Every finding on record at Chi National Home Care, LLC

Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, 2 of 7 Staff observed (Staff-DD and Staff-R)  failed to follow the agency policy and procedures for proper hand hygiene and glove use while providing cares to 2 of 7 patients (Patient- 1 and Patient 4 respectively). Seven observations were conducted. The total sample size was 28. The Census was 77 (including 11 inpatient hospice patients and 66 branch patients). --- Findings are: A. Review of the agency policy and procedure, specific to the inpatient facility, titled Infection Control/Standard and Universal Precautions, revised 8/2/22 revealed: 1. Staff were to complete hand hygiene before and after contact with patients, after contact with objects in the patient's immediate area, when moving from contaminated body site to clean body site during care, and after removal of gloves.2. The policy also refers to Administrative 33.900, Hand Hygiene policy for further information.  B. Review of the agency policy and procedure titled 33.900, Hand Hygiene revised 8/10/22 revealed:1. The purpose was to maintain cleanliness of the employees' hands and to prevent cross-contamination and spread of infections. 2. Staff were to perform hand hygiene before and after direct patient contact, even if hands appear clean, before handling clean supplies, when moving from contaminated body site to clean site, between tasks on same patient, after removing gloves, before and after using the restroom, and before and after food preparation.  C. Review of Patient 1's Hospice Certification and Plan of Care for the certification period of 8/15/25 through 11/12/25 revealed orders for Skilled Nurse (SN) 2 times per week for 3 weeks, and 4 as needed visits for symptom management, patient/family support, complications related to disease condition.  D. Review of Patient 4's Hospice IDG Comprehensive Assessment and Plan of Care Update Report for the certification period of 7/17/25 through 9/12/25 revealed facility staff to provide cares including assistance with showering/bathing, activities of daily living (ADL's), personal cares, and hygiene. E. The observation of the provision of SN services on 8/27/25 at 10:30 AM by Staff-DD to Patient 1 revealed the SN failed to perform hand hygiene after completing a lower body assessment and prior to obtaining toothettes (sponge toothbrush) and completing oral cares to the patient.  F. The observation of the provision of morning cares on 8/26/25 at 8:20 AM by the inpatient certified nursing assistant (CNA) (Staff- R) to Patient 4 revealed the CNA failed to perform hand hygiene after completing a partial bath and toilet hygiene and prior to leaving the patient room, and prior to entering the community kitchen area to obtain a cup of coffee for Patient 4 from the community coffee machine. G. During an interview on 9/2/25 at 1:30 PM, the Inpatient Executive Director and the Inpatient Clinical Manager confirmed hospice staff failed to follow the hospice's policies for proper hand hygiene when providing cares to Patient 1 and 4.

Based on record review, policy and procedure review, and staff interview, the hospice failed to update the Hospice Aide (HA) Plan of Care (POC) with patient specific interventions and needs to ensure the hospice aide has all necessary information to provide care and services for 3 of 16 patients who receive HA services from the agency (Patient's 11, 16, and 19). The total sample size was 28. The Census was 77 (including 11 inpatient hospice patients and 66 branch patients). --- Findings are: A.   Review of the agency policy and procedure titled, 33.37 Aide and Homemaker Plan of Care, revised 8/10/22 revealed: 1. The Aide and Homemaker Plan of Care (POC) is a means to assess, plan, implement, evaluate, and coordinate all aspects of the patient's care give by the aide.2. The POC can be individualized to include special orders, requests, frequencies, and assistance needed.3. The POC was to be reviewed and updated at the beginning of every certification period and as needed with patient change in condition.4. Review and or changes to the POC are to be documented in the patient's medical record. 5. Was to be reviewed by the HA prior to each visit.  B. Review of Patient 11's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 8/20/25 through 11/17/25 included:  a.  Orders for hospice aide (HA) one time per week for one week, then two times per week for twelve weeks, the one time a week for one week to provide assistance with personal care, hygiene, and activities of daily living (ADL's).   