Every finding on record at Cozy Comfort Care Hospice, Inc.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive from hospice. During RRD/C#1 it was noted lack of a signed Notice of Non Medicare Coverage (NOMNC) when the patient was discharged for an extended prognosis. This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRD/C#1 it was noted the area on the consent of the right to choose an attending physician was blank. This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRBR#3 it was noted lack of an initial bereavement assessment documented in the patient record. This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRD/C#1 it was noted during the initial RN assessment lack of documentation of the need for volunteer services to offer support or respite to the patient, family, or other caregivers. The section of the record to document if volunteer services were needed was blank. This was reviewed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV#2 it was noted through 3 certification periods there was lack of documented progress toward goals. The problems and goals remain documented as pending. The POC goals were established during the initial comprehensive assessment in January 2026 and have remained the same as of the most recent recertification in May 2026. This was discussed with the Administrator.

Observed in Record Review. In 12 of 14 patient records reviewed, It was noted throughout the review of patient records goals did not contain specific, individualized information with outcome time frames to assist staff in determining if the patient was progressing toward achieving their goals. During RRD/C#1 it was noted the following: goals for the MSW: Complement added resources and support, as needed, Pt/Family/PCG will have mortuary plan in place (without an outcome date to assess if achieved), Spiritual Counselor (SC) goals: Pt/ Family/PCG will freely verbalize spiritual needs and concerns. SN goals: Blood glucose levels will remain within hospice comfort parameters, Caregiver will verbalize understanding of simplified diabetic management for comfort care, appetite and intake will be monitored to guide insulin administration, Reduce discomfort. During RRD/C#2 it was noted the following goals that were not measurable or individualized: Pt needs will be met on a day to day basis as communicated. Will minimize episodes of confusion and forgetfulness, Patient will verbalize or demonstrate adequate pain control, Patient will remain comfortable at rest, Patient will tolerate movement with minimal pain, Patient will experience decreased localized pain, Patient will achieve improved sleep quality, Patient will fall asleep with minimal difficulty. During RRBR#2 it was noted the goals were not individualized as follows: goals: Achieve and maintain peripheral circulation for Pt comfort. The following goals were documented to be accomplished by the end of the certification in 90 days: Pt/Family/PCG will verbalize understanding of increased risk of fall. Pt/Family/PCG will verbalize understanding of safety intervention. During RRBR#3 it was noted goals without individualized outcome measures as follows: Pt needs will be met on a day to day basis as communicated. -Patient will have adequate sleep. Be able to cope with changes, Pt will have adequate food and fluids as tolerated or desired. Pt will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication. Patient will have adequate sleep, facilitate a spiritual environment to begin the bereavement process -Healing road to peace. During RRBR#1 it was noted some goals established were not measurable with identified outcome dates as follows: goals: Facilitate bowel movement, Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. Minimize complications due impaired mobility. The MSW goals as follows were to be accomplished as documented with the target date, six months after the POC was documented as follows: Complement added resources and support, as needed, Pt and Family to be learned on progression of illness, dying process and grieving, Pt/Family/PCG will exhibit functional coping skills, Pt/Family/PCG will express feeling of grief / loss, Pt/Family/PCG will receive emotional support to adequately cope with illness and death, Pt/Family/PCG will remain adequately informed of palliative/comfort care, Pt/Family/PCG will increase socialization/access support system to improve quality of life, Reduce emotional pain and suffering of anticipated loss, Family will verbalize feelings of grief, loss, anticipatory bereavement and other emotions related pt. transition. During RRNHV#2 it was noted goals that were not measurable or individualized as follows: Facilitate bowel elimination and comfort, Facilitate bowel movement, Patient`s bowel movements will be regular and normal, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, Pt needs will be met on a day to day basis as communicated. During RRHV#3 it was noted goals that were not individualized or measurable with identified outcome dates as follows: Facilitate bowel elimination and comfort, facilitate bowel movement bowel movements will be regular and normal, maintain mobility and independence, minimize complications due impaired mobility, increase strength/energy for functional activities. Spiritual care needs will be met at an acceptable level and evaluated every 14 days. During RRNHV#2 it was noted the following goals that were not individualized or measurable as follows: facilitate bowel elimination and comfort, facilitate bowel movement, patient`s bowel movements will be regular and normal, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, treatment will be provided as ordered for the next 30 days ,pt. needs will be met on a day to day basis as communicated. During RRNHV#3 it was noted goals that were not individualized as follows: treatment will be provided as ordered over the next 30 days, Spiritual care needs will be met at an acceptable level and evaluated every 14 days, comprehensive spiritual assessment will be completed and implemented into plan of care within 5 days of admission, achieve and maintain peripheral circulation for Pt comfort. During RRNHV#3-6 it was noted the same goals were documented and were not individualized and not measurable as follows: facilitate bowel elimination and comfort, facilitate bowel movement, Pt/Family/PCG will verbalize having elimination needs met at an acceptable level, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, Increase strength/energy for functional activities, Pt needs will be met on a day to day basis as communicated, will minimize episodes of confusion and forgetfulness. This was discussed with the Administrator.

