Hearth Record

Vegas Life Care Hospice

A hospice in Las Vegas, Nevada 89123

8760 Smaryland Pkwy Suite 118, Las Vegas, Nevada 89123. (702) 881-4033.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 23, 2026.

The last 24 months 51 deficiencies in 2 months of the last 36. Last cited Jan 2025. Most serious: Condition-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
Condition-level deficiency
For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.

What did inspectors find?

51 deficiencies cited in the last three years

The middle of the 76 hospices serving ZIP code 89123 had 6.

The last inspection on record was on Jan 17, 2025: an initial inspection by the Accreditation Commission for Health Care.

5 deficiencies at condition level, the more serious of CMS’s two levels

Source:

CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.

CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.

When those deficiencies happened

51 deficiencies in 2 months of the last 36. Last cited Jan 2025. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.

51 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 NovDec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOct

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.

Jan 17, 2025: initial inspection by the Accreditation Commission for Health Care3 deficiencies
  • Timeframe for completion of assessment (42 CFR 418.54(b))

    “Upon patient record review 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7:There is no evidence that the MSW completed a psychosocial assessment within 5 days.”

    Rule L0523. Standard-level.

  • Content of plan of care (42 CFR 418.56(c)(4))

    The inspectors’ words, 103 words

    “Upon patient record review, 2 of 13 (Patient #2,#4) 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 2:The medical record includes nursing documentation that the patient is on a cardiac diet. There is no evidence that the plan of care includes an order for a cardiac diet. Patient 4:The medical record includes nursing documentation that the patient received education on a low sodium diet. There is no evidence that the plan of care includes an order for a low sodium diet.”

    Rule L0549. Standard-level.

  • Content of plan of care (42 CFR 418.56(c)(5))

    “Upon patient record review, 1 of 13 (Patient #9) 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 equipment and supply needs. Patient 9:The medical record includes an order on 11/26/24 for Albuterol nebulizers for symptom management. There is no evidence that the plan of care includes nebulizer equipment and supplies.”

    Rule L0550. Standard-level.

Oct 1, 2024: initial inspection by the Accreditation Commission for Health Care48 deficiencies
  • Initial & comprehensive assessment of patient (42 CFR 418.54)

    “Condition of Participation: Initial and Comprehensive Assessment of the Patient.”

    Rule L0520. Condition-level.

  • IDG, care planning, coordination of services (42 CFR 418.56)

    “Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536”

    Rule L0536. Condition-level.

  • Quality assessment & performance improvement (42 CFR 418.58)

    “Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.”

    Rule L0559. Condition-level.

  • Hospice aide and homemaker services (42 CFR 418.76)

    “Condition of Participation: Hospice Aide and Homemaker Services. L607”

    Rule L0607. Condition-level.

  • Organizational environment (42 CFR 418.100)

    “Condition of Participation: Organization and Administration of Services.”

    Rule L0648. Condition-level.

  • Names and Contact Information (42 CFR 418.113(c)(1))

    “Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients’ physicians • Other hospices The agency emergency communication plan did not include the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients’ physicians • Other hospices”

    Rule E0030. Standard-level.

  • Primary/Alternate Means for Communication (42 CFR 418.113(c)(3))

    “Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice’s employees and Federal, state, tribal, regional, and local emergency management agencies. The agency Emergency Communication Plan did not include primary and alternate means for communicating with the hospice’s employees.”

    Rule E0032. Standard-level.

  • Notice of rights and responsibilities (42 CFR 418.52(a)(2))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.”

    Rule L0503. Standard-level.

  • Notice of rights and responsibilities (42 CFR 418.52(a)(3))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.”

    Rule L0504. Standard-level.

  • Exercise of rights/respect for proprty/person (42 CFR 418.52(b))

    “Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one’s property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient #3: The RN arrived at the visit with her spouse driving her. This violates confidentiality and right to privacy for patient.”

    Rule L0505. Standard-level.

  • Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(3))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.”

    Rule L0507. Standard-level.