b.  The patient is on 5 liters per minute of oxygen.  c.  The patient becomes dyspneic (short of breath- SOB) with minimal exertion.  d.  Needs fall precautions.  e.  Needs seizure precautions. 2.  A Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 8/27/25 revealed the patient has frequent falls, gets very SOB with any activity, can have behavioral and aggression with staff. 3. The Aide Care Plan Report (the POC) developed 8/20/25 did not include patient specific interventions or instructions for the HA to utilize for SOB, fall precautions, seizure precautions, oxygen use, and behavior management.  B Review of Patient 16's clinical record revealed:1. The Hospice Recertification and Plan of Care Update for the certification periods of 5/20/25 through 8/17/25 and 8/18/25 through 10/16/25 included orders for HA two times per week to provide assistance with personal care, hygiene, and ADL's.2.The Hospice IDG comprehensive Assessment and Plan of Care Update Report Update dated 5/28/25 revealed the patient had buttock/coccyx wounds with treatments in place. 3.The Hospice IDG comprehensive Assessment and Plan of Care Update Report Update dated 8/6/25 revealed the patient had buttock/coccyx wounds with treatments in place, wounds to bilateral heels, left lateral heel, and leg, heel protectors, floating heels to off-load feet, and a request for the caregiver to administer pain medication before bath, cares, or repositioning. 4.The Aide Care Plan Report (the POC) developed 2/20/25 did not include updated patient specific interventions or instructions for the HA to utilize for buttock/coccyx wounds, wounds to bilateral heels, left lateral heel, and leg, heel protectors, floating heels to off-load feet, and to verify the caregiver administered pain medication before bath, cares, or repositioning.  C. Review of Patient 19's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 7/22/24 through 10/19/24 included orders for HA one time a week for one week, the two times a week for twelve weeks provide assistance with personal care, hygiene, and ADL's.2.The Hospice IDG comprehensive Assessment and Plan of Care Update Report Update dated 10/2/24 revealed the patient has a nephrostomy tube (a thin catheter inserted directly into the kidney that drains urine into a bag) to his right side, a suprapubic catheter (a urinary catheter that is inserted directly into the bladder through a small incision in the lower abdomen to drain urine), unable to bear weight, a hoyer lift for transfers, and use of oxygen due to SOB with exertion. 3. The Aide Care Plan Report (the POC) developed 7/22/24 did not include updated patient specific interventions or instructions for the HA to utilize for the nephrostomy tube to his right side, a suprapubic catheter, inability to bear weight, a hoyer lift for transfers, and use of oxygen due to SOB with exertion. D. During an interview on 9/9/25 at 3:15 PM, the Administrator, the Market Director of Operations, and the Manager of Clinical Services confirmed the HA POC for Patient's 11, 16, and 19 were not updated with patient specific interventions and needs to ensure the hospice aide has all necessary information to provide care and services to the agency's hospice patients.

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure a Registered Nurse (RN) conducted an on-site visit at least every 14 days to the patient's home, for 4 of 16 patients reviewed (Patient 5, 16, 18, and 19), who received hospice aide (HA) services, to ensure the HA services meet the needs of the patient. The total sample size was 28. The census was 77 (including 11 inpatient hospice patients and 66 branch patients). --- Findings are:  A. Review of the agency policy and procedure titled 33.37 Aide and Homemaker Plan of Care, last revised 8/10/22, revealed the RN was to visit the patient's residence to supervise the aides at least every 14 days when aide services are provided. The visit was to include an assessment of the aide services, with or without the aide present.  B. Review of Patient 5's clinical records revealed:1. The Hospice Recertification and Plan of Care Update for the certification periods of 6/2/25 through 7/31/25 and  8/1/25 through 9/29/25 included orders for HA services two times per week for assistance with personal cares, hygiene, and activities of daily living (ADL's). 