Every finding on record at Comfort Care Hospice & Healthcare Services LLC

Based on interview and record reviews, the agency failed to implement the agency’s emergency preparedness plan for developing individualized patient emergency plans for 15 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15) of 15 sampled patients reviewed for individualized emergency preparedness plan requirements Findings: --- Review of the agency’s Emergency Plan, with an approved date of 01/20/2026, revealed, in part, each patient would have a patient emergency preparedness plan (Patient Disaster Plan Identification Card-Tab 9) included as part of the comprehensive patient assessment which must be conducted at admission.  Review of the agency’s Patient Disaster Plan Identification Card (Tab 9) revealed the following information was required, in part, listing of required durable medical equipment, supplier name, pharmacy name, the number of persons needed to evacuate with the patient, the evacuation destination, and the alternate evacuation destination.  Review of Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15’s records revealed no evidence that the above mentioned individualized emergency plan had been implemented The agency presented no evidence of individualized emergency plans for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15 when asked on 06/04/2026 at 2:10PM and 2:30PM. In an interview on 06/04/2026 at 12:43PM, S1Administrator/Director of Nursing (DON) indicated the agency did not implement their emergency preparedness plan to ensure the Patient Disaster Plan Identification Card-Tab 9 was part of their comprehensive patient assessment which must be conducted at admission for the above-mentioned patients as required.

Based on interview and record reviews, the agency failed to ensure the chaplain completed the spiritual assessment within five calendar days of admission for 1 (Patient #14) of 15 sampled patients reviewed for comprehensive assessments requirements.  Findings: --- Review of Patient #14’s Hospice Interdisciplinary Plan of Care dated 03/27/2026 revealed, in part, Patient #14 had an admission date of 03/27/2026. Further review revealed Patient #14 required chaplain services.  Review of Patient #14’s record revealed no evidence of a chaplain initial assessment or evidence an initial chaplain assessment was attempted within 5 days of Patient #14’s admission date of 03/27/2026. In an interview on 06/04/2026 at 1:46PM, S1Administrator/Director of Nursing indicated the chaplains failed to ensure the initial spiritual assessment was attempted and/or completed within 5 days of admission.

Based on interviews and record reviews, the agency failed to ensure the chaplain communicated with the patient’s case manager regarding the patient’s request to discontinue chaplain services for 3 (Patient #4, Patient #6, Patient #12) of 15 sampled patients reviewed for coordination of care requirements.  Findings: --- Patient #4 Review of Patient #4’s Hospice Interdisciplinary Plan of Care dated 11/21/2025 revealed Patient #4 was to receive chaplain services once a month.  Review of Patient #4’s Updated Plan of Care from admission to 05/06/2026 revealed, in part, the interdisciplinary team was documenting chaplain services were required once a month.  In an interview on 06/04/2026 at 1:50PM, S1Administrator/Director of Nursing (DON) indicated Patient #4’s caregiver cancelled multiple home visits with the chaplain and ultimately decided to cancel all chaplain services. S1Administrator/DON further indicated the chaplain failed to communicate Patient #4 wanted to discontinue chaplain services to Patient #4’s case manager so chaplain services could be removed from Patient #4’s plan of care.   Patient #6Review of Patient #6’s Hospice Interdisciplinary Plan of Care dated 10/02/2025 revealed Patient #6 was to receive chaplain services once a month.  Review of Patient #6’s Updated Plan of Care from admission to 05/06/2026 revealed, in part, the interdisciplinary team was documenting chaplain services were required once a month. Review of Patient #6’s Interdisciplinary Group (IDG) Progress Note dated 02/20/2026 revealed, in part, Patient #6’s son requested hospice to stop chaplain services for now.  In an interview on 06/04/2026 at 1:33PM, S1Administrator/DON indicated the chaplain failed to communicate to Patient #6’s nurse case manager for the chaplain services to be removed from the plan of care.  Patient #12Review of Patient #12’s Hospice Interdisciplinary Plan of Care dated 10/01/2025 revealed Patient #12 was to receive chaplain services once a month. Review of Patient #12’s Updated Plan of Care from admission to 05/06/2026 revealed, in part, the interdisciplinary team was documenting chaplain services were required once a month. Review of Patient #12’s IDG Progress Note dated 10/04/2025 revealed, in part, Patient #12 declined chaplain services. In an interview on 06/04/2026 at 1:40PM, S1Administrator/DON indicated the chaplain failed to communicate Patient #12 wanted to discontinue chaplain services to Patient #12’s nurse case manager so chaplain services could be removed from Patient #12’s plan of care.