  • Rights of the patient (42 CFR 418.52(c)(2))

    “Upon client record review, 1 of 5 (Patient #5) did not have evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient #5: The patient record did not include any documentation.”

    Rule L0513. Standard-level.

  • Rights of the patient (42 CFR 418.52(c)(4))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: The electronic record did not have evidence of signed admission documents or election of benefits form that patient was given opportunity to elect attending.”

    Rule L0515. Standard-level.

  • Rights of the patient (42 CFR 418.52(c)(5))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.”

    Rule L0516. Standard-level.

  • Rights of the patient (42 CFR 418.52(c)(7))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.”

    Rule L0518. Standard-level.

  • Rights of the patient (42 CFR 418.52(c)(8))

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.”

    Rule L0519. Standard-level.

  • Initial assessment (42 CFR 418.54(a))

    “Upon patient record review 1 of 5 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #5: There was no evidence of a hospice registered nurse completed an initial assessment within 48 hours of election of benefit.”

    Rule L0522. Standard-level.

  • Content of comprehensive assessment (42 CFR 418.54(c))

    The inspectors’ words, 262 words

    “Upon patient record review 5 of 5 (Patients #1, 2, 3, 4, 5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #2: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #3: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #4: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #5: The record did not include any evidence of a comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process”

    Rule L0524. Standard-level.

  • Content of comprehensive assessment (42 CFR 418.54(c)(7))

    The inspectors’ words, 94 words

    “Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. There was no evidence of bereavement assessment on any of these patients.”

    Rule L0531. Standard-level.

  • Update of comprehensive assessment (42 CFR 418.54(d))

    The inspectors’ words, 158 words

    “Upon patient record review, 4 of 5 (Patients #1, 2, 3, 4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: There is no evidence of any further nursing assessments after the initial comprehensive assessment. Patient #2: There is no evidence of any further nursing assessments after the initial comprehensive assessment. Patient #3: There is no evidence of any further nursing assessments after the initial comprehensive assessment. Patient #4: There is no evidence of any further nursing assessments after the initial comprehensive assessment.”

    Rule L0533. Standard-level.

  • Content of plan of care (42 CFR 418.56(c))

    “Upon patient record review, 1 of 5 (Patient #5) 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 #5: There was no plan of care in the clinical record.”

    Rule L0545. Standard-level.

  • Review of the plan of care (42 CFR 418.56(d))

    The inspectors’ words, 217 words

    “Upon client record review, 5 of 5 (Patients #1, 2, 3, 4, 5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #1:There is no evidence that the IDG documented sharing of information between all disciplines providing care and services in all settings. The IDG updates were not signed by the IDG team. There is no evidence that the MSW or SC participated in creation of the POC. Patient #2: IDG documented for 09/13/24. There is no further IDG that has been completed. There was an IDG meeting entered in the system for 09/27/24, however, it is not inclusive of input from core services. Patient #3: IDG documented for 09/13/24. There is no further IDG that has been completed. There was an IDG meeting entered in the system for 09/27/24, however, it is not inclusive of input from core services. Patient #4: IDG documented for 09/13/24. There is no further IDG that has been completed. There was an IDG meeting entered in the system for 09/27/24, however, it is not inclusive of input from core services. Patient #5: There was no evidence of any IDG available in patient record”

    Rule L0552. Standard-level.

  • Coordination of services (42 CFR 418.56(e)(2))

    The inspectors’ words, 102 words

    “Upon client record review, 4 of 5 (Patients #1, 2, 3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: There is no evidence that the frequencies ordered for RN of once weekly were made. Patient #2: There is no evidence that the frequencies ordered for RN of once weekly were made. Patient #3: There is no evidence that the frequencies ordered for RN of once weekly were made. Patient #4: There is no evidence that the frequencies ordered for RN of once weekly were made.”

    Rule L0555. Standard-level.

  • Program data (42 CFR 418.58(b)(1))

    “Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. The agency had not created a QAPI program plan.”

