Caris Healthcare

“Based on policy, record review and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in four of five full records reviewed (Records/Patients #1, #2, #3 and #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current active medication orders, printed 06/09/2026, showed the following discrepancies:- The hospice provider’s medication report showed Milk of Magnesia (a medication for constipation) 400 mg/5ml oral suspension, tree (3) ml daily as needed. The LTCF’s medication orders showed Milk of Magnesia suspension 400 mg/5ml, 30 ml once a day as needed; - The hospice provider’s medication report showed Insulin Aspart (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous as needed three times daily per sliding scale instructions for blood sugar levels. The LTCF’s medication orders failed to include the sliding scale insulin; and - The LTCF’s medication orders showed oxygen (O2) at 2 liters/minute via nasal cannula to maintain O2 sats greater than 92% as needed every shift. The hospice provider’s medication report failed to include the oxygen. The hospice provider failed to maintain an accurate drug profile. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a LTCF. Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current medication administration record (MAR), printed 06/10/2026, showed the following discrepancies: - The hospice provider’s medication report showed Insulin Glargine 100 unit/ml subcutaneous 10 units daily at bedtime. The LTCF’s MAR failed to include the Glargine insulin; and - The hospice provider’s medication report showed Insulin Lispro (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous as needed four times daily per sliding scale instructions for blood sugar levels. The LTCF’s MAR failed to include the sliding scale insulin; and - The LTCF’s MAR showed glipizide (a medication used to lower blood sugar) 5 mg one tablet once a day. The hospice provider’s medication report failed to include the glipizide. The hospice provider failed to maintain an accurate drug profile. Findings included:Review of the provider’s policy titled, “Medication Management,” dated 04/28/2026, showed in part, that a medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient’s terminal illness. The profiles is updated at the time of each comprehensive assessment at a minimum and/or when new medication is added or changes are made to existing medications. Review of the provider’s policy titled, “Medication Assessment and Reconciliation,” dated 07/05/2021, showed in part, on every skilled nursing visit, perform medication reconciliation to ensure all medications are correctly documented in the electronic record (EMR). Medication reconciliation for patients residing in the long-term care facility (LTCF) includes the following:- Review facility medication administration record (MAR) and confirm against what is in the medication profile of the EMR. If discrepancies noted, make changes in the EMR; and- Review each medication’s strength/dosage/frequency. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with the terminal diagnosis of cerebral atherosclerosis (ICAD; the buildup of fatty plaque in the arteries that supply blood to the brain), hemiplegia following cerebral infaaction affecting left non-dominate side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere) and aphasia (language impairment) and dysphagia (difficulty swallowing) following cerebral infarction. The patient resided in a LTCF.Review of the LTCF MAR on 06/09/2026 beginning at 11:18 AM, showed the following discrepancy: -The hospice provider’s client medication report, printed on 06/08/2025, showed the patient was ordered Duloxetine (an antidepressant) 20 milligrams (mg) tablet by mouth (PO) once a day; and -The LTCF MAR did not show this medication was being given. The hospice providers chronological list of medications and equipment, printed on 06/08/2026, included duloxetine.The hospice provider failed to maintain an accurate drug profile. RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis. The patient resided in a LTCF. Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current MAR, printed 06/09/2026, showed the following discrepancies:- The hospice provider’s medication report showed Milk of Magnesia (a medication for constipation) 400 mg/5ml oral suspension, three (3) milliliters (ml) daily as needed. The LTCF’s medication orders showed Milk of Magnesia suspension 400 mg/5ml, 30 ml once a day as needed; - The hospice provider’s medication report showed Insulin Aspart (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous as needed three times daily per sliding scale instructions for blood sugar levels. The LTCF’s medication orders failed to include the sliding scale insulin; and - The LTCF’s current MAR showed oxygen (O2) at 2 liters/minute via nasal cannula to maintain O2 sats greater than 92% as needed every shift. The hospice provider’s medication report failed to include the oxygen. The hospice provider failed to maintain an accurate drug profile. