Mercy Hospice

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in two of four records reviewed (Records/Patients #5 and #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, “MHS HOSPICE Medication Monitoring Policy,” dated 11/04/2025, showed in part:- Hospice will maintain a current, accurate list of all prescription, over-the-counter medications, supplements and home remedies taken by the patient, on the medication profile; - Medication reconciliation with a full bottle/medication check is completed during the initial nursing assessment, the nursing next day visit (visit the day following the admission), the first scheduled nursing visit of the week and at any time the patient moves home location. *For Hospice House inpatients, medications are reviewed and reconciled daily; and - The Hospice nurse will verify at all scheduled nursing visits if there have been any changes in medication orders, since the last visit. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 06/27/2025 with a terminal diagnosis of chronic kidney disease (a long-term, progressive loss of kidney function). The patient had secondary diagnoses of protein calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and/or calories) and dysphagia (difficulty swallowing). The patient resided in a skilled nursing facility. During a home visit observation on 02/10/2026 at 12:00 PM, a comparison of the provider’s medication profile (PMP) to the facility’s medication administration record (FMAR) showed the following discrepancies: - The FMAR showed the patient was to use Remedy Clinical Silicone Cream (a cream used to protect the skin) to the patient’s buttocks, the PMP failed to list this medication; - The FMAR showed the patient was to receive a nutritional supplement three times per day, the PMP failed to list this medication; - The PMP showed the patient was to take acetaminophen (a nonnarcotic pain medication) as needed, the FMAR failed to list this medication; and- The PMP showed the patient was to use Eucerin cream daily (a petrolatum-based ointment), the FMAR failed to list this medication. During an interview on 02/11/2026 at 9:00 AM, the administrator designee (AD1) stated that they would expect the FMAR and PMP to contain the same medications, and they were unable to provide evidence to resolve the identified discrepancies. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2025 with a terminal diagnosis of malignant neoplasm of pancreas (highly aggressive cancer with poor prognosis), alcoholic cirrhosis (severe, generally irreversible scarring of the liver caused by long-term, excessive alcohol consumption, leading to liver failure), esophageal varices without bleeding (swollen veins in the lower esophagus caused by high pressure in the liver (portal hypertension), usually due to cirrhosis), portal venous hypertension (elevated blood pressure, in the portal venous system, primarily caused by liver cirrhosis restricting blood flow from the spleen and intestines), and chronic diastolic heart failure (heart muscle becomes too stiff to properly relax and fill with blood, despite maintaining a normal pumping strength). The patient resided at his/her own home with spouse. On 02/11/2026 at 10:00 AM, during the home visit observation with RN (Registered Nurse) 2 and interview with the spouse (caregiver), showed the following discrepancies between the provider’s current medication profile on the plan of care, dated 01/27/2026 to 02/10/2026, and the patient’s home medication bottles:- The patient had Morphine (opiate for moderate to severe pain) 100 milligrams (mg)/5 milliliter (ml) (20 mg/ml) take 0.5 ml every two hours as needed, filled 09/04/2025. The patient’s medication list failed to include Morphine; - The patient had Glycopyrrolate (anticholinergic to treat peptic ulcers) 1 mg/5 ml, take 5 ml every four hours as needed, filled 09/04/2025. The patient’s medication list failed to include Glycopyrrolate;- The patient had hydrocortisone cream (mild topical corticosteroid for itching, redness, and inflammation and rashes) to apply to the face twice a day for rash. The patient’s medication list failed to include hydrocortisone cream. The patient’s spouse stated the patient had been using for one and a half months; - The patient’s medication list had albuterol sulfate aerosol inhaler (fast-acting bronchodilator to treat COPD or asthma) take two puffs by inhalation every six hours as needed for shortness of breath. The patient’s spouse stated that he/she hasn’t used for four to five years; - The patient’s medication list had diphenhydramine (antihistamine and sedative) 25 mg take 50 mg by mouth at bedtime. The patient’s spouse stated that he/she hasn’t used since September;- The patient’s medication list had diphenoxylate-atropine (opioid to treat diarrhea) 2.5 mg-0.025 mg tablet take one to two tablets by mouth four times daily as needed. The patient’s spouse stated that he/she hasn’t used since being on chemotherapy; - The patient’s medication list had heparin (anticoagulant) lock flush 