Hospice of New Mexico, LLC

“Based on record review and staff interviews, the facility failed to meet the Condition of Participation to provide an emergency preparedness plan that is formulated with a comprehensive approach, including risk assessment and updates at least every 2 years. This deficient practice could possibly result in serious harm, injury or death for all patients as the facility is not prepared to handle an emergency. The findings are: A. The facility failed to provide an emergency preparedness plan that was based on a comprehensive approach and updated every 2 years. Refer to tag E-0004.B. The facility failed to maintain an emergency preparedness plan using an “all-hazards,” approach (an approach that incorporates identifying hazards such as natural, man-made, or facility emergencies including emerging infectious disease (EID)) threats and developing a plan to effectively handle a disaster) that was updated every 2 years. Refer to tag E-0006. C. The facility failed to maintain an emergency preparedness plan that specifies the population which the facility serves. Refer to tag E-0007.D. The facility failed to provide a maintained integrated response plan (a collective and collaborative process with local, tribal, regional, State and Federal emergency preparedness officials during an emergency or disaster.) as required in the facility’s emergency preparedness plan. Refer to tag E-0009.E. The facility failed to maintain emergency preparedness plan policies and procedures based on the risk assessment and communication plan. Refer to tag E-0013.F. The facility failed to maintain an emergency preparedness plan with policies addressing procedures for follow-up with staff on duty and patients during an emergency or disaster event. Refer to tag E-0016.G. The facility failed to have a policy in place addressing staffing strategies during an emergency or disaster event. Refer to tag E-0024.H. The facility failed to maintain an emergency preparedness plan that included policies and procedures addressing arrangements with other facilities to receive patients in the event of an emergency. Refer to tag E-0025.I. The facility failed to maintain a communication plan in its emergency preparedness plan that is reviewed and updated at least every two years. Refer to tag E-0029.J. The facility failed to maintain an emergency preparedness plan with a communication plan that contains accurate contact information and is updated every 2 years. Refer to tag E-0030.K. The facility failed to maintain an emergency preparedness plan with a communication plan that contains accurate contact information for emergency officials. Refer to tag E-0031.L. The facility failed to maintain an emergency preparedness plan with a communication plan that lists accurate primary and alternate means of communication. Refer to tag E-0032.M. The facility failed to maintain an emergency preparedness plan with an effective emergency preparedness training and testing program. Refer to tag E-0036.N. The facility failed to maintain an emergency preparedness plan with an effective emergency preparedness training program. Refer to tag E-0037.O. The facility failed to maintain an emergency preparedness plan with an effective emergency preparedness training program. Refer to tag E-0039.”

“Based on record review and staff interview, the facility failed to provide an Emergency Preparedness Plan that was based on a comprehensive approach (an all-encompassing plan for handling an emergency or disaster which includes the four core elements such as an all hazards approach, Policy and Procedures, Communication Plan, and Training and Testing Program) and updated every 2 years. This deficient practice could lead to the facility being unprepared to serve their patients in an emergency. Findings are: A. Record request for documentation providing dates of review and updates to the Emergency Preparedness Plan revealed the facility could not provide.B. Record review of the facility’s undated binder titled, “EMERGENCY PREPAREDNESS PLAN (EPP),” did not reveal any evidence the EPP is developed with a comprehensive approach.C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, confirmed she was unable to determine when the Emergency Preparedness Plan was last reviewed and updated.”

“Based on record review and staff interview, the facility failed to maintain an Emergency Preparedness Plan using an “all-hazards,” (an approach that incorporates identifying hazards such as natural, man-made, or facility emergencies including emerging infectious disease [EID]) threats and developing a plan to effectively handle a disaster) approach that was updated every 2 years. This deficient practice could lead to the facility being unprepared to address emergencies that are specific to area and population served by the hospice. The findings are:A. Record review of the facility’s undated binder titled, “EMERGENCY PREPAREDNESS PLAN (EPP),” did not reveal any evidence emergency preparedness plan is reviewed every two years. B. Record request for documentation providing dates of review and updates to Emergency Preparedness Plan revealed the facility could not provide.C. Record review of facility’s undated document titled, “Hospice of New Mexico Disaster Risk Assessment & Emergency Plan.” This document revealed that the hazards identified included earthquakes, extreme heat, wildfires, floods, transportation incidents, and terrorist attacks. The document did not reveal any evidence that the EPP analyzed risks for emerging infectious diseases such as recent COVID pandemic that affected the area. D. Record review of facility’s document titled, “6.27 ANALYSIS OF RISK ASSESSMENT FOR POTENTIAL DISASTERS” dated 11/18/2025 revealed in section C: Epidemic, the section is blank. This document did not identify earthquakes or transportation incidents as a risk. E. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, confirmed she was unable to determine when the Emergency Preparedness Plan was last reviewed and updated. S1 explained that the document “6.27 ANALYSIS OF RISK ASSESSMENT FOR POTENTIAL DISASTERS” was just filled out.”

“Based on record review and staff interview, the facility failed to maintain an emergency preparedness plan that specifies the population which the facility serves. This deficient practice could lead to patients of the hospice not receiving the care they need in an emergency. Findings are:A. Record request for documentation providing dates of review and updates to the emergency preparedness plan revealed the facility could not provideB. Record review of the facility’s undated document titled, “Hospice of New Mexico Disaster Risk Assessment & Emergency Plan.” Did not identify the population which the facility serves.C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, confirmed she was unaware that the specificity of the facilities population served was required in the emergency preparedness plan.”