    Rule L0563. Standard-level.

  • Program data (42 CFR 418.58(b)(2))

    “Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement The agency has not developed a QAPI plan.”

    Rule L0564. Standard-level.

  • Program activities (42 CFR 418.58(c)(1)(iii))

    “Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.”

    Rule L0568. Standard-level.

  • Performance improvement projects (42 CFR 418.58(d)(2))

    “Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.”

    Rule L0573. Standard-level.

  • Executive responsibilities (42 CFR 418.58(e)(1))

    “Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. The Agency had not developed or implemented a QAPI program.”

    Rule L0574. Standard-level.

  • Executive responsibilities (42 CFR 418.58(e)(2))

    “Upon observation, there was no evidence the hospice’s governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. The Agency had not developed or implemented a QAPI program.”

    Rule L0575. Standard-level.

  • Executive responsibilities (42 CFR 418.58(e)(3))

    “Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities. The agency did not develop or implement a QAPI program or designate person responsible.”

    Rule L0576. Standard-level.

  • Control (42 CFR 418.60(b)(2))

    “Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The agency does not have an established QAPI plan.”

    Rule L0581. Standard-level.

  • Licensed professional services (42 CFR 418.62(c))

    “Upon observation, there was no evidence licensed professionals participate in the hospice’s QAPI program. There is not development of the QAPI program in this agency.”

    Rule L0586. Standard-level.

  • Competency evaluation (42 CFR 418.76(c))

    The inspectors’ words, 173 words

    “Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #9: There is no evidence of a competency assessment being completed with a patient or pseudo patient. corrected on site”

    Rule L0615. Standard-level.

  • Competency evaluation (42 CFR 418.76(c)(3))

    “Upon observation, there was no evidence the Home Health Aide competency evaluation is performed by a Registered Nurse in consultation with other skilled professionals, as appropriate. There was no evidence that the Home Health Aide had a competency evaluation by an RN”

    Rule L0617. Standard-level.

  • Hospice aide instructor qualifications (42 CFR 418.76(e))

    “Upon personnel record review, 1 of 12 (Personnel #3) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel #3: The Director of Clinical services did not have a resume in his HR file.”

    Rule L0623. Standard-level.

  • Hospice aide assignments and duties (42 CFR 418.76(g)(1))

    The inspectors’ words, 264 words

    “Upon patient record review, 4 of 5 (Patients #1, 2, 3, 4) 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: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen. Patient #2: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen. Patient #3: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen. Patient #4: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen.”

    Rule L0625. Standard-level.

  • Hospice aide assignments and duties (42 CFR 418.76(g)(2))

    The inspectors’ words, 129 words

    “Upon patient record review 4 of 5 (Patients #1, 2, 3, 4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: There is no evidence that the frequencies ordered for aide once weekly were carried out. Patient #2: There is no evidence that the frequencies ordered for aide once weekly were carried out. Patient #3: There is no evidence that the frequencies ordered for aide once weekly were carried out. Patient #4: There is no evidence that the frequencies ordered for aide once weekly were carried out.”

    Rule L0626. Standard-level.

  • Governing body and administrator (42 CFR 418.100(b))

    The inspectors’ words, 115 words

    “Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence the Board of Directors/governing body or administrator provided oversight of agency ensuring patient needs are met by qualified individuals who have been properly trained. In addition, there is not evidence of Quality Assessment Performance Improvement program. The Administrator nor the Director of Clinical services were actively supervising and taking steps to ensure the quality of services due to not providing oversight for care of patients ensuring that patients were being seen as ordered to meet needs and that staff was properly trained.”

    Rule L0651. Standard-level.

  • Training (42 CFR 418.100(g)(2))

    “Upon personnel record review, 8 of 12 (Personnel #1, 2, 3, 4, 8, 9, 11,12) did not have evidence that the hospice employees have received orientation on their specific job requirements.”

    Rule L0662. Standard-level.