Based on observation, interviews, and record reviews, the agency failed to ensure the nurse followed infection control standards of practice during a patient’s wound care for 1 (Patient #1) of 1 sampled patients observed for wound care infection control requirements.  Findings: --- Review of the agency’s Personal Protective Equipment policy, with a revision date of January 2005, revealed, in part, disposable gloves would be removed and discarded after contact with each person, fluid item, surface, or when their ability to function as a barrier was compromised. Further review revealed the employee’s hands must be washed immediately after removal of gloves.  Review of Patient #1’s physician order dated 05/05/2026 revealed, in part, clean Patient #1’s sacral wound with normal saline or wound cleanser, apply zinc barrier cream to Patient #1’s sacral wound, and cover with a silicone foam dressing once a week and as needed.  Observation on 06/02/2026 at 9:06AM, revealed S2Assistant Director of Nursing (ADON) performed a patient assessment, repositioned Patient #1, and then removed the patient’s sacral wound dressing without removing gloves or performing hand hygiene. S2ADON then used the same gloves to assess the wound by using her left gloved finger to press on the wound, cleaned the wound, and then proceeded to apply zinc cream (medicated cream used to protect skin and promote healing). After completing wound care, S2ADON removed her gloves, performed hand hygiene, and applied a clean dressing. In an interview on 06/02/2026 at 9:30AM, S2ADON indicated she should have changed her gloves and performed hand hygiene after touching things in the environment, Patient #1, and between removing the soiled bandage, cleaning the wound, and prior to applying the zinc cream. In an interview on 06/02/2026 at 12:10PM, S1Administrator/Director of Nursing (DON) indicated S2ADON should have followed infection control standards of practice.

Based on interviews and record reviews, the agency failed to ensure a registered nurse measured wounds weekly to assess for the healing status of the wound for 2 (Patient #5, Patient #13) of  4 sampled  patients reviewed for weekly wound care measurements.  Findings: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Further review revealed comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Patient #5Review of Patient #5’s Nursing Note dated 05/07/2026 revealed, in part, Patient #5 was assessed with redness to Patient #5’s coccyx (area of the upper buttock) and a blister to the right lower extremity. Further review revealed no evidence of wound care measurements being obtained. Review of Patient #5’s Nursing Note dated 05/14/2026 revealed, in part, Patient #5 was assessed with a skin tear to the right shin. Further review revealed no evidence of wound care measurements being obtained. In an interview on 06/04/2026 at 1:30PM, S1Administrator/Director of Nursing indicated the agency was unable to locate documentation of the weekly wound care measurements were obtained for the above mentioned wounds for the above mentioned dates. Patient #13Review of Patient #13’s Nursing Note dated 06/25/2025 revealed scattered blisters to the right arm and bilateral (both) lower extremities. Further review revealed no evidence of wound care measurements being obtained. Review of Patient #13’s Nursing Note dated 06/30/2025 revealed scattered blisters to the right arm and bilateral (both) lower extremities. Further review revealed no evidence of wound care measurements being obtained. Review of Patient #13’s Nursing Note dated 07/09/2025 revealed scattered blisters to the right arm and bilateral (both) lower extremities and a skin tear to Patient #13’s penis. Further review revealed no evidence of wound care measurements being obtained. In an interview on 06/04/2026 at 1:42PM, S2Assistant Director of Nursing (ADON) indicated she did not realize all wounds needed to be measured weekly, and was under the understanding a registered nurse only had to measure pressure ulcers weekly. S2ADON further indicated Patient #13’s blisters and skin tear were not measured weekly, as required.