“Based on record review and staff interview, the facility failed to provide a maintained integrated response plan (a collective and collaborative process with local, tribal, regional, State and Federal emergency preparedness officials during an emergency or disaster) as required in the facility’s emergency preparedness plan. This deficient practice could lead to lack of communication with local, tribal, regional, State, and Federal emergency preparedness officials’ delayed response in an emergency. The findings are:AA. Record review of the facility’s undated documents titled, “Communication Plan” and “Communication Plan Make this Specific to your Area” had different individuals listed as contacts for local officials and tribal officials. The undated document titled, “Communication Plan” lists a contact for the State official and does not have a contact listed for the regional or federal official. B B. Record review of the facility’s undated document titled, “Communication Plan Make this Specific to your Area” does not have a contact listed for the regional, state or federal official. C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, confirmed the presence of two documents titled communication plans in the EPP binder have conflicting information.”

“Based on record review, the facility failed to maintain emergency preparedness plan policies and procedures based on the risk assessment and communication plan. This deficient practice could possibly result in staff being unaware how to serve patients in an emergency. The findings are:A. Record request for the facility’s policy and procedure using an “all-hazards,” approach (an approach that incorporates identifying hazards such as natural, man-made, or facility emergencies including emerging infectious disease (EID) threats and developing a plan to effectively handle a disaster) along with the communication plan, revealed the facility could not provide.”

“Based on record review and staff interview, the facility failed to maintain an emergency preparedness plan with policy and procedures addressing procedures for follow-up with staff on duty and patients during an emergency or disaster event. This deficient practice could possibly result in staff and patients being unaware that facility has enacted emergency procedures. The findings are:A. Record review of the facility’s undated document titled, “Communication plan Make this specific to your area, in the second paragraph of the document it reads… “In the event of an emergency the above officials will be notified of patients in need of assistance and agency staff that is available to assist within the community. If the agency is unable to reach by telephone the agency will utilize alternative communication means such as Zello app which is a walkie talkie app on cell phones…” Howbeit, there are no policies and procedures present addressing methods of communication to follow-up with staff on duty and patients during an emergency or disaster event. B. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, stated she was unaware of an app named Zello listed in the communication plan and was unsure if that was still the appropriate method of communication since S1 was unsure when the emergency plan was last reviewed.”

“Based on record review and staff interview, the facility failed to have a policy in place addressing staffing strategies during an emergency or disaster event. This deficient practice could possibly lead to the facility not having staff to meet patient needs in an emergency. The findings are: A. Record request for the facility’s policy and procedure addressing staffing strategies and any surge needs in the event of an emergency, revealed the facility could not provide. B. Record review of the facility’s undated document titled, “Disaster Response Phone Tree,” had six staff names that were not included on the undated document titled, “Colleague Phone List.” It is unclear if this list has been updated and these six staff members are current employees. C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, it was stated that the undated document titled, “Colleague Phone List,” is the most recent and updated employee list. When S1, non-clinical, was asked if she realized the two undated documents, “Disaster Response Phone Tree” and the “Colleague Phone List,” in the Emergency Preparedness Plan binder have conflicting information, S1 replied, she was unaware.”

“Based on record review, the facility failed to maintain an emergency preparedness plan that included policies and procedures addressing arrangements with other facilities to receive patients in the event of an emergency. This deficient practice could possibly result in serious harm, injury or death. The findings are:A. Record review of the facility’s document titled, “Mutual AID Agreement,” dated 09/29/2020 revealed an arrangement with another hospice facility. There are no signatures on this agreement. B. Record review of the facility’s undated document titled, “Communication Plan Make this specific to your area” revealed the facility has an arrangement in place with another hospice agency and the document also stated, “[name of facility] is also looking to contract with local hospitals in the near future. This plan will become a part of the agencies policies and procedure…” There was no evidence that policies and procedures were developed based on this plan. C. During an interview with Staff(S)1, non-clinical, on 11/20/2025 at 10:30 am it was confirmed that they do not have any other contracts with facilities in place.”

“Based on record review and staff interview, the facility failed to maintain a communication plan in its emergency preparedness plan that is reviewed and updated at least every two years. This deficient practice could possibly result in poor communication of patient needs during an emergency. The findings are:A. Record request for documentation providing dates of review and updates to the Emergency Preparedness Plan revealed the facility could not provide. B. Record review of the facility’s undated document titled, “Communication Plan Make this specific to your area,” is present in the facility’s Emergency Preparedness Plan binder. There is no evidence of updates to this document. C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, stated she was unable to recall when the communication plan was last reviewed and updated, however the document titled, “Communication Plan Make this specific to your area,” is the communication plan she would follow.”

“Based on record review and staff interview, the facility failed to maintain an emergency preparedness plan with a communication plan that contains accurate contact information and is updated every 2 years. This deficient practice could possibly lead to poor communication during an emergency. The findings are:A. Record request for documentation providing dates of review and updates to Emergency Preparedness Plan revealed the facility could not provide. B. Record review of the facility’s undated document titled, “Communication Plan Make this specific to your area,” does not provide contact information of the hospice facility the agency has contracted with in the event of an emergency. C. Record review of the facility’s undated document titled, “Disaster Response Phone Tree,” on page 2 there were six staff listed that are not listed on the document titled, “Colleague Phone List” it is unclear if these staff are still employed. D. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, she confirmed it is difficult to assess when the facility’s Emergency Preparedness Plan was last reviewed and updated.”

“Based on record review and staff interview, the facility failed to maintain an emergency preparedness plan with a communication plan that contains accurate contact information for emergency officials. This deficient practice could possibly result in poor communication during an emergency. The findings are: A. Record review of the facility’s undated documents titled, “Communication Plan” outlines procedure for collaboration and cooperation with local, tribal, regional, state and federal preparedness officials. However, this undated document does not list contact information for regional and Federal officials. B B. Record review of the facility’s undated documents titled, “Communication Plan Make this specific to your area,” outlines procedure for collaboration and cooperation with local, tribal, regional, state and federal preparedness officials. However, this undated document does not list contact information for regional and Federal officials. C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, confirmed it is difficult to assess when the facility’s Emergency Preparedness Plan was last reviewed and updated.”