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2026 with the terminal diagnosis of Alzheimer’s disease (a progressive, irreversible disorder that destroys memory, thinking skill and the ability to perform simple tasks), hemiplegia following cerebral infarction affecting the left non-dominant side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere). The patient resided in a long-term care facility (LTCF).Review of the LTCF MAR on 06/09/2026 beginning at 10:08 AM, showed the following discrepancies:-Bisacodyl suppository to be given once daily; -Chloraseptic throat spray to be give twice daily;-Glucerna meal shake to be given twice daily; -Juven collagen packets to be give twice daily; and-ProTGold protein supplement and collagen supplement to be given twice daily. The hospice provider’s client medication report did not include the following: Bisacodyl suppository, Chloraseptic throat spray, Glucerna (or any other brand) of meal shake, Juven collagen packets or ProTGold protein supplements.The hospice provider failed to maintain an accurate drug profile. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a LTCF. Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current MAR, printed 06/10/2026, showed the following discrepancies: - The hospice provider’s medication report showed Insulin Glargine (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous 10 units daily at bedtime. The LTCF’s MAR failed to include the Glargine insulin; and - The hospice provider’s medication report showed Insulin Lispro 100 unit/ml subcutaneous as needed four times daily per sliding scale instructions for blood sugar levels. The LTCF’s MAR failed to include the sliding scale insulin; and - The LTCF’s MAR showed glipizide (a medication used to lower blood sugar) 5 mg one tablet once a day. The hospice provider’s medication report failed to include the glipizide. The hospice provider failed to maintain an accurate drug profile. During an interview on 06/11/2026 at 10:12 AM, the governing body appointee (GBA; known at the provider as the regional vice president of clinical care), stated that he/she would expect the medication reconciliation to be done at least weekly, and would expect the profile to reflect what the patient was taking in the home.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the durable medical equipment (DME) necessary to meet the needs of the patient 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. Review of the provider’s policy titled, “Plan of Care – Content,” dated 04/28/2025, showed in part, the patient’s plan of care includes all services necessary for the palliation and management of the primary terminal illness and related diagnoses and conditions. The plan of care includes, but is not limited to medical supplies, DME, and appliances necessary to meet the needs of the patient. RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the recertification updated POC, dated 05/19/2026, and the POC update report, dated 06/02/2026, showed, in part: - DME included a wheelchair, low air loss mattress, and electric bed; and- The POC failed to include a Broda chair (a type of specialty wheeled chair) and fall mat, necessary to meet the needs of the patient. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a LTCF. Review of the POC, dated 04/04/2026, showed, in part: - No DME or supplies listed; - Activities Permitted included, up as tolerated with walker; and- The POC failed to include a walker, necessary to meet the needs of the patient. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a LTCF. Review of the POC, dated 05/04/2026, showed, in part, no DME or supplies listed. Review of the POC Update Report, dated 06/02/2026, showed, in part:- No DME or supplies listed;- The POC failed to include an oxygen concentrator and supplies, for oxygen ordered on 05/15/2026, necessary to meet the needs of the patient. Review of the provider’s policy titled, “Plan of Care – Content,” dated 04/28/2025, showed in part, the patient’s plan of care includes all services necessary for the palliation and management of the primary terminal illness and related diagnoses and conditions. The plan of care includes, but is not limited to medical supplies, DME, and appliances necessary to meet the needs of the patient. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with the terminal diagnosis of cerebral atherosclerosis (ICAD; the buildup of fatty plaque in the arteries that supply blood to the brain), hemiplegia following cerebral infraction affecting left non-dominate side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere) and aphasia (language impairment) and dysphagia (difficulty swallowing) following cerebral infarction. The patient resided in a long-term care facility (LTCF).Review of the Plan of Care (POC) dated 04/03/2025, showed, in part, the following: The patient would use a wheelchair for activities.The POC failed to list a Broda chair (a type of specialty wheeled chair) necessary to meet the needs of the patient. The hospice provider failed to maintain an accurate list of DME. Observation on 06/09/2026 