10 unit/ml inject 5 units by intravenous injection one time as needed. The patient’s spouse stated it was stopped when the patient went on hospice; and- The patient’s medication list had ondansetron (to prevent nausea and vomiting) 8 mg dissolve one pill every eight hours as needed for nausea and/or vomiting after chemo. The patient’s spouse stated he/she hasn’t used for years and uses Protonix. During an interview on 02/11/2026 at 1:55 PM, the Administrator stated that:- The nurse is to check medications on admission to the hospital discharge list;- The medication bottles are checked once a week on the first visit of the week;- Check the medication bottles and medication profile list and ask the patient and caregiver about any changes and over the counter medications; - Any medication discrepancies are to be followed up with the physician to get the medication profile to reflect with the medication bottles; - The nurse is to ask every visit about medication changes and make sure there are enough medications to get through to next week.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure all care and services furnished to patients and their families follow an individualized, written plan of care (POC) in five of six full records reviewed (Records/Patients #1, #2, #5, #6, and #10). This deficient practice has the potential to affect the care of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “MS EAST HOSPICE Plan of Care Policy,” dated 11/24/2025, showed in part:- Hospice will complete an individualized plan of care update for each individual admitted to hospice. The care provided to the individual will be in accordance with the care plan which is based on the patient’s goals and the time frames, settings and services required to meet those goals; - The plan of care will be reviewed and updated, at least every 14 days, by the attending physician, the medical director and the Interdisciplinary Group (IDG) and will be documented in the record. Documentation on the plan of care shall reflect the changing needs of the patient/family and the services required to meet those needs; - Content of the Plan of Care: The hospice will develop an individualized written plan of care for each patient which will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms; - Identification of the patient’s/family’s problems and needs; and - The detailed statement of the scope and frequency of services needed to meet the patients and family’s needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice on 08/01/2025 with a terminal diagnosis of oropharyngeal dysphagia (difficulty initiating a swallow, causing food to stick in the throat, coughing, choking, or nasal regurgitation). The patient was admitted to the inpatient hospice house on 02/09/2026.Review of the Hospice House Plan of Care (POC), dated 02/09/2026, showed an intervention dated 10/01/2025 for a clear liquid diet as tolerated. The POC also showed an order dated 02/09/2026 for a pureed diet as tolerated.During an interview on 02/10/2026 at 11:00 AM, the patient’s mother stated that the patient ate pureed foods at mealtimes.During an interview on 02/11/2026 at 2:00 PM, the inpatient hospice administrator stated that there were conflicting orders in the plan of care and only the current order should be listed.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice on 09/05/2025 with a terminal diagnosis of metastatic non-small cell lung cancer (occurs when cancer cells spread from the lungs to distant organs like the brain, bones, or liver). The patient was admitted to the inpatient hospice house on 09/22/2025.Review of the Hospice Plan of Care (POC), dated 09/17/2025, showed the interdisciplinary group (IDG) note that the patient/family refused chaplain at that time. The POC showed a chaplain visit frequency of one visit every 28 days for 28 days.During an interview on 02/11/2026 at 2:00 PM, the inpatient hospice administrator stated that chaplain service was not declined, and chaplain was visiting once every 28 days. The administrator stated that the IDG was documented in error. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 06/27/2025 with a terminal diagnosis of chronic kidney disease (a long-term, progressive loss of kidney function). The patient had secondary diagnoses of protein calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and/or calories) and dysphagia (difficulty swallowing). The patient resided in a skilled nursing facility.Review of the updated POC, dated 02/05/2026, showed that the patient had a secondary diagnosis of severe protein calorie malnutrition and dysphagia.Review of the facility medication administration records for 01/01/2026 to 02/10/2026 showed the orders for a monthly weight related to severe protein calorie malnutrition and Med Pass supplements (a high calorie/protein nutritional shake) three times per day related to abnormal weight loss.During an interview on 02/11/2026 at 9:00 AM, the administrator designee (AD1) stated that they would expect the patient’s protein calorie malnutrition to be addressed on the POC, and he/she was unable to locate interventions or goals to address the diagnosis on the current POC. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2025 with a terminal diagnosis of malignant neoplasm of pancreas (highly aggressive cancer with poor prognosis), alcoholic cirrhosis (severe, generally irreversible scarring of the liver caused by long-term, excessive alcohol consumption, leading to liver failure), esophageal varices without bleeding (swollen veins in the lower esophagus caused by high pressure in the liver (portal hypertension), usually due to cirrhosis), portal venous hypertension (elevated blood pressure, in the portal venous system, primarily caused by liver cirrhosis restricting blood flow from the spleen and intestines), and chronic diastolic heart failure (heart muscle becomes too stiff to properly relax and fill with blood, despite maintaining a normal pumping strength). The patient resided at his/her own home with spouse.Review of the chaplain’s initial visit dated 09/04/2025, showed the following:- Patient and patient’s spouse have a couple of family friends who offer spiritual and emotional support; and- Chaplain will continue to visit once every 28 days and as needed. Review of the chaplain’s visit dated 11/03/2025, showed the chaplain called the spouse to schedule routine visit and the spouse reported the patient was feeling well, but stated he/she was not quite ready for the chaplain. The spouse reports the patient has a friend who is a minister, and he/she feels more comfortable with that support. Chaplain offered to be as needed, and the spouse accepted. Chaplain will be as needed moving forward. Review of the Hospice POC, updated 01/27/2026, showed a chaplain visit frequency of one visit every 28 days for 28 days and as needed. During an interview on 02/11/2026 at 1:55 PM, the administrator stated the POC should be updated to reflect what the chaplain visits are and what he is doing. RECORD/PATIENT: #10Review of the clinical record showed the patient was admitted to hospice services on 02/08/2025 with a terminal diagnosis of left upper lobe small cell lung cancer (a fast-growing type of cancer that originates in the upper portion of the left lung). The patient lived at home with three caregivers until his/her discharge on 06/13/2025. Review of the initial assessment, dated 02/08/2025, showed the following:- The patient complained of pain across his/her chest and into the left side of the neck and rated his/her pain as 6 out of 10 in severity on the pain scale (a tool used to assess the intensity of pain using a numerical scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable) and the pain was described as aches/cramping, constant, exacerbated by movement, and relieved by rest and positioning;- The patient’s highest pain rating on the pain scale was 8 out of 10 and the patient’s lowest pain rating was 5 out of 10;- The patient’s pain goal was 3 out of 10 on the pain scale;- The pain was further described as gradually worsening, affected the patient’s sleep, appetite, physical activity, and made the patient unable to complete tasks easily, the patient was no longer able to drive or work, and the caregiver’s perception of the patient’s pain was that it was uncontrolled;- PRN (pro re nata- as needed) medications available included Norco (a medication used to treat severe pain) which the patient had not taken since picking up from the pharmacy and THC products (substances derived from the cannabis plant and used to treat pain);- The patient verbalized fear of taking medications and being “foggy” and being unsure of side effects;- The skilled nurse (SN) discussed taking the Norco at bedtime to help with pain and sleep and the patient was agreeable to the plan; and- The pain level remained at 6 out of 10 at the end of the visit. Review of the plan of care, dated 02/08/2025, showed the following under physical discomfort:- Goals included patient’s pain/physical discomfort will be reduced to the level of patient’s stated goal or patient does not demonstrate s/s (signs or symptoms) of physical discomfort if unable to communicate in one week and throughout hospice care and patient/caregiver will verbalize understanding of the pain management plan in three days and throughout hospice care;- Interventions included assess and document: the cause, location, intensity, quality, frequency and duration of pain; alleviating and aggravating factors; current medication regimen and treatments; effects of pain on patient’s sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity. Assess patient’s pain utilizing an appropriate pain scale for age and cognition. Evaluate the effectiveness of the current pain treatment regimen and notify physician for the need for changes in the plan of care. Instruct patient/caregiver on pain medication regimen and alternative strategies to relieve pain; and- The plan of care failed to include the patient’s pain management goal, interventions for the patient’s reluctance