2.There was no documentation in the clinical record that a supervisory visit by an RN was conducted 6/1/25 through 6/16/25 and 6/18/25 through 9/2/25. C Review of Patient 16's clinical records revealed:1. The Hospice Recertification and Plan of Care Update for the certification periods of 5/20/25 through 8/17/25 and  8/18/25 through 10/16/25 included orders for HA services two times per week for assistance with personal cares, hygiene, and ADL's. 2. There was no documentation in the clinical record that a supervisory visit by an RN was conducted 6/1/25 through 9/10/25. D. Review of Patient 18's clinical records revealed:1.The Hospice Certification and Plan of Care for the certification period of 5/8/25 through 8/5/25 included orders for HA one time per week for thirteen weeks for assistance with personal cares, hygiene, and ADL's. 2. The Hospice Recertification and Plan of Care Update for the certification periods of 8/6/25 through 11/3/25 included orders for HA services  one time per week for assistance with personal cares, hygiene, and ADL's. 3. There was no documentation in the clinical record that a supervisory visit by an RN was conducted 6/1/25 through 7/1/25 and 7/3/25 through 7/29/25. E. Review of Patient 19's clinical records revealed:1. The Hospice Certification and Plan of Care for the certification period of 7/22/24 through 10/19/24 included orders for HA one time per week one week then 2 times a week for twelve weeks for assistance with personal cares, hygiene, and ADL's. 2. There was no documentation in the clinical record that a supervisory visit by an RN was conducted 7/24/24 through 8/8/24 and 8/16/24 through 9/24/24. F. During an interview on 9/9/25 at 3:15 PM, the Administrator, the Market Director of Operations, and the Manager of Clinical Services confirmed a RN did conducted an on-site visit at least every 14 days to the home of Patient 5, 16, 18, and 19 to ensure the HA services meet the needs of the patient.

Based on review of inpatient hospice policies and procedures, material safety data sheet (MSDS), inpatient hospice observations, and staff interviews, the inpatient hospice failed to ensure hazardous chemicals were stored in accordance with the MSDS and the inpatient hospice policies and procedures. The inpatient census was 11. --- Findings are:A. Review of the inpatient hospice policy titled Hazard Communication, revised 1/11/23, revealed the inpatient hospice is responsible for the proper use, storage and disposal of hazardous chemicals per the chemicals MSDS.B. Review of the inpatient hospice MSDS titled Virex TB Ready-To-Use-Disinfectant Cleaner, revised 7/31/24, revealed this disinfectant cleaner must be stored in a well-ventilated place and avoid inhalation and eye and skin exposure.C. Observation of the inpatient hospice dirty oxygen storage closet on 8/25/25 at 1:45 PM the following were identified:1. Two spray bottles labeled Virex Tb Redi-To-Use Disinfectant, one bottle containing 1/8th of the disinfectant and the second bottle containing 1/4th of the disinfectant.D. During staff interview on 8/27/25 at 11:30 AM, the Clinical Nurse Manager (CNM) revealed they were unaware of the two spray bottles containing the Virex TB Redi-To-Use Disinfectant located in the dirty oxygen storage closet. The CNM confirmed it is the expectation that all chemicals are locked up to ensure resident safety.

Based on review of inpatient hospice policies and procedures, inpatient hospice observations, and staff interviews, the inpatient hospice failed to have a process for storage and removal of used empty aluminum cans away from the inpatient hospice catering kitchen dry goods pantry.  This failed practice had the potential to affect all 11 patients on census at the inpatient hospice as well as any families, inpatient hospice staff and volunteers. --- Findings are:A. Review of the undated inpatient hospice policy titled Dietary Services, revealed the inpatient hospice is responsible to procure, store, prepare, distribute, and serve all food under sanitary conditions.B. Review of the undated inpatient hospice policy titled Utilization of Family and Common Area Kitchen Equipment, revealed inpatient hospice employees will oversee the kitchen for proper clean-up following food preparation.C. During observation of the inpatient hospice catering kitchen on 8/25/25 at 10:45 AM with the Clinical Nurse Manager, the following were identified on the floor of the pantry:1. Three large, clear trash bags containing used empty aluminum cans.D. During staff interview on 9/2/25 at 1:30 PM, the Executive Director revealed the three bags were placed there to be recycled at a later date. The Executive Director confirmed a process did not exist within the inpatient hospice policies for the storage and removal of recyclables.