beginning at 11:20 AM, showed the patient was sitting in a Broda chair (a rolling reclining chair the is pushed by a second person) sleeping in his/her room. RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the recertification updated POC, dated 05/19/2026, and the POC update report, dated 06/02/2026, showed, in part: - DME included a wheelchair, low air loss mattress, and electric bed; and- The POC failed to include a Broda chair (a type of specialty wheeled chair) and fall mat, necessary to meet the needs of the patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2026 with the terminal diagnosis of Alzheimer’s disease (a progressive, irreversible disorder that destroys memory, thinking skill and the ability to perform simple tasks), hemiplegia following cerebral infarction affecting the left non-dominant side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere). The patient resided in a long-term care facility (LTCF).Review of the POC dated 05/07/2026, showed, in part the following: The patient would use a wheelchair for activities.-The POC failed to list a Broda chair necessary to meet the needs of the patient. Observation on 06/09/2026 at approximately 10:15 AM, showed Patient #3 sitting in a Broda chair in the SNF religious program. The hospice provider failed to maintain an accurate list of DME. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a LTCF. Review of the POC, dated 04/04/2026, showed, in part: - No DME or supplies listed; - Activities Permitted included, up as tolerated with walker; and- The POC failed to include a walker, necessary to meet the needs of the patient. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a LTCF. Review of the POC, dated 05/04/2026, showed, in part, no DME or supplies listed. Review of the POC Update Report, dated 06/02/2026, showed, in part:- No DME or supplies listed;- The POC failed to include an oxygen concentrator and supplies, for oxygen ordered on 05/15/2026, necessary to meet the needs of the patient. During an interview on 06/11/2026 at 10:12 AM, the governing body appointee (GBA; know at the provider as the regional vice president of clinical care), stated that the durable medical equipment (DME) should be updated whenever equipment is added, it should be in the nurse’s narrative as well.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure the nursing needs of the patients were met in two of five full records reviewed (Records/Patients #2 and #5). This deficient practice has the potential to adversely affect all patients served by the hospice provider. Findings included:Review of the provider’s policy titled, “Wound Care Treatment,” dated 12/02/2022, showed in part the following:- The nurse will perform a complete head-to-toe assessment of the patient’s skin integrity on a weekly basis and document the findings in the electronic medical record (EMR);- If a wound/pressure injury is present, the documented findings include location, appearance, measurements, drainage, odor, and treatment orders as well as the education provided to the patient/caregiver. The plan of care will include wound orders, interventions, and the measurable outcomes;- If the patient resides in a long-term care facility (LTCF) and the facility prefers to continue treating with their wound protocol, the hospice nurse still needs to visualize the wound weekly and document findings in the EMR. As the Hospice Case Manager, the hospice nurse must collaborate with the facility nurse to ensure the treatment to resolve the wound/pressure injury is appropriate. If the hospice nurse removes the dressing to visualize the wound, the hospice nurse must re-dress the wound correctly unless the facility nurse indicates otherwise. RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a LTCF. Review of the provider’s Interdisciplinary Group (IDG) Comprehensive Assessment and POC Update Reports, dated 03/10/2026. 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 05/19/2026, 06/02/2026, showed in part the following:- The patient had a diagnosis of unstageable pressure ulcer of sacral region; and- Skilled nurse (SN) to provide wound care per orders, cleanse area with wound cleanser, then apply collagen powder into wound, use Dakins solution to moisten non-woven gauze, pack wound bed, apply dry gauze then cover with an island dressing twice a day and as needed. Review of the hospice provider’s registered nurses’ (RN) notes from 04/14/2026 through 06/022026 showed in part the following:- The hospice RN failed to assess the sacral wound on 4/14/2026, 04/23/2026, 04/30/2026, 05/06/2026, 05/11/2026, 05/19/2026, 05/28/2026, and 06/02/2026; and- The RN discussed the wound with the LTCF’s nurse on 04/23/2026 and 04/30/2026, recorded the LTCF’s measurements of the sacral wound, but failed to visualize and assess the wound. During observation of RN-A’s visit with the patient on 06/09/2026, beginning at 9:00 AM, RN-A failed to observe the patient’s sacral wound or remove or change the wound dressing. In an interview on 06/09/2026 at 09:45 AM, RN-A stated that he/she did not change the sacral wound dressing, and it was done by the LTCF on the evening shift. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a LTCF. Review of the initial hospice certification and POC, dated 05/04/2026, showed in part the following:- Diagnosis of abrasion right ankle;- SN visits two times per week; and- Iodosorb 0.9% topical gel, apply to right outer ankle area at bedtime, small pea size amount. Review of physician’s narrative statement and orders, dated 05/06/2026, showed in part, the patient had multiple skin irritation areas and blisters on the right side of the back and a stage two wound on the lateral aspect of the right ankle. Review of the hospice RN visit notes from 05/04/2026 through 06/08/2026, showed in part the following:- On 05/04/2026, the RN assessment showed right lateral ankle wound identified, measuring 2 cm x 1.5 cm x 0 cm, irregular shape, no odor or drainage¸ wound care and dressing change completed;- On 05/06/2026, the RN failed to assess wound;- On 05/14/2026, the RN failed to assess the wound and stated “caregiver completed”;- On 05/15/2026, the RN failed to assess wound and stated “caregiver completed”;- On 05/16/2026, the RN failed to assess wound;- On 05/21/2026, the RN failed to assess the wound and stated “caregiver completed”;- On 05/22/2026, the RN assessed the right ankle wound, measured wound at 0.2 cm x 0.5 cm x 0 cm, and changed the dressing;- On 05/22/2026 during the second RN visit, the RN failed to assess the ankle wound. LTCF staff reported redness to coccyx but RN failed to visualize coccyx;- On 05/26/2026, the RN failed to assess wound;- On 05/28/2026, the RN assessed the coccyx area for redness and applied barrier cream. The RN failed to assess the ankle wound;- On 06/01/2026, the RN failed to assess wound;- On 06/04/2026, the RN failed to assess wound; and- On 06/08/2026, the RN failed to assess wound. During an interview on 06/11/2026 at 10:12 AM, the governing body appointee (GBA; know at the provider as the regional vice president of clinical care), stated that he/she would expect the medication reconciliation to be done at least weekly, and would expect the profile to reflect what the patient was taking in the home or LTCF.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure the hospice aide followed the aide plan of care (POC) in two of five full records reviewed (Record/Patient #3 and #4). This deficient practice has the potential to adversely affect all patients receiving aide services. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2026 with the terminal diagnosis of Alzheimer’s disease (a progressive, irreversible disorder that destroys memory, thinking skill and the ability to perform simple tasks), hemiplegia following cerebral infarction affecting the non-dominant side. The patient resided at skilled nursing facility (SNF) and the SNF staff were the primary caregivers. Review of the hospice aide POC, dated 05/07/2026, showed, in part, the following aide services were to be provided on every visit:- Bathing – shower;- Shampoo;- Hair Care;- Oral Care; and- Perineal Care. Review of the “Visit Note Report,” showed, in part, the aide tasks marked as refused, or not required as the following:- Shower/ bath, refused 05/13/2026, not required 05/22/2026, not required 05/26/2026, not required 05/28/2026, not required 06/02/2026;-Oral care/ mouth care, already completed 05/13/2026, not required 05/22/2026, not required 05/28/2026;- Shampoo/ hair care, refused 05/13/2026, not required 05/22/2026, not required 05/26/2026, not required 05/28/2026, not required 06/02/2026; and- Perineal care, refused 05/13/2026, not required 05/22/2026, 2026, not required 05/26/2026, not required 05/28/2026. During an interview on 06/11/2026 at 10:32 AM, TM stated that an action plan was put in place during a quality improvement meeting due to the number of missed and refused visits. Aides should contact the director of nurses to plan another visit, or additional actions needed. Findings included: Review of the job description titled “Hospice Aide Assignments and Duties”, dated 05/14/2025, showed the hospice aide provides services that are ordered by the interdisciplinary group and included in the POC. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a long term care facility. Review of the hospice aide POC, dated 04/04/2026, showed, in part, the following aide services were to be provided on every visit:- Bathing – shower;- Shampoo;- Hair Care;- Oral Care;- Skin care; - Ear Care;- Nail Care;- Foot Care;- Perineal Care;- Dressing;- Assistance with ambulation;- Offer fluids;- Empty trash;- Change linens;- Make bed;- Straighten patient’s area; and- Three most important things. Observation of the aide visit on 06/10/2026, beginning at 9:00 AM, showed the aide failed to complete or offer the following:- Bathing – Shower was offered but patient declined;- Shampoo was offered but patient declined;- Oral care;- Foot care;- Perineal care was offered but patient declined;- Fluids;- Empty trash;- Change linens; and- Three most important things.”