or refusal to take pain medications, or any changes made to the patient’s pain treatment regimen based on the initial assessment. Review of a SN note, dated 05/01/2025, showed the following:- The patient complained of pain in his/her neck and rated his/her pain as 10 out of 10 in severity and the pain was described as aching and constant, exacerbated by movement, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 8 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening and having a high impact on the quality of life and the caregiver’s perception of the patient’s pain was that it was not being controlled with medication;- PRN medications taken in the last 24 hours included Norco one tablet every 4 hours PRN (three doses taken) and Morphine Concentrate (a medication used to treat severe pain) 0.5 milliliters (mL) every 4 hours PRN (two doses taken);- The patient’s pain level at the end of the visit showed that the patient was very teary eyed in pain and the patient stated that he/she had just taken a pain pill and was going to try to lay down and sleep;- The SN educated the patient and caregiver on pain medications and the patient agreed to be more consistent with using PRN medications for pain; and- The visit note showed, “current care plan reviewed, effective, and no changes at this time.” Review of a SN note, dated 05/07/2025, showed the following:- The patient complained of pain in his/her neck and rated his/her pain as 10 out of 10 in severity and the pain was described as aching, constant, exacerbated by movement, and relieved by medications and rest;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 9 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as having a high impact on the quality of life and the caregiver’s perception of the patient’s pain was that it was not being controlled with medication;- PRN medications taken in the last 24 hours included Roxanol (a medication used to treat severe pain and also known as Morphine Concentrate) 0.5 mL every 2 hours (two doses taken) and Fentanyl (a medication that comes in patch form and treats severe pain) 25 micrograms (mcg) per hour and change every three days was scheduled;- The patient’s pain level at the end of the visit showed that the patient still had pain 10 out of 10 in severity;- The SN educated the patient and caregiver on pain medications; and- The visit note showed, “current care plan reviewed, effective, and no changes at this time.” Review of a SN note, dated 05/09/2025, showed the following:- The patient complained of pain in his/her neck and rated his/her pain as 10 out of 10 in severity and the pain was described as stabbing and constant;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 10 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as having a high impact on the quality of life and the caregiver’s perception of the patient’s pain was that it was not being controlled with medication;- PRN medications taken in the last 24 hours included Fentanyl and Morphine Concentrate 0.5 mL every 2 hours PRN (12 doses taken);- The patient’s pain level at the end of the visit showed that the patient still had pain 10 out of 10 in severity;- The physician was notified, and a new order was received for the Fentanyl patch to increase to 50 mcg/hour and the Morphine to increase to 1 mL every 2 hours PRN and the SN educated the patient and caregiver on the new medication orders and instructed them to call the office if patient’s pain was not controlled; and- The visit note showed, “current care plan reviewed, effective, and no changes at this time.” Review of a SN note, dated 05/13/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 5 out of 10 in severity and the pain was described as aching/sharp, constant, exacerbated by deep breathing and movement, and relieved by medications and rest;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 2 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as waxing and waning (increasing and decreasing in severity), affected the patient’s sleep, mood, concentration, physical activity, had minimal impact on the patient’s quality of life, and the caregiver’s perception of the pain was that a new pain regimen had been started, and the patient was “trialing to see how effective it is”;- PRN medications taken in the last 24 hours included Morphine Concentrate 1 mL every 2 hours PRN (four doses taken);- The patient’s pain level at the end of the visit showed that the patient had pain 5 out of 10 in severity; and- The visit note showed the patient reported forgetting to change his/her Fentanyl patch the day before and that the caregiver reported using Morphine 0.75 mL instead of the 1 mL that was ordered by the physician and education regarding medication was given to the patient and caregiver. Review of a SN note, dated 05/16/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 7 out of 10 in severity and the pain was described as aching, constant, exacerbated by movement, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 3 