Based on record review and interview the agency failed to have an agency based and community-based risk assessment utilizing an all-hazards approach. Findings: --- Review of the agencys Emergency Preparedness Plan revealed no documented evidence and the agency presented no documented evidence of an all-hazard vulnerability assessment having been completed by the agency. In an interview on 06/08/2023 at 11:07 a.m., S2Co-Owner/Licensed Practical Nurse stated he was in charge of emergency preparedness and the agency could not present an all hazard vulnerability assessment having been completed.

Based on record review and interview the agency failed to have a documented system on how the agency would track patients and staff in the field. Findings: --- Review of the agencys Emergency Preparedness Plan revealed patients and staff in the office or field will be tracked (insert method of tracking, such as typed list, tracking program, etc.). Further review revealed no documented evidence and the agency presented no documented evidence of the method used to track the patients and staff. In an interview on 06/08/2023 at 11:18 a.m., S1Administrator/Director of Nursing stated the agency had no documentation of the method used to track patients and staff.

Based on record review and interview the agency failed to have documented evidence staff had been trained on the agencys Emergency Preparedness Plan. Findings: --- Review of the agencys Emergency Preparedness Plan and staff Personnel Files revealed no documented evidence and the agency presented no documented evidence of the agency had provided training to the staff on the agencys Emergency Preparedness Plan. In an interview on 06/08/2023 at 11:18 a.m., S1Administrator/Director of Nursing stated the agency had no documentation the agency staff had completed training on the agencys Emergency Preparedness Plan.

Based on record review and interview the agency failed to participate in a full scale exercise or actual event which tested the agencys emergency preparedness plan. Findings: --- Review of the agencys Emergency Preparedness Plan revealed no documented evidence and the provider presented no documented evidence of activation or a full scale exercise having been completed to test the agencys Emergency Preparedness Plan. In an interview on 06/08/2023 at 11:07 a.m., S2Co-Owner/Licensed Practical Nurse stated he was in charge of emergency preparedness and the agency had not activated the emergency preparedness plan nor did the agency have documentation a full scale exercise had been completed to present to the surveyor.

Based on record review and interview the agency failed to ensure an initial bereavement assessment was completed for 1 (Patient #4) of 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) sampled patients reviewed for initial bereavement assessments. Findings: --- Review of Patient #4s record revealed Patient #4 was admitted to the agency on 05/17/2023. Further review revealed Patient #4 was being provided hospice services while a patient at a long-term care facility. Review of Patient #4s Initial Psychosocial Assessment dated 05/20/2023 revealed, in part, Patient #4 had no family for bereavement services. Review of Patient #4s record revealed no documented evidence and the agency presented no documented evidence of the agency having conducted an initial bereavement assessment with the long-term care facility staff in the absence of family. In an interview on 06/08/2023 at 4:00 p.m., S1Administrator/Director of Nursing stated the social worker did not complete the initial bereavement assessment due to Patient #4 not having family; however, per the regulations and the facility contract bereavement was to be offered to facility staff. S1Administrator/Director of Nursing stated the social worker should have completed the initial bereavement assessment with the facility staff.