Based on review of hospice house policies and procedures, facility observations, and staff interviews, the inpatient hospice failed to store food at the proper temperature in the catering kitchen. This failed practice had the potential to affect all 11 patients on census at the hospice house as well as any families, facility staff and volunteers utilizing the catering kitchen. --- Findings are: A. Review of the undated facility policy titled Dietary Services, revealed the inpatient hospice is responsible to procure, store, prepare, distribute, and serve all food under sanitary conditions and in accordance with the Food Code Neb. Rev. Stat. 81-2,244.01.B. Review of the undated inpatient hospice policy titled Utilization of Family and Common Area Kitchen Equipment, revealed hospice employees will oversee the kitchen and anyone using the kitchen is responsible for proper clean-up following food preparation.C. During observation of the inpatient hospice catering kitchen on 8/25/25 at 10:45 AM with the Clinical Nurse Manager, the following were identified:1. A bowl containing 12 packets of butter and 15 packets of whipped margarine, all of which were labeled individually with instructions to refrigerate, were at room temperature.  D. During staff interview on 9/2/25 at 1:30 PM, the Executive Director confirmed the inpatient hospice failed to refrigerate the packets of butter and whipped margarine.

Based on record review, policy and procedure review, and staff interview, the in-patient hospice failed to ensure intravenous (IV) medications were administered to 1 of 2 patients sampled, who received IV medications (Patient 3), in accordance with the requirements of Nebraska State Law at Title 175 NAC Chapter 16-006.11 Administration of Medications: The hospice must establish and implement policies and procedures to ensure patients receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and prevailing professional standards; and at 16-002: Five rights means getting the right drug to the right recipient in the right dosage by the right route at the right time. The total sample size 4. The census was 86 (16 in-patient and 70 multiple location patients). --- Findings are: A. Review of the agency policy and procedure titled, Medications, revised 2/2024, revealed medications were to be administered according to the five rights (a standards of practice which require the person administering medication to verify the right patient, the right drug, the right time, the right dose, and the right route prior to administering a medication). B. Review of Patient 3's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 2/9/24 through 5/8/24 included orders for: a. Amiodarone 450 milligrams (mg) / 250 milliliters (ml) (1.8 mg/ml) in dextrose 5 percent (%) intravenous solutions with instructions to infuse 360 mg/200 ml continuous infusion via the right intrajugular (IJ) central venous catheter (CVC) (is a long, flexible tube inserted into a vein in your neck, that leads to your vena cava, a large vein that empties into your heart) using the blue pigtail (a port on the catheter) at 33.3 ml/hour for heart rhythm. b. Lidocaine hydrochloride 20 mg/ml (2%) injection solution with instructions to give lidocaine 2 grams/250 ml continuous infusion through the right IJ CVC using the brown pigtail at 4.5 ml/hour for ventricular tachycardia (rapid irregular heart beat). 2. An untitled medication record sheet with information to nurses regarding the amiodarone. The notation informed the nurse that the amiodarone was set at a high flow rate and the (medication) bag would need to be replaced every shift as it administers over a 5- to- 6 hour time period. 3. A nurses note dated 2/10/24 at 03:20 AM. The Registered Nurse (RN) documented that a new lidocaine bag was hung (placed on the infusion pump used to administer the IV medication) at 03:05 AM. The same RN documented at 07:45 AM, when checking IVs with the day shift nurse it was discovered duplicate doses of lidocaine were being administered to the patient through both ports instead of one port with lidocaine and one port with amiodarone. C. During an interview on 2/26/24 at 2:45 PM, RN-E: 1. Was able to verbalize knowledge of the 5 rights of medication administration. 2. Confirmed [gender] did not follow the 5 rights of medication administration to ensure the right medication (amiodarone) was administered to Patient 3 on 2/10/24 at 3:05 AM. 3. Confirmed the wrong medication was administered to the patient at 3:05 AM on 2/10/24. D. During an interview on 2/15/24 at 2:45 PM, the in-patient Clinical Manager confirmed RN-E failed to follow the agency policy and procedure to follow the 5 rights of medication administration and failed to administer the correct medication to Patient 3 at 3:05 AM on 2/10/24.

Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the provision of all cares and services followed a physician approved written Plan of Car (POC) and failed to notify the patient's physician and/or Interdisciplinary team of the missed visits for 7 of 18 patient records reviewed (Patients 1, 5, 6, 10, 12, 13, and 14). The Census was 82 (including 20 inpatient hospice patients and 62 branch patients). Findings are: A. Review of the agency policy and procedure titled, The Hospice Plan of Care, revised 11/22/19, revealed services are furnished in accordance with a written POC. The policy also revealed that interim changes to the POC were to be documented by the Interdisciplinary Group (IDG) member instituting the change and was to be cosigned by the attending physician. B. Review of Patient 1's clinical record revealed: 1. The patient resided at the inpatient hospice residence and was admitted on 8/26/22. 2. The Resident Care Information form (inpatient plan of care) indicated the patient was to receive a sponge bath. 3. The Hospice House (inpatient residence) Aide Visit Report revealed the patient receive a shower instead of a sponge bath on 9/2/22 and 9/6/22. C. Review of Patient 5's clinical record revealed: 1. The updated Hospice Certification and Plan of Care for the certification period of 7/28/22 through 10/25/22 included orders for Medical Social Worker (MSW) 1 time per month for three months. 2. There was no documentation of a MSW visit conducted for the month of August 2022. 3. There was no documentation the MSW notified the patient's attending physician or the IDG of the missed visit for August. D. Review of Patient 6's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 5/31/22 through 8/28/22 included orders for Home Health Aide (HHA) services 1 time a week for 1 week, then 2 times a 2 week for 11 weeks, then 1 time a week for 1 week. 2. A HHA visit was conducted 7/28/22. There was no documentation of a second visit conducted the week of 7/24/22 - 7/30/22 (1 missed visit). 3.There was no documentation the patient's attending physician or the IDG of the missed visit. E. Review of Patient 10's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 5/21/22 through 7/19/22 included orders for HHA services 1 time a week for 8 week and Skilled Nursing (SN) services 2 times a week for 8 weeks, then 1 time a week for 1 week, and 3 as needed visits. 2. The Hospice Certification and Plan of Care for the certification period of 7/20/22 through 9/17/22 included orders for HHA services 1 time a week for 9 week and SN services 1 time a week for 1 week, then 2 times a week for 8 weeks, and 3 as needed visits. 3. There was no documentation that a HHA visit was conducted the weeks of 7/10/22 - 7/16/22 and 8/21/22 - 8/27/22 (2 weekly visits were missed). 4. A SN visit was conducted 7/6/22 and 7/13/22. There was no documentation of a second SN visit conducted the weeks of 7/3/22- 7/9/22 and 7/10/22- 7/16/22 (1 SN visit missed each week for 2 weeks). 5. There was no documentation the patient's attending physician or the IDG of the missed visits by the HHA and the SN. F. Review of Patient 12's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 6/3/22 through 8/1/22 included orders for HHA services 1 time a week for 8 week and SN services 1 time a week for 1 week, then 2 times a week for 8 weeks, then 1 time a week for 1 week, and 3 as needed visits. 2. The Hospice Certification and Plan of Care for the certification period of 8/2/22 through 9/30/22 included orders for HHA services 1 time a week for 9 week and SN services 1 time a week for 1 week, then 2 times a week for 8 weeks, and 3 as needed visits. 3. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report included orders for HHA services 2 times per week for 1 week, then 3 times per week 6 weeks beginning 8/14/22. 4. A SN visit was conducted 7/8/22, 7/198/22 and 9/12/22. There was no documentation a second visit was conducted the weeks of 7/3/22 - 7/9/22, 7/17/22 - 7/23/22, and 8/7/22 -8/13/22 (1 missed visit each week). 5. HHA visits were conducted 9/7/22 and 9/9/22. There was no documentation of a third visit conducted by the HHA the week of 9/4/22 - 9/10/22 (1 missed visit). 6. There was no documentation the patient's attending physician or the IDG of the missed visits by the HHA and the SN. G. Review of Patient 13's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 7/29/22 through 10/26/22 included orders for SN 2 times a week for 13 weeks then 1 time a week for 1 week, and 3 as needed visits. 2. A SN visit was conducted 9/8/22. There was no documentation of a second SN visit conducted the week of 9/4/22 - 9/10/22 (1 missed visit). 3. There was no documentation the patient's attending physician or the IDG of the missed visits by the SN. H. Review of Patient 14's clinical record revealed: 1. The Hospice Certification and Plan of Care for the certification period of 8/31/22 through 11/28/22 included orders for SN 2 times a week for 13 weeks and 3 as needed visits. 2. A SN visit was conducted 9/8/22. There was no documentation of a second SN visit conducted the week of 9/4/22 - 9/10/22 (1 missed visit). 3. There was no documentation the patient's attending physician or the IDG of the missed visits by the SN. I. During an interview on 9/21/22 at 1:40 PM, the Director of Hospice (DOH) confirmed the patients plan of care was not followed when the HHA provided a shower to Patient 1's and when visits were missed by the SN, MSW, and/or HHA as listed above for Patients 5, 6, 10, 12, 13, and 14. The DOH staff did not follow the agency policy and procedure to notify the patient's attending physician and the IDG when a missed visit occurred.

Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, Staff-H failed to follow the agency policy and procedures for proper hand hygiene, glove use, and bag technique when providing cares to Patient- 3. Four observations were conducted. The total sample size was 18. The Census was 82 (including 20 inpatient hospice patients and 62 branch patients). Findings are: A. Review of the agency policy and procedure titled, Hand Hygiene, revised 8/10/22, revealed hand hygiene was to be performed: 1. Using soap and water or an alcohol- based hand rub before and after direct patient contact even if the hands appear clean. 2. When visibly soiled. 3. Before re-entering the clinician's supply bag or handling clean supplies. 4. After removing gloves. B. Review of the agency policy and procedure titled, Bag Technique, revised 2/11/22 revealed hand hygiene was to be performed before entering or re-entering the clinicians supply bag. C. Review of Patient 3's clinical record revealed The Home Health Certification and Plan of Care for the certification period of 9/1/22 through 10/30/22 included orders for Skilled Nurse (SN) services 1 time per week for 1 week, then 2 times a week for 8 weeks, and 3 as needed visits. D. The observation of the provision of SN services on 9/13/22 at 11:00 AM by Staff-H to Patient 3 revealed the SN failed to perform hand hygiene after removing gloves after the completion of a head- to- toe assessment of the patient and prior to entering the clinician supply bag to remove a blood pressure cuff. E. An interview with the Clinical Manager on 9/13/22 at 11:00 AM, during the observation of the provision of cares confirmed the SN did not perform hand hygiene after removing gloves after the completion of a head- to- toe assessment of the patient and prior to entering the clinician supply bag to remove a blood pressure cuff. F. During an interview on 9/21/22 at 1:40 PM, the Director of Hospice confirmed the SN did not follow the agency policy and procedure for hand hygiene and bag technique when providing SN services to Patient 3.

Based on record review, policy and procedure review, observation of the provision of cares, and staff interview, the hospice failed to update the Hospice Aide (HHA) Plan of Care (POC) with patient specific interventions and needs to ensure the hospice aide has all necessary information to provide care and services for 5 of 15 patients who receive HHA services from the agency (Patient's 1, 2, 4, 7, and 15). The total sample size was 18. The Census was 82 (including 20 inpatient hospice patients and 62 branch patients). Findings are: A. Review of the agency policy and procedure titled, The Hospice and Homemaker Plan of Care, revised 8/10/22 revealed: 1. The HHA plan of care was to be completed at time of admission or start of service. 2. The POC can be individualized to include special orders, requests, frequencies, and assistance needed. 3. The POC was to be updated as needed. B. Review of the policy and procedure titled, Hospice Care for Nursing Facility Residents-Hospice Plan of Care, revised 12/7/21, revealed the Registered Nurse (RN) Case Manager (CM) was to establish and maintain a written plan of care in consultation with the facility representative. C. Review of Patient 1's clinical record revealed: 1. The Resident Care Information (Hospice aide POC for facility staff) dated 8/26/22 indicated the patient was to receive a sponge bath. 2. Documentation by the hospice aide revealed the patient received a shower on 9/2/22 and 9/6/22. 3. The POC was not updated to include the ability of the hospice aide to perform a shower and/or sponge bath. D. The observation of the provision of cares by the hospice aide to Patient 2 on 9/12/22 at 8:50 AM, revealed: 1. The hospice aide assisted the patient from a wheelchair, using 1 assist, and a gait belt, to ascend 3 steps to a mechanic chair lift for stairs and the same procedure to descend the steps after bathing services were provided. 2. The patient was able to maneuver and control the mechanical chair lift to ascend the remaining steps to the second- floor landing. 3. The patient's eyes closed, and the head rolled back while the patient was ascending the stairs in the mechanical lift (the patient's caregiver indicated these were signs the patient was about to begin a seizure). 