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening, affected the patient’s concentration and physical activity, had minimal impact on the patient’s quality of life, and the caregiver’s perception of the pain was that it was controlled;- PRN medications taken in the last 24 hours included Morphine (three doses taken) and the patient reported only taking 0.5 mL or 0.75 mL per dose instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed that the patient had pain 7 out of 10 in severity; and- The visit note showed that the family did not appear to be consistent with administration of pain medication and was not using the correct dose of Morphine for breakthrough pain and education regarding medication was provided to the patient and caregiver. Review of a SN note, dated 05/20/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 10 out of 10 in severity and the pain was described as tight, constant, exacerbated by movement, and relieved by medications and rest; - The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 3 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening and affected the patient’s sleep and physical activity;- PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed 3 out of 10 in severity; and- The visit note showed that pre-filled Morphine syringes were left at the bedside for break-through pain management, the physician was notified of patient’s pain level and a new order was obtained for Methadone (a medication that is used to treat severe chronic pain) 10 mg every 12 hours, and the SN educated the patient and caregiver on the new medication regimen. Review of a SN note, dated 05/23/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 4 out of 10 in severity and the pain was described as tight and intermittent;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 0 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually improving and had minimal impact on the patient’s quality of life;- PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed 4 out of 10 in severity; and- The visit note showed that the patient reported hallucinations during the night related to taking Methadone and issues with nausea and vomiting related to taking Methadone. The SN provided education to the patient regarding side effects of Methadone and notified the physician of the patient’s complaint of hallucinations. Review of a SN note, dated 05/27/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 4 out of 10 in severity, the pain was described as aching and tight, constant, exacerbated by movement and deep breathing, and relieved by rest, medications, and pressure;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 2 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as waxing and waning, associated with depression, affected relations with others and physical activity, and the impact on the patient’s life was gradually improving when he/she took pain medications consistently and was able to decrease severity to 3 out of 10 on the pain scale when consistent;- PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (three doses taken) instead of the 1 mL dose that was ordered by the physician; and- The patient’s pain level at the end of the visit showed 4 out of 10 in severity and controlled. Review of a SN note, dated 05/29/2025, showed the following:- The patient complained of left shoulder pain and rated his/her pain as 7 out of 10 in severity and the pain was described as tight, constant, exacerbated by movement and breathing, and relieved by medications and rest;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 3 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening, associated with nausea, affected the patient’s appetite, concentration, relations with others, and physical activity, and the impact on the patient’s quality of life was high;-PRN medications taken in the last 24 hours included Morphine 0.5 mL every 2 hours PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient’s pain level at the end of the visit showed 7 out of 10 in severity and gradually coming down; and- The visit note showed that the patient reported he/she stopped taking Methadone the night before due to nausea and vomiting and that he/she was “withholding Morphine because he/she does not want his/her kids to see him/her sleepy and needing more assistance.” The physician was notified and a new order was received to increase Fentanyl to 75 mcg/hour every 3 days and education was provided to the patient and caregivers. Review of a SN note, dated 06/03/2025, showed the following:- The patient complained of pain in bilateral shoulders, neck, and left rib cage and rated his/her pain as 10 out of 10 in severity and the pain was described as tight, constant, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 0 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as gradually worsening, associated with guarding (an involuntary or voluntary protective behavior used to prevent harm to an area), affected the patient’s sleep, mood, behavior, concentration, and physical activity, the impact