“Based on record review and staff interview, the facility failed to maintain an emergency preparedness plan with an effective emergency preparedness training and testing program. This deficient practice could possibly lead to the facility and staff not being prepared to activate the emergency preparedness plan effectively. The findings are:A. Record request for documentation providing dates of review and updates to Emergency Preparedness Plan revealed the facility could not provide. B. Record request of Emergency Preparedness plan- full-scale exercise revealed the facility could not provide documentation.C. During an interview with Staff (S)1, non-clinical, on 11/20/2025 at 10:30 am, it was stated the agency had conducted a full-scale exercise within 2025. However, S1 was unable to provide documentation of the full-scale exercise.”

“Based on record review and staff interview, the facility failed to maintain an emergency preparedness plan with an effective emergency preparedness training program. This deficient practice could possibly lead to the facility and staff not being prepared to activate the emergency preparedness plan effectively. The findings are:A. Refer to Tag E-0036B. Record request for documentation that emergency preparedness training is provided to staff every two years revealed the facility could not provide documentation. C. Record request for training on updated policy and procedures related to the emergency preparedness plan revealed the facility could not provide documentation. D. Record request for documentation of all emergency preparedness training, revealed the facility could not provide documentation”

“Based on record review, the facility failed to ensure that 9 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, and P9) out of 9 (P1, P2, P3, P4, P5, P6, P7, P8, and P9) patients received effective pain management and symptom control. This deficient practice can lead to poorly controlled pain, a failure to ensure comprehensive person-centered care, increased hospital admission rates, and is in violation of patient’s rights. The findings are:A. Record review of the facility’s policy “PC.P10 Pain and Symptom Management” stated: “Procedure: 5. Procedures and protocols for pain assessment and management are developed and implemented, using a numerical or other rating scale for pain assessment.” And “7. Pharmacological and Non-Pharmacological interventions are considered for the treatment of pain.” B. Record review of the facility’s policy “PC. P50 Plan of Care” stated: “Procedure: 11. Measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by Care Hospice, and are used as part of the Care Hospice’s QAPI (Quality Assurance and Performance Improvement) Program.” C. Record review of P(patient)1’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.D. Record review of P2’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.E. Record review of P3’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.F. Record review of P4’s patient care plan did not list non-pharmacological interventions for the treatment of pain, did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.G. Record review of P5’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.H. Record review of P6’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.I. Record review of P7’s patient care plan did not list non-pharmacological interventions for the treatment of pain, did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.J. Record review of P8’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.K. Record review of P9’s patient care plan did not have a numerical or other rating scale for pain assessment, did not list pharmacological interventions for the treatment of pain, did not list non-pharmacological interventions for the treatment of pain, and did not identify an effective measurable outcome to demonstrate effective pain management and symptom control.”

“Based on record review, the facility failed to ensure that 8 (P[patient]1, P2, P3, P4, P5, P7, P8, and P9) out of 9 (P1, P2, P3, P4, P5, P6, P7, P8, and P9) patients were involved in developing his or her hospice plan of care. This deficient practice can lead to lack of informed decision making, control over their own care, and is in violation of patient’s rights. The findings are:A. Record review of the facility’s policy “PC.P50 Plan of Care” stated: “Procedure: 6. The Hospice written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based on problems identified in the initial/updated assessment…. a. Participation by the patient/family/caregiver, based on ability and response to care.”B. Record review of P1, P2, P3, P4, P5, P7, P8, and P9’d plans of care were nearly identical to each other, without personalization of care to individual patients, families, and/or caregivers.”

“Based on record review, the facility failed to ensure that 14 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) comprehensive assessments fully identified and addressed the physical, psychosocial, emotional, and spiritual needs related to the terminal illness of the patient. This deficient practice failed to reflect the patients’ history and current status, affected the interdisciplinary team’s care planning ability, and may have potentially compromised patients’ quality of life. The findings are:A. Record review of the facility’s policy “PC. P10 Pain and Symptom Management” stated: “Procedure: 3. The patient’s pain and other symptoms related to the terminal condition are thoroughly assessed in the comprehensive assessment of the patient by the RN [registered nurse] case manager or designee.”B. Record review of P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14’s initial assessments lacked evaluation of: history of pain treatment, the patient/family goals for pain management, and the patient/family satisfaction with the current level of pain control.”

“Based on record review, the facility failed to ensure that data elements for 14 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) patients comprehensive assessments were used in individual care planning and in the QAPI (Quality Assurance and Performance Improvement) program in a defined and measurable methodology. This deficient practice fails to ensure that patient care planning and applied interventions are effective at the individual or systems level. The findings are:A. Record review of P1, P2, P3, P4, P5, P6, P7, P8, and P9’s individual plans of care did not contain data elements from the corresponding patient’s comprehensive assessment. B. Record review of the facility’s QAPI program did not contain evidence of data elements from patient comprehensive assessments.”