Based on observation, record review, and interview the agency failed to ensure the hospice aide: 1. Applied a barrier under her bag (S6Hospice Aide (HA)); and, 2. Removed her gloves and washed her hands after touching items in the patients environment, prior to initiating Patient #2s bed bath, after providing perineal care, and prior to bathing Patient #2s back for 1 (S6HA) of 3 (S1Administrator/Director of Nursing, S3Medical Social Worker, and S6HA) sampled employees observed during home visits. Findings: --- Review of the agencys Standard Precautions Policy and Procedure revealed, in part, hands should be washed with soap and warm water immediately and thoroughly before and after patient contact. Observation on 06/07/2023 at 8:25 a.m. revealed S6HA entered Patient #2s room and placed her workbag with supplies on Patient #2s dresser without placing a barrier under her workbag. S6HA entered Patient #2s bathroom and washed her hands, then applied gloves and proceeded to set up her soiled linen bag, linen on the over the bed table, then S6HA took two wash basins to the bathroom and filled the basins with water. Observation revealed S6HA did not remove gloves or perform hand hygiene after touching the linen bag, touching the faucets in the bathroom, touching the basins, and prior to starting Patient #2s bed bath. Observation during Patient #2s bed bath revealed after S6HA had washed Patient #2s legs and feet, S6HA wiped her left hand on the soiled bed linen. Observation revealed S6HA continued to bath Patient #2 without removing her gloves or performing hand hygiene, cleaned Patient #2s groin, perineal area, and buttock. Further observation revealed S6HA did not perform hand hygiene or change gloves after cleaning Patient #2s perineal area and then bathed Patient #2s back. In an interview on 06/07/2023 at 3:53 p.m., S6HA stated she should have used a barrier under her work bag. S6HA further stated she should have changed her gloves and performed hand hygiene after touching items in the environment and prior to starting the bath, and she should have changed gloves and performed hand hygiene after completing perineal care. In an interview on 06/07/2023 at 4:15 p.m., S1Administrator/Director of Nursing confirmed the above observations were breaches in infection control standards of practice.

Based on record review and interview the agency failed to ensure the registered nurse measured pressure ulcers weekly per professional standards for 4 (Patient #4, Patient #5, Patient #12, and Patient #14) of 4 (Patient #4, Patient #5, Patient #12, and Patient #14) sampled patients with pressure ulcers. Findings: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #4 Review of Patient #4s Skin Impairment Assessment dated 05/17/2023 revealed, in part, the following wounds were present without any measurements documented, in part: left hip unstageable (wound which due to necrotic (dead) tissue the depth of the wound was unable to be visualized) pressure ulcer; left great toe deep tissue pressure injury (pressure wound which has bruised appearance in which the final depth was unable to be determined); left third toe deep tissue pressure injury; left great distal (end of toe) toe deep tissue pressure injury; left lateral foot deep tissue pressure injury; right buttock deep tissue pressure injury; left buttock deep tissue pressure injury; and sacral deep tissue pressure injury. Review of Patient #4s Nursing Note dated 05/22/2023 revealed the area of wounds waere documented as see narrative. Further review revealed the narrative listed the locations and treatments of the wounds, and documented the nursing facility was providing wound care; however no documentation of the assessment of the wounds by the hospice nurse was documented. Patient #5 Review of Patient #5s Progress Note for skilled nurse visit dated 05/22/2023 revealed, in part, deep tissue pressure injury noted to left heel. Further review revealed no documented evidence and the agency presented no documented evidence of an assessment of Patient #5s left heel wound having been completed. Review of Patient #5s Nursing Note dated 05/24/2023 revealed, in part, blister open and draining to left hip. Review revealed no measurement of the left hip wound, or description of the wound tissue or type of drainage documented. Further review revealed no documented evidence and the agency presented no documented evidence of the left heel wound had been assessed on the visit. Patient #12 Review of Patient #12s Skin Impairment Assessment dated 06/25/2021 revealed Patient #12 was admitted with a stage II (wound which is open exposed the second layer of skin) pressure ulcer to the left buttock measuring 1.5 centimeters (cm) by 1.7cm by 0.1cm; and an unstageable pressure ulcer to the left medial foot measuring 1cm by 1.5cm by 0.1cm. Review of Patient #12s Nurses Notes from 06/25/2021 through 02/22/2022 revealed no documented evidence and the agency presented no documented evidence of measurements having been obtained on Patient #12s left buttock and left medial foot pressure ulcers. Review of Patient #12s Nursing Note dated 03/02/2022 revealed a stage II pressure ulcers to Patient #12s right and left buttock. Further review revealed no documented evidence and the agency presented no documented evidence of measurements having been obtained on Patient #12s left buttock and right buttock pressure ulcers. Review of Patient #12s Nursing Note dated 03/08/2022 revealed a wound to Patient #12s sacral area with no documented evidence and the agency presented no documented evidence of an assessment of Patient #12s sacral wound, nor an assessment of Patient #12s left and right buttock wounds. Review of Patient #12s Nursing Note dated 03/15/2022 revealed wounds to Patient #12s left and right buttock with no documented evidence and the agency presented no documented evidence wound care measurements having been obtained. Further review revealed no documented evidence and the agency presented no documented evidence of the sacral wound having been assessed. Review of Patient #12s Nursing Note dated 03/21/2022 revealed a wound to Patient #12s sacral area with no documented evidence and the agency presented no documented evidence of an assessment of Patient #12s sacral wound, nor an assessment of Patient #12s left and right buttock wounds. Review of Patient #12s Nursing Note dated 03/23/2022 revealed wounds to Patient #12s left and right buttock with no documented evidence and the agency presented no documented evidence wound care measurements having been obtained. Further review revealed no documented evidence and the agency presented no documented evidence of the sacral wound having been assessed. Patient #14 Review of Patient #14s Nurses Notes dated 02/02/2023, 02/10/2023, 02/16/2023, 02/21/2023, 02/23/2023, 02/28/2023, 03/03/2023, 03/07/023, 03/16/2023, 03/23/2023, 03/28/2023, 04/03/2023, and 05/03/2023 revealed the presence of a stage IV (pressure ulcer with the bone exposed when at the wounds deepest stage) to the upper back. Further review revealed no documented evidence and the agency presented no documented evidence of the wound had weekly wound care measurements to determine the healing status of the wounds. In an interview on 06/08/2023 at 4:00 p.m., S1Administrator/Director of Nursing (DON) stated the agency did not have documented evidence of the agencys nurses had assessed and measured the wounds weekly per professional standards.