of the pain on the patient’s quality of life was high, and the caregiver’s perception of the pain was that the patient did not appear to be taking Morphine at night and was waking up in an extreme amount of pain;-PRN medications taken in the last 24 hours included Morphine 0.5 mL every 1 hour PRN (four doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient was asleep at the end of the visit; and- The visit note showed that the patient was not taking enough Morphine during the day and was not using it at night and would wake up in extreme pain, the physician was notified and a new order was obtained for MS Contin (a medication used for severe pain) 15 mg at bedtime, and education was provided to the patient and caregiver regarding medications. Review of a SN note, dated 06/06/2025, showed the following:- The patient complained of pain in bilateral shoulders, the left neck, and the left rib cage and rated his/her pain as 8 out of 10 in severity and the pain was described as aching and tight, constant, exacerbated by movement, and relieved by rest and medications;- The patient’s highest pain rating on the pain scale was 10 out of 10 and the patient’s lowest pain rating was 0 out of 10;- The patient’s pain goal was 0 out of 10 on the pain scale;- The pain was further described as waxing and waning, affected the patient’s sleep, mood, concentration, and physical activity, impact on quality of life is high, and the caregiver’s perception of the pain was that the patient was not getting any pain medication from 0800 (8AM) to 1200 (noon) and was waking up in pain around 1200 to 1300 (1PM); - PRN medications taken in the last 24 hours included Morphine 0.5 mL every 1-hour PRN (seven doses taken) instead of the 1 mL dose that was ordered by the physician;- The patient was asleep at the end of the visit; and- The SN educated the patient and caregiver on pain medications and the need to give a dose of pain medication between 0800 and 0900 (9AM) to help prevent a pain spike around 1200. Review of the plan of care, dated 06/11/2025, showed the following under physical discomfort:- Goals included patient’s pain/physical discomfort will be reduced to the level of patient’s stated goal or patient does not demonstrate s/s (signs or symptoms) of physical discomfort if unable to communicate in one week and throughout hospice care and patient/caregiver will verbalize understanding of the pain management plan in three days and throughout hospice care;- Interventions included assess and document: the cause, location, intensity, quality, frequency and duration of pain; alleviating and aggravating factors; current medication regimen and treatments; effects of pain on patient’s sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity. Assess patient’s pain utilizing an appropriate pain scale for age and cognition. Evaluate the effectiveness of the current pain treatment regimen and notify physician for the need for changes in the plan of care. Instruct patient/caregiver on pain medication regimen and alternative strategies to relieve pain; and- The plan of care failed to include the patient’s pain management goal, interventions for the patient’s reluctance or refusal to take pain medications as prescribed, and interventions used to increase the likelihood of compliance with the medication regimen. During an interview on 02/11/2026 at 1:50 PM, the administrator stated that he/she would expect that the patient’s plan of care would be updated as changes were made and as the plan is adjusted those changes should be reflected in the plan of care.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure the plan of care (POC) specifically identified which provider was responsible for performing the respective functions that had been agreed upon at the skilled nursing facility (SNF) and was included in the POC in one of one record reviewed (Record/Patient #6). This deficient practice has the potential to affect the provision of care for all the provider’s patients that resides in a facility. Findings included: Review of the provider’s policy titled, “Hospice in Facility Policy,” approved 12/23/2025, showed that when the hospice patient resides in a nursing facility, the hospice collaborates with the nursing facility providing care to the patient/family to ensure coordination of services. There shall be a coordinated single plan of care in the nursing facility which may be multiple documents that identify the care and services which each shall provide; and is updated to reflect changes in the patient/family condition, needs, and care. Review of the provider’s coordinated task plan (CTP) instructions, dated 07/19/2017, showed that clinicians were to circle the days of the week the hospice aide planned to visit; update any on-going schedule changes on the next line; and list the frequency of foley catheter (a sterile tube placed in the bladder to drain urine) care under each party responsible. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 06/27/2025 with a terminal diagnosis of chronic kidney disease (a long-term, progressive loss of kidney function). The patient had secondary diagnoses of protein calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and/or calories), dysphagia (difficulty swallowing), and required a foley catheter. The patient resided in a SNFReview of the POC, last updated 02/05/2026, showed that the hospice aide was to visit the patient two times per week, and the skilled nurse (SN) was to change the patient’s foley catheter every 30 days. Review of the patient’s clinical record, for the date period of 01/07/2026 to 02/06/2026, showed that the hospice aide had visited the patient two times per week on Tuesday and Friday. Review of the provider’s CTP last updated 01/27/2026, located in the patient’s binder at the facility, showed that the hospice aide was to visit on Tuesday and Thursday, and hospice would provide foley catheter supplies. The CTP failed to contain identification of who was responsible for the change of the patient’s foley catheter every 30 days and failed to be accurate with the days the hospice aide was going. During an interview on 02/10/2026 at 12:00 PM, the facility nurse (FN)-1 stated that he/she was unable to locate identification of who was responsible for changing the patient’s foley catheter every 30 days, and the hospice aide was to visit on Tuesday and Thursday. During an interview on 02/11/2026 at 9:00 AM, the administrator designee (AD)-1 stated that they would expect the CTP to identify who was responsible for changing the patient’s foley catheter and a visit schedule reflecting the actual days the aide visits were performed. He/she stated that the hospice clinical record contained a CTP dated 01/27/2026 that had identification of who was responsible to change the foley catheter and the correct visit schedule. This state agent (SA) informed the AD-1 that the CTP he/she had presented was not available in the facility binder at the time of the SA review.”

“Based on nationally recognized standards, observation, and interview the inpatient hospice provider failed to ensure a safe environment by storing oxygen cylinders in vacant patient rooms and bathrooms. This deficient practice has the potential to affect all the patients, staff, and visitors. Findings included: Review of the National Fire Protection Association (NFPA) 101, 2012 edition, showed 8.7.3.2* No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure, unless otherwise permitted by 8.7.3.1. Review of the NFPA 99, 2012 edition, showed 5.1.3.3.2 Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1. (2) They shall be secured with lockable doors or gates or otherwise secured. (3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits. (4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. (5) They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations. (6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required. (7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty. (8) They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6. (9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials. (10) They shall protect electrical devices from physical damage. Observation on 02/10/2026 beginning at 8:15 AM, showed the following:- Room one had an oxygen cylinder that was ¼ full stored in a closet;- Room five had an oxygen cylinder that was empty stored in the patient room;- Room six had an oxygen cylinder that was ¾ full stored in the patient room and an oxygen cylinder that was empty stored in the patient’s bathroom;- Room seven had two oxygen cylinders stored in the patient bathroom that were empty;- Room eight had an oxygen cylinder that was ¼ full stored in the patient bathroom;- Room nine had an oxygen cylinder that was empty stored in the patient bathroom;- Room 10 had an oxygen cylinder that was empty stored in the patient bathroom;- Room 11 had an oxygen cylinder that was ¾ full stored in the patient room;- Room 12 had an oxygen cylinder stored in the patient room that was empty;- Room 13 had an oxygen cylinder that was ¼ full stored in the patient bathroom;- Room 14 had an oxygen cylinder stored in the patient bathroom that was empty;- Room 15 had an oxygen cylinder stored in the patient bathroom that was empty;- Room 17 had an oxygen cylinder stored in the patient room that was empty;- Room 18 had an oxygen cylinder stored in the patient room that was empty;- The utility room had two oxygen storage cylinders stored that were empty; and- By storing oxygen cylinders in vacant patient rooms and bathrooms the provider created a hazardous environment in the event of a fire. During an interview on 02/10/2026 at 9:48 AM, the inpatient clinical manager stated that the oxygen cylinders were usually stored in the patient’s bathroom and that this had been the practice for a few months or more. During an interview on 02/10/2026 at 2:20 PM, the director of public safety and security stated that the expectation would be for all oxygen to be stored in the storage area when not in use and not in the patient’s room or bathroom.”