“Based on record review, the facility failed to ensure that 8 (P[patient]1, P2, P3, P4, P5, P7, P8, and P9) out of 9 (P1, P2, P3, P4, P5, P6, P7, P8, and P9) patients were involved in developing his or her hospice plan of care and also failed to ensure that 14 (P[patient]1, P2, P3, P4, P5, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) patient’s comprehensive assessments fully identified and addressed the physical, psychosocial, emotional, and spiritual needs related to the terminal illness of the patient. These deficient practices failed to reflect the patients’ history and current status, affected the interdisciplinary team’s care planning ability, potentially compromised patients’ quality of life, can lead to lack of informed decision making, control over a patient’s own care, and is in violation of patient’s rights. The findings are:A. Refer to Tag L-0513B. Refer to Tag L-0524”

“Based on record review, the facility failed to ensure that data elements (a specific characteristic being measured) from 14 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) patients anticipated measurable outcomes were used in individual care planning. This deficient practice fails to ensure that patient care planning and applied interventions are providing effective outcomes for patients. The findings are:A. Record review of the facility’s policy “PC.P50 Plan of Care” stated: “Procedure: 11. Measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by Care Hospice, and are used as part of the Care Hospice’s QAPI [Quality Assessment and Performance Improvement] Program.”B. Record review of P1, P2, P3, P4, P5, P6, P7, P8, and P9’s individual plans of care did not contain a measurable outcome.”

“Based on record review, the facility failed to ensure that interdisciplinary group notes (revised plans of care) for 14 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) patients did not correlate with documented “Team Care Plans” (facility plan of care for patient). This deficient practice demonstrates a lack of continuity of care between: 1) initial and ongoing assessments, 2) case managers updating the individual care plan, 3) interdisciplinary team meeting scribe’s annotation to the patient chart, and 4) a lack of defined measurable outcomes for determination of effective care treatment/data collection. This can lead to miscommunication between providers, medication errors, and serious harm to patients. The findings are:A. Refer to Tag L-0524B. Refer to Tag L-0535C. Refer to Tag L0545”

“Based on record review and staff interview, the facility failed to effectively measure, analyze and track quality indicators which enable the facility to assess processes of care. This deficient practice can lead to patients not receiving consistent, high-quality care and places them at risk for negative outcomes. The findings are:A. Record review of the facility’s document titled, “Adverse Event. Detail,” revealed 76 patient falls with injury. There was no evidence of a performance improvement plan related to falls. B. During staff interview on 11/20/2025 at 9:30 am with Staff (S)1, clinical, stated reports are run monthly to evaluate areas in need of improvement, however, after discussing falls S1 confirmed the facility did not have a performance improvement plan for falls.”

“Based on record review and staff interview, the facility failed to effectively monitor the effectiveness and safety of services and quality of care. This deficient practice can lead to patients not being protected from preventable errors resulting in compromised patient safety and quality of care. A. Record review of the facility’s document titled, “Performance Improvement Plan Quarter 3, 2025,” does not include any methodology for monitoring or measurable goals. B. Record review of the facility’s document titled, “Adverse Event. Detail,” revealed 76 patient falls with injury.C. Record requests for a Falls Performance Improvement Plan (PIP) revealed the facility was unable to provide the document.D. During staff interview on 11/20/2025 at 9:30 am with S(staff)1, clinical, confirmed document titled, “Performance Improvement Plan Quarter 3, 2025,” was unclear and S1 was unable to indicate how monitoring would occur. Furthermore, S1, was unable to find a measurable goal on the document.”

“Based on record review, the facility failed to ensure an effective quality improvement program that was overseen by the governing body. This deficient practice could lead to the governing body not being aware of areas of concern, ensuring that actions are taken to correct these areas leading to poor patient outcomes. The findings are:A. Record requests for Governing Board Minute revealed the facility was unable to provide the document.B. Record requests for documentation on how the facility ensures reporting to the Governing Board revealed the facility was unable to provide documentation.C. Record review of the facility’s documents titled, “Care Hospice Quarterly QAPI Meeting Minutes: HONM Q1 2025,” had no documentation that this information is reported to the Governing Board.”

“Based on record review and staff interview, the facility failed to implement activities that focus on high risk, high volume, or problem-prone areas. This deficient practice can lead to patients not receiving safe and effective care. A. Record review of document titled, “Adverse Event. Detail,” revealed 76 patient falls with injury.B. Record requests for a Falls Performance Improvement Plan (PIP) revealed the facility was unable to provide the document.C. During staff interview on 11/20/2025 at 9:30 am with S(staff)1, clinical, confirmed a PIP for falls should be in place, but there isn’t one.”

“Based on record review and staff interview, the facility failed to provide a QAPI (Quality Assessment and Performance Improvement) program that effectively implements and monitors outcomes resulting from palliative care provided. This deficient practice can lead to poor patient outcomes. A. Record review of the facility’s document titled, “Performance Improvement Plan (PIP) Q3, 2025,” is unclear what the area of focus for improvement is and provides no evidence of monitoring of outcomes. B. During staff interview on 11/20/2025 at 9:30 am with S(staff)1, clinical, stated the PIP for Q3, 2025 was to focus on pain/symptoms management. S1 also confirmed it was difficult to show the monitoring of the outcomes.”

“Based on record review and staff interview, the facility failed to provide any evidence the facility’s QAPI (Quality Assessment and Performance Improvement) program effectively monitors, and tracks improvement activities to ensure improvements are sustained. This deficient practice can lead to compromised patient safety and quality of care. A. Record review of the facility’s document titled, “Care Hospice Quarterly QAPI Meeting Minutes: HONM Q1 2025,” identifies falls as an area for improvement, however, in section: Performance Improvement Projects (PIPs) of the document, falls are not listed. B. Record review of the facility’s document titled, “Care Hospice Quarterly QAPI Meeting Minutes: HONM Q2 2025,” identifies falls as an area for improvement, however, in section: Performance Improvement Projects (PIPs) of the document, falls are not listed.C. During staff interview on 11/20/2025 at 9:30 am with S(staff)1, clinical, confirmed a PIP for falls should be in place, but there isn’t one.”

