Every finding on record at Grace Healthcare Services, LLC

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure confidentiality of clinical records was maintained as indicated in facility policy in 1 of 27 medical records reviewed (Patient (P)20), and affected the information of ten patients (P28, P29, P30, P31, P32, P33, P34, P35, P36, and P37). --- Findings include:Undated facility policy titled, “Patient Rights and Responsibilities”, states, “…Procedures: … 3. The notice of the patient’s rights and responsibilities includes, but is not limited to, the patient’s right: … g. to confidentiality of protected health information [such as patient names, date of admission, and date of death]…”On 01/29/26 a review of P20’s medical record was conducted and revealed the following:The “Episode Attachments” section of P20’s Electronic Medical Record (EMR) contained a file titled “382 Forms." The file contained eight documents titled “The State of New Jersey Department of Human Services Division of Medical Assistance and Helth [sic] Services Physician’s Certification/Recertification for Hospice Benefits” which included patient name and benefit period dates for P20, P28, P29, P30, P31, P32, P33, and P37. The file also contained three documents titled, “State of New Jersey Department of Human Services Division of Medical Assistance and Health Services Termination of Hospice Benefits,” which included patient name and date of death for P34, P35, and P36.On 01/29/26 at 1:40 PM, an interview was conducted with Staff (S)5. S5 confirmed the documents containing patient names, benefit period dates, and/or date of death for P28, P29, P30, P31, P32, P33, P34, P35, P36, and P37 should not have been included in P20’s medical record. S5 stated he/she was unaware of this issue or how it occurred.