4. The patient's caregiver administered lorazepam (used in this instance to prevent a seizure) when the patients eyes closed, and the head rolled back. E. Review of Patient 2's clinical record revealed the Aide Care Plan Report did not include patient specific interventions for ambulating steps, use of gait belt, or interventions to take in the case the patient shows signs and symptoms of the beginning of a seizure. F. The observation of the provision of cares by the hospice aide to Patient 4 on 9/14/22 at 10:00 AM, the patient was observed to be irritable and easily distracted and the hospice aide needed to provide frequent cueing, redirection, and reassurance to the patient. G. Review of Patient 4's clinical record revealed the Aide Care Plan Report did not include patient specific interventions to assist the hospice aide when the patient displays distractibility and irritability. H. Review of Patient 7's clinical record revealed: 1. The Hospice IDG (interdisciplinary group) Comprehensive Assessment and Plan of Care Update Report revealed a note by the registered nurse (RN) that the patient displayed "behaviors" with cares, especially when being provided a shower. 2. The Aide Care Plan Report did not include patient specific interventions for the hospice aide to utilize when the patient begins to display "behaviors". It also did not define the types of behaviors the patient displays when being provided a shower. I. Review of Patient 15's clinical record revealed the Reside Care Information sheet did not include interventions for personal cares, including the type of bath to be provided, assist level, or other personal care tasks. J. During an interview on 9/21/22 at 1:40 PM, the Director of Hospice confirmed the Aide Care Plan/ Resident Care Information sheets for the above listed patients did not include patient specific interventions for the hospice aide to follow while providing cares to the hospice patients.

Based on observation, review of policies and procedures, review of Material Safety Data Sheets (MSDS -adocument that contains information and instructions on hazardous materials present in the workplace. An MSDS contains details about hazards and risks relevant to the substance and requirements for its safe handling) and staff interview, the facility failed to ensure hazardous materials were stored in accordance with the MSDS recommendations and facility policy and procedure. Total sample size was 18 (including 5 inpatient and 13 branch patient's). The inpatient census was 20. This practice had the potential to affect the 20 hospice patients currently being cared for in the facility. Findings are: A. Review of the policy and procedure titled, Hospice House- The Josie Harper Residence Policies and Procedures, revised 3/22, revealed cleaning supplies used by housekeeping staff and all Hospice House staff members are to be maintained in locked cabinets and cupboards or in the environmental services locked cabinets. B. During the environmental tour with the facility Executive Director and Clinical Manager on 9/8/22 from 9:15 AM to 10:45 AM, the following chemicals were found unsecured: 1. A one-gallon bottle of Cen-Kleen Clean IV/One-step disinfectant, was found in the unlocked North Personal Care Room, sitting on the floor. 2. A 1-quart spray bottle of TB Quat (a ready to use, general-purpose cleaner and disinfectant) was found sitting on a shelf, in an unlocked room, used to store used oxygen equipment. C. The MSDS sheet for Cen-Kleen Clean IV/One-step disinfectant, no date indicated, revealed the disinfectant causes serious eye and skin irritation. The same form revealed the disinfectant was to be stored upright in a closed container and was to be locked up when stored. D. The MSDS for TB Quat revealed the user was to avoid contact with vapors, mists or spray and the use of eye protection was recommended, as was the use of protective clothing to prevent skin contact. E. During an interview on 9/8/22 from 9:15 AM to 10:45 AM, the hospice Executive Director confirmed Cen-Kleen Clean IV/ One-step disinfectant and TB Quat were to be stored in a locked/secured area as outlined in the facility policy and procedure.