“Based on record review and staff interview, the facility failed to provide any evidence that the facility has a system in place to communicate with all hospice personnel, patients, families and visitors about identified infectious concerns. This deficient practice can lead to staff, patients, families and visitors at higher risk for communicable disease transmission. A. Record requests regarding policy for communication of communicable and transmissible diseases amongst staff, patients, families and visitors revealed the facility was unable to provide the document.B. During staff interview on 11/20/2025 at 9:35am with S(staff)1, clinical, was unable to verbalize methods of effective communication when a communicable and transmissible outbreak occurs and the information needs to be shared with staff, patients, families and visitors.”

“Based on record review, the facility failed to ensure that bereavement counseling needs were assessed, identified, and extended to residents of a skilled nursing facility for 2 (P[patient]2 and P5) out of 9 patients individual plans of care. This deficient practice can lead to residential complicated grief, social isolation, as well as psychosocial and physical decline. The findings are:A. Record review of the facility’s policy “PC.B30 Bereavement - Services” stated: “Procedure: 2. …Bereavement services also extends [sic] to residents and facility staff when appropriate and identified in the bereavement plan of care…”B. Record review of P[patient]2 and P5 were in a skilled nursing facility (SNF). These records did not include bereavement counseling needs assessment for SNF residents or SNF staff.”

“Based on record review, the facility failed to ensure that bereavement counseling needs were assessed, identified, and extended to residents of a skilled nursing facility for 2 (P[patient]2 and P5) out of 9 patients individual plans of care. This deficient practice can lead to residential complicated grief, social isolation, as well as psychosocial and physical decline. The findings are:A. Record review of the facility’s policy “PC.B30 Bereavement - Services” stated: “Procedure: 2. …Bereavement services also extends [sic] to residents and facility staff when appropriate and identified in the bereavement plan of care…”B. Record review of P2 and P5 were in a skilled nursing facility (SNF). These records did not include bereavement counseling needs assessment for SNF residents or SNF staff.”

“Based on record review, the facility failed to record responses to medications, symptom management, treatments, and services for 14 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) patient records. This deficient practice can lead to delayed recognition of adverse reactions, inappropriate escalation of care, inconsistency of care, patient harm, and legal risk for the facility. The findings are:A. Record review of the facility’s policy “PC.C30 Clinical Records” stated: “Procedure: 1. Each patient’s clinical record contains: 8. Responses to medications, symptom management, treatments, and services.”B. Record review of p1, P2, P3, P4, P5, P7, P8, P9, P10, P11, P12, P13, and P14’s patient charts did not contain documentation of responses to medications, symptom management, treatments, and/or services.”

“Based on record review, the facility failed to record responses to medications, symptom management, treatments, and services for 14 (P[patient]1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) out of 14 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) patient records. This deficient practice can lead to delayed recognition of adverse reactions, inappropriate escalation of care, inconsistency of care, patient harm, and legal risk for the facility. The findings are:A. Record review of the facility’s policy “PC.C30 Clinical Records” stated: “Procedure: 1. Each patient’s clinical record contains:…27. Discharge summary, including the reason for discharge or transfer and the agency’s documented notice to the patient, the client’s physician; services provided to the client’s family (as applicable).”B. Record review of P11 and P12’s patient charts did not contain a discharge summary.”

“Based on record review, the facility failed to include documentation about the patient’s treatments, symptoms, pain management, and latest physician orders on the facility discharge summary document for 1 (P[patient] 14) out of 1 (P14) patient charts. This deficient practice can result in medication errors, polypharmacy, pain and symptom mismanagement, inappropriate interventions, and inaccurate care planning, all of which can cause potentially serious harm to patients. The findings are:A. Record review of P14’s discharge summary revealed the summary does not contain evidence of their treatments, symptoms, pain management, or latest physician orders.”

“Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #3: Surveyor arrived at visit with plan to observe hospice aide Noted RN was present as well. During interview with patient daughter, she stated she had “problems” with initial nurse. She reported that she didn’t know when to expect her and she provided very little education regarding patient needs. She further described incident when catheter was removed. She presented pictures on her phone of catheter balloon inflated vs catheter balloon deflated. She said she (the daughter herself) felt guilty that she didn’t know better the night the catheter was removed, because it was painful for the patient. She referred to gentleman in the home, who “is medical” and was aware of error and explained to her when saw removed catheter in trash can with balloon still inflated. She said she would not allow the nurse to replace catheter because of pain patient experienced, but she was not aware of cause during visit. Surveyor recalled chart review and inquired about subsequent retention experienced and replacement a few days later (October 1, 2025). Daughter replied “Yes, it was replaced, but not the same nurse. And that was okay.” She wouldn’t let initial nurse come back. She believes that nurse no longer is employed there. She is giving the new nurse a chance. She is very happy with aides providing care thus far, and other staff.”

“Upon patient record review, 2 of 19 (Patient #3, 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: Daughter states she only gives Senna prn- twice daily on medication profile. She has Ondansetron on hand and administered this am. It is not on medication profile. She no longer takes Metformin, which remains on medication profile 2 tablets twice/day. (She said nurse said stop some time back). Patient does not take Alendronate which is once per week on medication profile or MiraLAX ordered twice/day. Patient #11: Narcan, Lorazepam, Haldol, Dulcolax supp on hospice medication profile and not on facility list. Facility has Glucagon and MiraLAX, but hospice does not.”

“Upon patient record review, 2 of 19 (Patient #2, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: Warfarin prescribed q HS. Problems, goals interventions do not include bleeding precautions. Patient #9: Plavix prescribed daily. Problems, goals interventions do not include bleeding precautions.”