Based on record review and interview the agency failed to ensure the hospice aide notified the registered nurse when a patient had not had a bowel movement for more than 3 days for 1 (Resident #3) of 6 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #6, and Patient #8) sampled patients who received hospice aide services reviewed for hospice aide notification to the nurse. Findings: --- Review of Patient #3s Nursing Assistant Plan of Care dated 10/27/2022 revealed Patient #3 was to receive hospice aide services three times a week. Further review revealed the hospice aide was to check for a bowel movement every visit. Review of Patient #3s Certified Nursing Assistant (CNA) Note dated 04/19/2023, 04/21/2023, and 04/24/2023 revealed all three notes had the date of Patient #3s last bowel movement documented as 04/17/2023. Further review revealed no documented evidence and the agency presented no documented evidence of the hospice aide had notified the nurse when Patient #3 had not had a bowel movement within 3 days. In an interview on 06/08/2023 at 3:50 p.m., S1Administrator/Director of Nursing (DON) stated the hospice aide did not notify the nurse of no bowel movement after 3 days. S1Administrator/DON further stated the hospice aide should notify the nurse if a patient does not have a bowel movement within 3 days so the registered nurse can obtain orders to assist with the constipation.

Based on record review and interview the agency failed to ensure the registered nurse completed a supervisory visit on the hospice aide every 14 days for 1 (Patient #6) of 6 (Patient #1, Patient #2, Patient #3, Patient #5, Patient #6, and Patient #8) sampled patients who received hospice aide services. Findings: --- Review of Patient #6s Updated Plan of Care dated 04/05/2023, 04/19/2023, and 05/03/2023 revealed Patient #6 was to receive hospice aide services twice a week. Review of Patient #6s record revealed Patient #6 received hospice aide services twice a week for weeks of 04/17/2023 to 04/23/2023, 04/24/2023 to 04/30/2023, 05/01/2023 to 05/07/2023, 05/08/2023 to 05/14/2023, and 05/15/2023 to 05/21/2023. Review revealed the only registered nurse supervisory hospice aide visits were completed on 04/13/2023 and 05/22/2023, which were 39 days apart. Further review revealed no documented evidence and the agency presented no evidence of hospice aide supervision having been completed by the registered nurse every 14 days. In an interview on 06/08/2023 at 4:26 p.m., S1Administrator/Director of Nursing stated the hospice aide supervision was not completed every 14 days for Patient #6 per regulation.