“Based on nationally recognized standards, observation, and interview the inpatient hospice provider failed to ensure that the sprinkler system was maintained according to National Fire Protection Association (NFPA) standards, that sprinkler heads were not blocked in closet areas, and that ceiling tiles were in place to decrease the movement of smoke throughout the building. This deficient practice has the potential to affect all the 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 13, 2010 edition, showed 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.Review of the NFPA 101, 2012 edition, showed 8.6 Vertical Openings. 8.6.1 Floor Smoke Barriers. Every floor that separates stories in a building shall meet the following criteria: (1) It shall be constructed as a smoke barrier in accordance with Section 8.5. (2) It shall be permitted to have openings as described by 8.6.6, 8.6.7, 8.6.8, 8.6.9, or Chapters 11 through 43. 8.6.2 Continuity. Openings through floors shall be enclosed with fire barrier walls, shall be continuous from floor to floor, or floor to roof, and shall be protected as appropriate for the fire resistance rating of the barrier. Observation on 02/10/2026 beginning at 8:15 AM, showed the following:- The linen storage room had an opening in a ceiling tile that measured 1 and ½-inches by ¼-inch and two ceiling tiles that were not in the tracks designed to keep them in place;- The biohazard room had a missing ceiling tile;- Room number one had a shelf in the closet containing several pillows wrapped in plastic bags that decreased the clearance of the sprinkler head to approximately 6-inches (clearance of the sprinkler head should be 18-inches to ensure that all areas of the closet are protected in the event of a fire);- Room number five had a shelf in the closet containing pillows that decreased the clearance of the sprinkler head to approximately 6-inches and a sprinkler head that was hanging down from the ceiling;- Room six had a missing escutcheon creating an opening in the ceiling approximately ¼-inch around the sprinkler head;- Room seven had a sprinkler head hanging out of the ceiling tile and the ceiling tile was not in the track designed to keep it in place;- Room ten had an escutcheon in the bathroom that was not flush with the ceiling that created ¼-inch gap around the sprinkler head;- Room nine had a sprinkler head that was corroded and rusted near the window;- Room 18 had a sprinkler head near the door that was leaking green fluid from the head of the sprinkler;- Room 15 had a missing escutcheon on the sprinkler near the door;- Room 17 had a sprinkler in the closet that was corroded and missing the escutcheon and the 18-inch clearance in the closet was blocked by the light fixture;- Room 16 had the 18-inch clearance in the closet blocked by the light fixture; and- The office closet had a sprinkler that was covered in dry wall dust. During an interview on 02/10/2026 at 2:20 PM, the facilities manager (person in charge of the fire alarms, sprinkler system, and cleanliness) stated that he/she would expect all ceiling tiles to be in place, the 18-inch clearance to be maintained to ensure that sprinklers were able to provide protection in the closet areas, and that all sprinklers should be clean and in good working order at all times.”

“Based on observation and interview the inpatient hospice provider failed to ensure that all intake and exhaust air ducts were maintained to prevent the entrance of dust, dirt, and other contaminating material into the facility. This deficient practice has the potential to affect all the patients, staff, and visitors. Findings included:Observation on 02/10/2026 beginning at 8:15 AM, showed the following:- Room one had two ducts with dust build-up;- The laundry room had one duct with dust build-up;- The staff bathroom labeled 1122 had one vent with dust build-up;- Room nine had one duct by the window with dust build-up;- Room 12 had one duct in the bathroom with dust build-up;- The staff bathroom containing the locker room had one vent with dust build-up; and- The office labeled 1207 had one vent with dust build-up. During an interview on 02/10/2026 at 2:20 PM, the facilities manager (person in charge of the fire alarms, sprinkler system, and cleanliness) stated that he/she would expect ducts in the building to be clean and free of dust build-up.”