“Upon patient record review, 1 of 19 (Patient #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #10: 10/14/25 SN Wound care to stage 2 pressure injury to right heel; Apply betadine, let dry, repeat, cover with 2x2 island dressing. (no frequency) 10/14/25 SN Patient/family to perform wound care as ordered Wound care to be completed by hospice RN or daughter every other day OR soilage - 10/14/25 Dakins Solution BLLE stasis ulcers. It is unclear if wound care frequency of every other day OR soilage is applicable to right heel or stasis ulcers BLLE. Furthermore, the frequency is unclear in that it says or rather than and.”

“Upon client record review, 5 of 19 (Patient #2, 3, 4, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: There is no order for volunteer service, but Volunteer Care Plan1-2/week. Provided 9/19 and 9/22/25 only. Patient #3: Patient admitted with Foley catheter in place. Orders to Insert catheter and change as prescribed (specify cath and balloon size, type and frequency) 16 Fr/10 ml. Change Foley catheter per policy and procedures. Change catheter monthly, when obstructed or leaking. SN visit 9/29/25 RN removed Foley, no specific documentation to obstruction or leakage. 10/1/25 SN Visit RN replaced Foley using 16 Fr. 30 cc balloon. No order for removal or replacement on these dates and/or specific catheter size. Patient #4: Patient admitted 9/10/25. No orders for volunteer. Volunteer Care Plan says 1x/week. Provided 9/16 and 10/3/25. No visit week of 9/22/25. Patient #10: Patient admitted 8/5/25. No orders for Volunteer service. Volunteer visits 8/15, 9/18, 10/2/25. Patient #11: Patient admitted 4/25/25. No orders for Volunteer service. Volunteer Visit provided 10/3/25.”

“Upon observation during home visits 3 of 4, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient#1: (Patient with known drug resistant, wounds). Noted RN placed nursing bag on sofa in patient room with small barrier, not fully covering surface area of bag. She did not prepare field for all equipment, which required multiple re-entries to bag, but hand sanitized only once. She put her stethoscope around her neck. She raised patient covers to check patient wound dressings and moved over bed table with her hands without sanitizing between. She went back and forth between patient and tablet without sanitizing. When she went to the bathroom to wash her hands, she laid the tablet on the bathroom sink. She did not sanitize the tablet between facility and car. Post visit interview with nurse and questioned about bag technique. She responded with information about bagging soiled items in garbage bag. Clarified was inquiring about nursing bag technique and she replied she couldn’t really answer for this agency. Patient #4: Pre-visit trunk supply review. Noted in nurses back seat of dual cab truck, supplies were abundant and somewhat scattered. Multiple supplies in large plastic bag. Surveyor pointed to items with possible expiration date to inquire about rotation of stock. 2 of 3 items reviewed were expired. Noted catheter insertion kit with expiration date of 6/30/24. Noted box of examination gloves with expiration date of 5/31/24. Noted RN placed bag on sofa arm, with small barrier not completely covering surface area of bag. She placed used equipment on the patient’s blanket covering sofa. She got equipment out one piece at a time, wiped it and placed it straight back in bag with no time allowed to dry. There is no clean/dirty space identified and no hand sanitizing from patient to bag. The same wipe is used repeatedly and most likely is dried out between equipment cleaning. Nurse had scales to weigh patients in large plastic bag. The plastic bag was placed on patient’s cloth sofa as was tablet and no barrier. Scales were used, cleaned with wipe and placed directly back in the bag with not time to dry. Patient #11: RN places nursing bag on over bed table in SNF patient room. There is no wiping/cleansing of table before or after placement and there is no barrier used. The tablet is also placed on table in same manner. (Surveyor observed stains on table, such as dried liquid of some sort.) Nurse did not sanitize hands each time between patient and bag or between patient and tablet. When wiping tools, there was no drying time before replacing in bag. Surveyor approached nursing bag and inquired about clean dirty space, she said she had a separate bag - noted small fabric bag, but equipment had been placed in area of bag, but not definitively in the separate bag. During post visit interview, she stated that she knows the facility wipes down tables, so she assumes it’s clean, but she uses barrier when she thinks home is unclean - asked to clarify, she stated clutter for example, indicates the home is not clean.”

“Upon patient record review, 3 of 19 (Patient #17, 18, 19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #17: Date of Death 10/14/24. Bereavement mailings care plan identifies mailings scheduled thru 7/29/25, however only completed thru 11/4//24 (1month). Patient #18: Date of Death 10/15/24. Bereavement mailings care plan identifies mailings scheduled thru 7/29/25, however only completed thru 3/5/25 Patient #19: Date of Death 10/5/24. Bereavement mailings care plan identifies mailings scheduled thru 7/29/25 (9 months), however only completed thru 5/30 (6 month)”

“Upon patient/client record review 1 of 19 (Patient #13), there was no evidence in the patient record that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family’s desires which include: •Providing spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service and in a manner consistent with their beliefs and desires Patient #13: Upon review, the initial SC assessment 8/18/25 spiritual counselor notes that patient and daughter are agreeable to monthly visits. There is no update to initial visit frequency of 1wk1, following evaluation/assessment visit. 9/11 and 9/25/25 IDG SC notes “There were no prn visits requested.” There is no evidence of September visit being offered, provided or declined.”

