03/20/2025, showed edema, blisters and failed to contain further assessments of the blisters;- He/she would have expected the patient’s problems to be discussed in IDG and documented, he/she expected the plan of care to be updated to accurately reflect the patient’s care and needs;- On 03/24/2025, the physician ordered skilled nursing visits three times a week and that was the last update to the POC; - The last IDG meeting in the medical record was on 03/20/2025. He/she had an IDG note from the meeting on 04/03/2025 and had not entered that note into the medical record, he/she would enter it now and provide a copy to the state agent;- He/she called the durable medical equipment (DME) company during the interview. The DME company delivered a bed and air mattress on 03/04/2025 and picked it up on 03/19/2025 because the patient did not like it. (On 03/11/2025, the patient/caregiver requested a low bed.) They delivered another bed on 04/03/2025 but the patient went to the emergency room; and- The chart was reviewed with the director, and he/she agreed with the findings and provided the IDG note, and no additional information was provided. During an interview on 04/15/2025 at 12:46 PM, the hospice medical director stated that he/she did not recall the patient’s specific pressure area. He/she expected all issues regarding the patient to be discussed in IDG or they could call him/her if they had concerns. If the staff were unable to provide care in the patient’s home, they should have suggested a long-term care facility and if the family refused, they would have to look at discharge.”