Observed in Record Review. In 5 of 14 patient records reviewed, During RRD/C#2 it was noted on the RN initial assessment the patient was at a high risk for falls and skin breakdown. Interventions for fall prevention and skin breakdown prevention were not added to the POC. There was lack of interventions for the MSW and the SC with frequency of visits for both that were documented as initial, recertification, +2 PRN. During RRBR#1 and RRBR#3 it was noted lack of an order changing the level of care from routine to continuous care (CC) and lack of interventions reflecting the change to the POC that the patients were imminently terminal. During RRBR#1 it was noted lack of SC interventions on the POC. During RRNHV#2 it was noted at the IDG meeting the beginning of May 2026 documentation that the patient is Possible transitioning,no oral intake for 2-3 days, no medications, semi responsive, eyes open but staring at nothing, rapidly declining. The POC lacked an update to include interventions related to the change in the patient condition. During RRHV#1 it was noted the patient pulled out her foley catheter with an order to leave the catheter out the middle of April 2026. The POC was not updated to reflect the change in the GU status.This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV#1 it was noted the frequency for the MSW and SC included PRN visits per certification. The frequency lacked the number of PRN visits/cert approved by the IDG. This was discussed with the Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, During RRD/C#2 it was noted lack of physician orders to drain a pleural catheter, perform dressing changes around the pleural catheter insertion site and dressing change orders for wound care to the patient's left forearm. In addition, there was lack of other interventions including assessment of the pleural catheter site and assessment of wound healing. During RRNHV#3 it was noted the patient was prescribed Eliquis 5mg daily. Interventions on bleeding precautions and S/S bleeding were not added to the POC. During RRNHV#4 it was noted wound care to multiple sites was being documented as Cont with wound tx. There was lack of physician orders for wound care for each wound site. This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV#1 it was noted the following order for wound care the middle of March 2026:Skin tear left FA: Cleanse w/ Wound cleanser, pat dry, apply triple antibiotic ointment, cover w/ telfa island dressing every SN visit and PRN x30 days. There was lack of documentation by the SN that the wound care was performed on the first 2 visits in April 2026. The documentation of the wound status during those 2 visits was skin tear mild. This was discussed with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRBR#1 and RRBR#3 it was noted the patient level of care was changed to continuous care (CC). There was lack of documentation of collaboration in the care of the patient and coordination in efforts to support the goals outlined in the plan of care. There was no evidence that the RN communicated the needs of the patient with the LVN who was assigned to provide the CC. This was discussed with the Administrator.

Observed in Record Review. In 3 of 13 patient records reviewed, who received hospice aide visits. During RRHV#3 it was noted the aide assignment form lacked information on the presence of a large sacral pressure ulcer dressing on the patient's sacrum with direction to the aide on notifying the RN if the dressing is dislodged or wet. During RRD/C#2 it was noted the aide assignment form lacked information on the presence of a pleural catheter with direction to the aide of the presence of the catheter, care to avoid dislodging the catheter and to notify the RN if the dressing around the catheter is not secure. During RRNHV#6 it was noted the patient had multiple lesions and necrotic areas on the right foot. The aide assignment form stated the bath type was shower chair. There was lack of documentation on the aide assignment form of the skin lesions and necrotic areas on the right foot that provided direction to the aide on personal care bathing on a shower chair. This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV#2 it was noted hypothyroidism was identified as a problem on the POC with interventions and goals that did not reflect the patient's treatment. The initial RN assessment medication profile lacked medications ordered for hypothyroidism and it was not listed as a comorbidity in the medical record. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients who were discharged alive from hospice. During RRD/C#2 it was noted the patient was transferred to a hospital per family request. There was lack of documentation that a transfer/discharge summary was sent to the facility where the patient was admitted. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients discharged alive from hospice. During RRD/C#1 it was noted a discharge summary in the patient record lacked documentation that it was sent to the patient's attending physician. This was discussed with the Administrator.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization did not conduct and document the assessment of anticipated discharge needs: bereavement care or survivor risk factors. Identified in the review of HV#1, and RR#3, there was no evidence that the initial bereavement assessment was completed. This was reviewed and validated with the CEO/Administrator.

Observed in Record Review. In 6 of 6 Plans of Care, the organization did not include a statement of the scope and frequency of the services necessary to meet the patients' needs. For example, in the review of all 6 patient records it was identified that as needed visits (PRN) did not include the details/reasons of what constitutes a need for a PRN visit. In HV#1 frequencies of visits were MSW 1 per month and 3 PRN; Spiritual Care 1 per month and 3 PRN; Skilled Nurse 1 per week and 3 PRN. In HV#2 frequencies of visits were RN 1 per week and 3 PRN; Spiritual Care 1 as needed and recertification. In HV#3 frequencies were Skilled Nurse 1 per week and 3 PRN; Spiritual Care 1 as needed and recertification. In RR#1 frequencies were Skilled Nurse 1 per week and 3 PRN; Spiritual Care 1 as needed and recertification. In RR#2 frequencies were Skilled Nurse 1 per week and 3 PRN; Spiritual Care as needed and recertification. In RR#3 frequencies were Skilled Nurse 1 per week and 3 PRN; Spiritual Care 1 as needed and recertification. This was reviewed and validated with the CEO/Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted standard precautions were not used to reduce the risk of infection in accordance with organizational policies No. 9-0091,2 Hand Hygiene, and No. 9-014.1,2 Bag Technique. For example, observed in HV#1, the Licensed Vocational Nurse (LVN) did not perform hand hygiene prior to entering the nurse bag to retrieve the reusable medical equipment, and prior to donning gloves. She also did not perform hand hygiene after doffing and donning gloves several times during the course of the patient's assessment, and prior to cleaning the reusable medical equipment. Observed in HV#3, the same LVN did not perform hand hygiene after doffing gloves following the completion of the patient's assessment and prior to cleaning the reusable medical equipment. This was observed in the presence of the Administrator.