“Upon patient record review, 5 of 19 (Patient #1, 2, 9, 13, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Paraplegic with suprapubic foley, colostomy, multiple wounds. Task assigned to provide urinary catheter care every visit, but also assist with urinal every visit. Patient is non ambulatory with task assigned to use cane or walker for ambulation. Patient #2: Patient has Warfarin prescribed, but there are no references to bleeding precautions. Patient #9: Plavix prescribed daily. There is no reference to bleeding precautions. Patient #13: Eliquis is prescribed. There is no reference to bleeding precautions Patient #14: Keppra is prescribed for patient’s seizure disorder. No seizure precautions.”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Related to wide spread observations during survey, and specifically related to Patient #3, there was not evidence hospice is providing the care and services in a manner that is consistent with accepted standards of practice, specifically nursing services. Upon observations during clinical record review, on site visit/family interviews, personnel file reviews and staff and patient/family interviews: Survey Day 1, during initial clinical record reviews, observed 9/29/25 SN visit note, when Foley catheter was removed. RN did not document deflating balloon and/or amount of water removed from balloon. Further stated Foley was difficult to get out and was quite painful due to swelling. Surveyor initially cited as documentation error (and also no physician order). However, additional data obtained during home visit Survey Day 2. Surveyor arrived at visit with plan to observe hospice aide Noted RN was present as well. During interview with patient daughter, she stated she had “problems” with initial nurse. She reported that she didn’t know when to expect her and she provided very little education regarding patient needs. Follow up in office: Complaint / grievance log: Identifies someone received call from daughter regarding concerns, but return calls x 2 of 3 and no answers. Interviews with Admin and DPCS for any additional information. They were aware and had evidence of communication with compliance and Human Resources concerning RN performance and patient daughter’s concerns. Reportedly, the nurse involved was a no call/no show in response to messages to investigate incident. In fact, she did not return to work at all. The administrator reports that she was attempting contact related to another incident. Spoke with Lydia, DPCS, who was aware of concerns that catheter balloon may not have been deflated. She also said when she attempted to call the RN to come in, she did not respond. She said she was a no show thereafter. Neither the Administrator or DPCS have spoken directly to daughter. Compliance and HR had been contacted and involved in ongoing investigation. Regarding personnel review for the nurse involved, staff had printed electronic personnel file. Upon review, noted some items not available, including no competency skills checklist on file. Questioned administrator (hired in January 2025), who was under the impression that online modules meet all requirements. Provided education. Further discussion revealed no staff hired since January had initial competency skills checklists completed.”

“Upon personnel record review, 14 of 15 (Personnel #1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel ##1, 2, 3, 4, 6, 7, 9, 10, 11, 12, 13, 14, 15: Printed personnel files provided did not include initial skills competency assessment for multiple employees hired 2025 and not available upon request. Personnel #5: There is no evidence of annual skills competency by anniversary date 3/6/23/25 per AD.X10 policy requirement and definition of annual.”

“Upon patient client record review, 2 of 19 (Patient #1, 3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: SN Visit 9/26/25 narrative note- referring to groin wound - lightly packed with Dakins soaked Kerlix gauze. 9/20/25 SN Visit note: RN received update that patient needed wound care. Wound care completed. Patient tolerated wound care well. 10/6/25 SN prn visit note: 10/6/25 prn visit: Wounds were all uncovered except right knee and ankle. All wounds were cleaned and dressed as best as possible. Patient tolerated well. 10/9/25 PRN visit for dressing change. Dressing to groin were no longer intact and not in place; other dressings were intact with some movement. Dressings were taken down individually and cleansed and redressed. Patient tolerated well. Specific locations and details of treatment are not specified in these visit notes Patient #3: 9/29/25 visit, RN documented removing Foley, 9/29/25 SN visit note, when Foley catheter was removed. RN did not document deflating balloon and/or amount of water removed from balloon. “RN then did wound care on the coccyx wound.” Specific details of treatment provided was not specified.”

“Based on record reviews the hospice agency failed to follow accepted standards of practice to ensure each patient has an individualized plan of care for 5 (P{patient} P1, P2, P3, P4 and P6) out of 6 patients (P1 through P6) records reviewed. This failure to provide a person-centered plan of care may result in a failure of team members to identify and respond to the patient’s needs because of the lack of written instructions. The findings are:A. Record review of P1’s Plan of Care dated 09/10/25, revealed it was not individualized as evidenced by the following statements: “Instruct patient/family in safe oxygen administration.” There was no additional information regarding what safe oxygen administration means to this patient or their family. “Assess for changes in respiratory symptoms every visit.” There were no additional instructions on P1’s current respiratory status and what significant changes might be anticipated as well as what interventions should be implemented if there are changes. “Instruct patient in fall and safety precautions.” There is no additional information regarding what specific fall and safety precautions are important to P1 and the family. “Instruct patient /family in safe mobility and transfers with assistive devices.” There is no additional information about what specific safe practices apply to P1 or what assistive devices are appropriate for P1. “Instruct patient/family in safe use/care of equipment.” There is no additional information regarding what equipment is being referred to or what constitutes safe use or care. “Address end-of -life (EOL) concerns /dynamics/barriers to a peaceful death.” There is no additional information regarding what if any concerns, dynamics, or barriers have been identified or what individualized interventions would be appropriate for P1. B. Record review of P2’s Plan of Care dated 09/10/25, revealed it was not individualized as evidenced by the following statements: “Instruct patient/family in safe oxygen administration.” There was no additional information regarding what safe oxygen administration means to this patient or their family. “Assess/instruct patient/caregiver in cardiac disease process and management of symptoms.” There is no information regarding what aspect of cardiac disease process is applicable to P2. There is no instruction regarding what symptoms P2 might be at risk to develop and what would be the appropriate intervention. “Assess/instruct patient/caregiver in short- and long-term memory deficits.” There is no information on whether P2 is experiencing short- or long-term memory deficits or what specific interventions would be appropriate for P2 if they were having short- or long-term memory loss. “Address EOL concerns /dynamics/barriers to a peaceful death.” There is no additional information regarding what if any concerns, dynamics, or barriers have been identified or what individualized interventions would be appropriate for P2. C. Record review of P3’s, Plan of Care dated 09/10/25, revealed it was not individualized as evidenced by the following statements: “Instruct patient/ family in signs/symptoms to report to hospice nurse.” There is no additional information on what signs and symptoms P3 or the family of P3 should be aware of. “Assess/instruct in skin breakdown prevention.” There is no additional information about the current condition of P3’s skin and what specific risks to P3’s skin integrity exist. There is no information on interventions that would be appropriate to prevent skin breakdown for P3. “Assess/instruct patient/family in signs and symptoms of infection.” There is no additional information regarding what signs and symptoms of infection might apply to P3 and what body system an infection might occur. “Assess/instruct patient/family in potential patient changes in response to environment/physiological stimuli.” There is no additional information regarding the specific changes P3 may experience in reference to specific “environmental or physiological stimuli.”D. Record review of P4’s Plan of Care dated 09/10/25, revealed it was not individualized as evidenced by the following statements: “Assess/instruct patient/caregiver in short- and long-term memory deficits.” There is no information on whether P4 is experiencing short- or long-term memory deficits or what specific interventions would be appropriate for P4 if they were having short- or long-term memory loss. “Instruct patient/family in fall and safety precautions.” There is no additional information regarding P4’s risk for falling or identification of possible safety hazards in P4’s environment. E. Record review of P6’s, Plan of Care dated 09/10/25, revealed it was not individualized as evidenced by the following statements: “Assess/instruct in skin breakdown prevention.” There is no additional information regarding the current skin integrity assessment of P6, or the specific risks identified for P6. There are no individualized interventions that are applicable to P6. “Assess/instruct patient/family in signs and symptoms of infection.” There is no additional information regarding what signs and symptoms of infection might apply to P6 and what body system an infection might occur. “Coordinate wound care with facility staff.” There is no additional information regarding what this statement means. “Instruct patient/family in fall and safety precautions.” There is no additional information regarding P6’s risk of falling or identification of possible safety hazards in P6’s environment. “Assess need for assistive devices.” There is no additional information regarding what, if any, possible functional limitations exist or may possibly develop to require assistive devices.”