Based on observations, review of policy and procedure, and staff interview the facility failed to store, prepare and distribute meals under sanitary conditions, from the kitchen area, located on the hallway for Rooms 1 to 16 to patients residing at the facility. Census was 20 and sample size was 18 (including 5 inpatient and 13 branch patient's). This practice had the potential to affect all patients residing at the facility. Findings are: A. Review of the policy and procedure titled, Hospice House- The Josie Harper Residence Policies and Procedures, revised 3/22, revealed: 1. Environmental Services are provided for several hours daily. 2. All staff and volunteer staff are expected to assist in keeping the house neat and clean. 3. Maintenance personnel are to attend to ongoing preventative maintenance and repair needs. B. During the environmental tour of the facility with the Executive Director and Nurse Manager on 9/8/22 from 9:15 AM to 10:45 AM, the following areas were identified in the food preparation/kitchen area on the hallway for Rooms 1 to 16: 1. The top of the food heating/cooling system had a build up of dust and food particles. 2. 3 of the ceiling tiles around the cold air return and the vent cover of the cold air return, had a buildup of black dust. 3. The fire sprinkler head near the cold air return vent was covered with cobwebs and dust. 4. A cloth covered basket that contained individual foil wrapped, pats of butter was sitting on the counter of the food preparation/ kitchen area and was not refrigerated. The cloth covering of the basket was stained and soiled. C. During an interview on 9/8/22 from 9:15 AM to 10:45 AM, the hospice Executive Director confirmed the areas identified in B1-4 needed cleaned and/or repaired, and the butter needed to be refrigerated to be maintained in a safe and sanitary condition.

Based on observation and interview, the facility failed to maintain exit path free of obstructions. This deficient practice would delay egress in the case of fire or other emergency which would affect approximately 10 occupants in 2 of 4 smoke compartments (North and Center). The facility has the capacity for 26 beds with a census of 24 on the day of survey. Findings are: Observations on 9-7-22 at 11:13 am revealed, patio table and chairs obstructed the exit path to the public way. During an interview on 9-7-22 at 11:13 am, Administration Staff A confirmed the table and chairs on the patio which obstructed the exit path. NFPA Standard: 2012 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, the facility failed to assure that fire sprinklers were free of foreign matter. This deficient practice would not allow the sprinkler system to activate as it was designed, and fire could spread outside of the room which would affect approximately 15 occupants in 1 of 4 smoke compartments (South). The facility has the capacity for 26 beds with a census of 24 on the day of survey. Findings are: Observation on 9-7-22 at 10:05 am revealed, the sprinkler in the soiled hold room was covered with a blue plastic. During an interview on 9-7-22 at 10:05 am, Administration Staff A confirmed the sprinkler had plastic attached to it.

Based on record review and interview, the facility failed to conduct receptacle testing for non-hospital grade outlets at resident care locations. These deficient practices would create electrical injury and fire hazards affecting all occupants 3 of 4 smoke compartments (North, South, East). The facility has a capacity of 26 and a census of 24 residents at the time of the survey. Findings are: Record review on 9-7-22 at 11:36 pm revealed: 1. Facility failed to provide testing documentation for non-hospital grade receptacles at resident care areas. During an interview on 9-7-22 at 12:36 pm, Administration Staff A confirmed the lack of current testing to non-hospital grade receptacles in resident rooms. NFPA Standard: NFPA 99, 2012, 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 2012 NFPA 99 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on documentation review and interview, the facility (prior to COVID) failed to provide documentation for all required weekly and monthly inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility which would affect all occupants. The facility has the capacity for 26 beds with a census of 24 on the day of survey. Findings are: Documentation review on 9-7-22 at 12:20 pm of the provided emergency generator maintenance log revealed: 1. The last fuel test provided was dated 1-13-2020 2. The last weekly inspection report was dated 3-15-2022 3. No time to transfer from normal power to generator power was provided on the monthly reports. 4. Facility failed provide a mathematical formula to assure 30 percent of the generator load was provided. 5. Facility failed to provide a yearly load bank test. During an interview on 9-7-22 at 12:20 pm, Administration Staff A confirmed the lack of generator documentation.