  • Training (42 CFR 418.100(g)(3))

    “Upon personnel record review, 8 of 12 (Personnel #1, 2, 3, 4, 8, 9, 11, 12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.”

    Rule L0663. Standard-level.

  • Initial certification of terminal illness (42 CFR 418.102(b))

    The inspectors’ words, 103 words

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #5: The record did not contain certification of terminal illness.”

    Rule L0667. Standard-level.

  • Content (42 CFR 418.104(a)(1))

    The inspectors’ words, 202 words

    “Upon patient client record review, 5 of 5 (Patients #1, 2, 3, 4, 5) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Citing the inaccuracy of a component of the record is cited under other standards) • Initial plan of care • Updated plan of care • Initial assessments • Comprehensive assessments • Updated comprehensive assessments • Signed and dated clinical and progress notes Patient #1: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #2: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #3: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #4: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #5: The record was open without any clinical content, including assessments, plan of care, or signed and dated clinical or progress notes.”

    Rule L0672. Standard-level.

  • Content (42 CFR 418.104(a)(2))

    “Upon patient client record review, 1 of 5 (Patient #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5: The patient record did not contain election statement or signed consents.”

    Rule L0673. Standard-level.

  • Authentication (42 CFR 418.104(b))

    “Upon patient client record review, 4 of 5 (Patients #1, 2, 3, 4) 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. Patients #1, 2, 3, 4: IDG notes were incomplete and not signed.”

    Rule L0679. Standard-level.

  • Discharge or transfer of care (42 CFR 418.104(e)(3))

    “Upon client record review, 1 of 5 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: There was no record of a discharge summary for this patient who went to the hospital on day 2 of care and was not readmitted.”

    Rule L0684. Standard-level.

  • Administration of drugs and biologicals (42 CFR 418.106(d)(1))

    The inspectors’ words, 111 words

    “Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient’s plan of care. Patient #5: There was no evidence in the patient record of any interdisciplinary group involvement in the POC or in the patient/caregiver’s ability to safely administer drugs and biologicals.”

    Rule L0692. Standard-level.

  • Personnel qualification (42 CFR 418.114(b)(4))

    “Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state’s Speech-Language Pathology Practice Act and the hospice’s policies and procedures and/or job descriptions. Agency unable to provide speech language pathologist HR file.”

    Rule L0788. Standard-level.

  • Criminal background checks (42 CFR 418.114(d)(1))

    “Upon personnel record review, 1 of 12 (Personnel #7 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Agency unable to produce speech language pathologist HR file.”

    Rule L0795. Standard-level.

All 2 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Jan 17, 2025Initial inspection by the Accreditation Commission for Health Care3 deficiencies cited
Oct 1, 2024Initial inspection by the Accreditation Commission for Health Care48 deficiencies cited

Is it certified?

  • Medicare-certified hospice since Jan 27, 2025.
  • CMS doesn’t list its type of ownership.
  • Cited at in the last three years: it didn’t meet a whole condition of Medicare’s rules.
Source:

CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.

CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.

Has anything been proven against it?

  • CMS doesn’t publish fines or other penalties for hospices, so none are shown.
  • 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.

Who does the caring?

  • CMS hasn’t published nursing time from Medicare claims for this hospice.
Source:

CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.

Who owns it?

  • 4 owners or officers are people: Bill Nassar (owns 5% or more directly, 50%); Bill Nassar (managing employee (on the payroll), 50%); Zaid Hasan (owns 5% or more directly, 50%); Josef Z Abbo (managing employee (on the payroll), 0%).
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.

What do families say?

  • CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
  • CMS gives no Hospice Care Index for this hospice.
Source:

CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.

How does it compare nearby?

  • Of the 76 hospices CMS’s data show serving patients in ZIP code 89123, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 6; this one had 51.
Source:

CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.

CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospices, so none are shown.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
  • Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Oct 27, 2026.

From the hospice

The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 8, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

Every fact names its source.

Who published it, when, and how often it changes sit beside each fact, with a link to the agency’s own file.

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