“Based on contract review, policy review, record review, observation and interview the hospice provider failed to ensure coordination of responsibility for wound care and foley catheter (a thin flexible tube inserted through the urethra into the bladder to drain urine) care between the hospice and the long-term care facility (LTCF) in two of five records reviewed of patients that resided in a LTCF (Records/Patients #2 and #5). This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. Findings included: Findings included: Review of the hospice provider’s policy titled, “Hospice Care for Nursing Facility Residents,” dated 04/28/2025, showed in part the following:- The hospice assumes full responsibility for the professional management of the facility patient’s hospice care and routinely provides all core services including nursing, medical social services and counseling; and- The hospice may use the facility’s nursing personnel to assist in the administration prescribed therapies included in the patient’s POC only to the extent that the hospice would routinely utilize the services of a hospice patient’s family in implementing the POC. Review of the agreement between the hospice provider and the LTCF titled, “Hospice Nursing Facility Services Agreement,” dated 2013, showed in part the following:- In accordance with applicable federal and state laws and regulations, facility shall coordinate with hospice in developing a hospice POC for each hospice patient that is consistent with the hospice philosophy and is responsive to the unique needs of each hospice patient and his or her expressed desires for hospice care;- Hospice retains primary responsibility for determining each hospice patient’s appropriate hospice POC in accordance with its applicable regulations; and- The hospice plan of care (POC) will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice POC. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the provider’s POC and POC Update Reports, dated 03/10/2026. 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 05/19/2026, 06/02/2026, showed in part the following:- The patient had a diagnosis of unstageable pressure ulcer of sacral region; - Skilled nurse (SN) to provide wound care per orders, cleanse area with wound cleanser, then apply collagen powder into wound, use Dakins solution to moisten non-woven gauze, pack wound bed, apply dry gauze then cover with an island dressing twice a day and as needed;- Skilled nurse to insert/change indwelling 16 French(FR)/30 cubic centimeters (cc) balloon foley catheter every 30 days using sterile technique; and- Skilled nurse to complete irrigation of urinary catheter using 30 to 60 cc acetic acid daily on Tuesday and Thursday with return. Observation and interview on 06/08/2026 at 9:45 AM, during the patient’s home visit in the LTCF, the LTCF RN assigned to the patient stated that all of the hospice paperwork was scanned into the electronic medical record (EMR), but the recent coordination notes (titled, “Hospice Coordinated Plan of Care) were kept in a folder. He/She stated that they do not have a coordinated task plan or plan of care, just the coordination notes. Review of the Hospice Coordinated Plan of Care notes completed by the hospice RNs, dated 04/06/2026, 04/23/2026, 04/30/2026, 05/06/2026, 05/11/2026, 05/17/2026, 05, 28, 2026, and 06/02/2026, showed in part the following:- The RN visits were marked with one day per week under “visit frequency” but had inconsistent days of the week documented including two Mondays, one Tuesday, one Tuesday/Wednesday, one Wednesday/Thursday, two Thursday and one not marked;- The RN recorded wound care by “facility staff” on five out of eight records, and one record was not documented; and- The RN failed to record the foley catheter and when care and changes were to be made and which staff (hospice or facility) were to complete the care on eight out of eight records.During an interview on 06/08/2026, RN-A stated that the Hospice Coordinated Plan of Care notes were completed after each visit and shared with the hospice nurse assigned to the patient. The provider failed to have a coordinated plan of care which indicated coordination of responsibility and identified which provider would be responsible for specific task (wound dressing changes, foley catheter changes, and foley catheter flushes). The provider also failed to provide the schedule for hospice staff (days of the week and times of day) for patient visits in the coordinated POC. In an interview on 06/08/2026, at 10:15 AM, the LTCF Assistant Director of Nursing stated that the facility did the foley catheter changes and flushes for all of the hospice patients. He/She also stated the LTCF wound nurse did the dressing changes for Patient #2. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided in a LTCF. Review of the initial hospice certification and POC, dated 05/04/2026, showed in part the following:- Diagnosis of abrasion right ankle;- SN visits two times per week; and- Iodosorb 0.9% topical gel, apply to right outer ankle area at bedtime, small pea size amount. Review of physician’s narrative statement and orders, dated 05/06/2026, showed in part, the patient had multiple skin irritation areas and blisters on the right side of the back and a stage two wound on the lateral aspect of the right ankle. Review of the POC Update Reports, dated 05/05/2026, 05/19/2026, and 05/02/2026, showed in part the following:- Diagnosis of abrasion right ankle;- Iodosorb 0.9% topical gel, apply to right outer ankle area at bedtime, small pea size amount;- POC failed to mention dressing change instructions or who was responsible for changing the dressing (hospice of the LTCF). Review of the Hospice Coordinated POC notes completed by the Registered nurse (RN) showed in part the following:- On 0/26/2026, the RN documented wound care right ankle per facility;- On 05/2028, the RN failed to document the wound care or party responsible;- On both 05/26/2026 and 05/28/2026, the RN failed to document visit frequency or day/time of scheduled visit. During an interview on 06/11/2026 at 10:15 AM, the governing body appointee (GBA; know at the provider as the regional vice president of clinical care) stated that wounds should be assessed weekly. He/she stated that the nurse should see the wound, assess the wound, and measure the wound. The GBA also stated that the foley catheter care should be done as ordered by the doctor, with no delineation of care.”