“Based on record reviews the hospice agency failed to follow accepted standards of practice to identify measurable goals in the plan of care for 5 (P{patient} P1, P2, P3, P4 and P6) out of 6 patients (P1 through P6) records reviewed. This failure to include quantifiable goals does not allow for evaluation of the effectiveness of nursing interventions. A. Record Review of P1’s plan of care dated 09/10/25, demonstrated that the goals listed were not specific, measurable, time-bound, or relevant to P1. This is evidenced by the following statements: “Patient and staff safety are maintained through the election process.” There is no additional information about how risks to patients or staff have been identified or what precautions may have to be put in place to maintain safety. “Patient/family demonstrates understanding of pulmonary disease (conditions of the lungs and respiratory system) and management of symptoms.” There is no additional information regarding what specific aspect of pulmonary disease the patient and family should demonstrate an understanding of or what symptoms should be learned and managed by what date. “Patient/family demonstrates safe, effective use of equipment.” There is no additional information regarding specific equipment that is applicable to P1 or how it would be used effectively or how steps to obtaining this goal will be measured. B. Record Review of P2’s plan of care dated 09/10/25, demonstrated that the goals listed were not specific, measurable, time-bound, or relevant to P2. This is evidenced by the following statements: “Support the patient’s decline in respiratory functioning (breathing) as patient progresses through the disease process.” There is no additional information regarding what disease process is being referred to, what the status of P2’s respiratory function is and what decline might be expected. “Patients cardiac symptoms (chest pain or discomfort, shortness of breath, dizziness or lightheadedness, fatigue or weakness, swelling in the feet or hands) will be managed.” There is no additional information regarding current cardiac symptoms and timely steps to achieve management. “Family verbalizes understanding of patient’s changing cognitive function.” There is no additional information regarding what specific changes the family should understand and how soon they should verbalize understanding.C. Record Review of P3’s plan of care dated 09/10/25, demonstrated that the goals listed were not specific, measurable, time-bound, or relevant to P3. This is evidenced by the following statements: “Patient/family demonstrates independence with wound care by…” There is no additional information regarding when the patient or family is to be able to demonstrate independence with wound care. “Family verbalizes understanding of patient’s changing cognitive function.” There is no additional information regarding what specific changes the family should understand and how soon they should verbalize understanding. “Patient/family demonstrates safe, effective use of equipment.” There is no additional information regarding specific equipment that is applicable to P3 or how it would be used effectively or how steps to obtaining this goal will be measured. D. Record Review of P4’splan of care dated 09/10/25, demonstrated that the goals listed were not specific, measurable, time-bound, or relevant to P4. This is evidenced by the following statements: “Family verbalizes understanding of patient’s changing cognitive function.” There is no specific timely goal for the family to verbalize understanding and the statement does not address what cognitive function or functions might change for P4. “Patient/family demonstrates safe mobility and transfer techniques.” There is no additional information regarding the specifics of what constitutes safe mobility and transfer techniques specific to P4, and no timeline designated for completion. E. Record Review of P6’s plan of care dated 09/10/25, demonstrated that the goals listed were not specific, measurable, time-bound, or relevant to P6. This is evidenced by the following statements: “Patient/family verbalizes knowledge of wound treatment plan by...”. There is no timeline for the patient or family to achieve the goal of verbalizing knowledge of the wound treatment plan. “Patient/family demonstrates safe, effective use of equipment.” There is no additional information regarding specific equipment that is applicable to P6 or how it would be used effectively or how steps to obtaining this goal will be measured or in what timeframe.”