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure all patients receive clinician visits in accordance with physician orders in 12 of 20 active medical records reviewed (Patient (P) 3, P4, P6, P7, P8, P10, P11, P14, P17, P18, P19, and P20). --- A review of P18's medical record was conducted and revealed the following:P18’s Plan of Care Orders for the certification period beginning 12/10/25 contained a physician order for the SN [Skilled Nurse] as "… Calendar Frequency: ... SN Effective 12/10/25 1WK9 [one visits a week for nine weeks] …"For the week of 12/10/25 through 12/13/25, P18’s medical record lacked evidence that P18 received an SN visit as per order and that a physician order and communication note were entered. Findings include:Facility document titled, "Protocol for Missed Visits," dated 11/17/22, stated, "… If a visit is missed a physician order needs to be entered for the missed visit. A communication note should be entered to explain efforts made to complete the scheduled visit …"  A review of P3's medical record was conducted and revealed the following:P3’s Plan of Care Orders for the certification period beginning 01/08/26 contained a physician order for the Home Health Aide (HHA) as "… Calendar Frequency: ... HHA Effective 01/08/2026 1-3WK1 [one to three visits a week for one week], 5-7WK8 [five to seven visits a week for eight weeks] …"For the week of 01/11/26 through 01/17/26 and 01/18/26 through 01/24/26, P3’s medical record lacked evidence that P3 received HHA visits as per order and that a physician order and communication note was entered.A review of P4's medical record was conducted and revealed the following:P4’s Plan of Care Orders for the certification period beginning 11/20/25 contained a physician order for the Skilled Nurse (SN) and Master of Social Work (MSW) as "… Calendar Frequency: SN Effective 11/20/2025 1EVERY2WK2 [one visit every two weeks for two weeks], 1WK12 [one visit a week for 12 weeks] ... MSW Effective 11/20/2025 1M1 [one visit a month for one month] …" For the week of 11/23/25 through 11/29/25, 12/07/25 through 12/13/25, and 12/21/25 through 12/27/25, P4’s medical record lacked evidence that P4 received a SN visit as per order and that a physician order and communication note was entered.For the month of 11/20/25 through 12/20/25, P4’s medical record lacked evidence that P4 received a MSW visit as per order and that a physician order and communication note was entered.A review of P6's medical record was conducted and revealed the following:P6’s Plan of Care Orders for the certification period beginning 12/10/25 contained a physician order for the HHA as "… Frequency/Duration of Visits: ... HHA [Effective 12/10/2025] 2-4WK1 [two to four visits a week for one week] …"For the week of 12/10/25 through 12/13/25, P6’s medical record lacked evidence that P6 received HHA visits as per order and that a physician order and communication note was entered.A review of P7's medical record was conducted and revealed the following:P7’s Plan of Care Orders for the certification period beginning 10/10/25 contained a physician order for the HHA as "… Frequency/Duration of Visits: ... HHA Effective 10/12/2025 3-5WK12 [three to five visits a week for 12 weeks] …"For the week of 10/12/25 through 10/18/25, P3’s medical record lacked evidence that P3 received HHA visits as per order and that a physician order and communication note was entered.A review of P8's medical record was conducted and revealed the following:P8’s Plan of Care Orders for the certification period beginning 12/05/25 contained a physician order for the HHA as "… Frequency/Duration of Visits: ... HHA [Effective 12/05/2025] 1WK1 [one visit a week for one week] …"For the week of 12/05/25 through 12/06/25, P8’s medical record lacked evidence that P8 received a HHA visit as per order and that a physician order and communication note was entered.A review of P10's medical record was conducted and revealed the following:P10’s Plan of Care Orders for the certification period beginning 01/03/26 contained a physician order for the HHA as "… Frequency/Duration of Visits: ... HHA Effective 01/04/2026 3-5WK12 [three to five visits a week for 12 weeks] …"For the week of 01/04/26 through 01/10/26 and 01/18/26 through 01/24/26, P10’s medical record lacked evidence that P10 received HHA visits as per order and that a physician order and communication note was entered.A review of P11's medical record was conducted and revealed the following:P11’s Plan of Care Orders for the certification period beginning 10/14/25 contained a physician order for the Chaplin (CH) as "… Calendar Frequency: ... CH Effective 10/14/2025 1-3M1 [one to three visits a month for one month] …"For the month of 10/14/25 through 11/15/25, P11’s medical record lacked evidence that P11 received a CH visit as per order and that a physician order and communication note was entered.P14’s Plan of Care Orders for the certification period beginning 11/20/25 contained a physician order for the SN and HHA as "… Frequency/Duration of Visits: SN [Effective 11/20/2025] 1WK13 [one visit a week for 13 weeks] … HHA [Effective 11/20/2025] 1-3WK1 [one to three visits a week for one week], 5-7WK12 [five to seven visits a week for 12 weeks] …" For the week of 12/21/25 through 12/27/25, P14’s medical record lacked evidence that P14 received a SN visit as per order and that a physician order and communication note was entered.For the week of 12/28/25 through 01/03/26, 01/04/26 through 01/10/26, and 01/11/26 through 01/17/26, P14’s medical record lacked evidence that P14 received HHA visits as per order and that a physician order and communication note was entered.P17’s Plan of Care Orders for the certification period beginning 12/16/25 contained a physician order for the SN, HHA, and CH as "… Calendar Frequency: SN Effective 12/16/2025 1EVERY2WK2 [one visit every two weeks for two weeks], 1WK11 [one visit a week for 11 weeks] ... HHA Effective 12/16/2025 2-4WK1 [two to four visits a week for one week], 3-5WK12 [three to five visits a week for 12 weeks] CH Effective 12/16/2025 1M1 [one visit a month for one month] …" For the week of 01/11/26 through 01/17/26 and 01/18/26 through 01/24/26, P17’s medical record lacked evidence that P17 received a SN visit as per order and that a physician order and communication note was entered.For the week of 01/04/26 through 01/10/26, P17’s medical record lacked evidence that P17 received HHA visits as per order and that a physician order and communication note was entered.For the month of 12/16/25 through 01/17/26, P17’s medical record lacked evidence that P17 received a CH visit as per order and that a physician order and communication note was entered.A review of P19's medical record was conducted and revealed the following:P19’s Plan of Care Orders for the certification period beginning 12/02/25 contained a physician order for the HHA as "… Calendar Frequency: ... HHA Effective 12/02/2025 2-4WK1 [two to four visits a week for one week], 3-5WK12 [three to five visits a week for 12 weeks] …"For the week of 12/28/25 through 01/03/26 and 01/04/26 through 01/10/26, P19’s medical record lacked evidence that P19 received HHA visits as per order and that a physician order and communication note was entered.On 01/30/26 at 10:57 AM, an interview was conducted with Staff (S) 1, S3, and S5. S5 stated that when a missed visit occurs, a physician order and note is to be placed in the medical record.On 02/04/26 at 11:07 AM, an interview was conducted with S5. S5 confirmed that the medical records for P3, P4, P6, P7, P8, P10, P11, P14, P17, P18, P19, and P20 did not follow the protocol for missed visits and lacked physician order and communication notes. Cross reference:NJAC 8:42C – 6.3(a)(6) Findings include:A review of P20's medical record was conducted and revealed the following:P20’s Plan of Care Orders for the certification period beginning 11/20/25 contained a physician order for the SN and HHA as "… Calendar Frequency: ... SN Effective 11/20/2025 1EVERY2WK2 [one visit every two weeks for two weeks], 1WK7 [one visit a week for seven weeks]… HHA Effective 11/20/2026 1-3WK1 [one to three visits a week for one week], 5-7WK8 [five to seven visits a week for eight weeks], 1WK1 [one visit a week for one week] AM [in the morning]; 1-3WK1 [one to three visits a week for one week], 5-7WK8 [five to seven visits a week for eight weeks], 1WK1 [one visit a week for one week] PM [in the afternoon]"For the week of 12/21/25 through 12/27/25 and 12/28/25 through 01/03/26, P20’s medical record lacked evidence that P20 received HHA visits as per order and that a physician order and communication note was entered.For the week of 01/11/26 through 01/17/26, P20’s medical record lacked evidence that P20 received SN visits as per order and that a physician order and communication note was entered.

Based on observation, staff interview, and review of facility documents, it was determined the facility failed to ensure that infection prevention standards of practice are implemented by: 1. Not adhering to appropriate equipment disinfection protocols, according to facility policy, in three of the six home visits (Patient (P) 1, P2, and P3), and 2. Not adhering to appropriate hand hygiene protocols, according to facility policy, in one of six home visits (P3). --- Findings include:1.Facility policy titled, "Infection Control – Bag Technique," dated 11/12/25, stated, "… Procedures: … 5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use …"  On 01/28/26 at 2:04 PM, S15 was observed providing care for P3.At 2:10 PM, S15 took P3’s vital signs (blood pressure, temperature, heart rate, and respirations) and then placed the contaminated vital signs equipment (thermometer, pulse oximeter, and automatic blood pressure cuff) on P3’s hospital bed. S15 placed his/her contaminated stethoscope around his/her neck.At 2:14 PM, S15 removed disinfectant wipes from his/her bag and was observed cleaning his/her stethoscope. S15 was then observed auscultating (listening to) P3’s heart and lungs and placed the re-contaminated stethoscope around his/her neck. At 2:36 PM, S15 was observed cleaning the contaminated thermometer, pulse oximeter, and automatic blood pressure cuff with the disinfectant wipes. The contaminated stethoscope was not cleaned and remained around S15’s neck. At 2:41 PM, S15 was observed exiting P3’s house with the contaminated stethoscope around his/her neck.At 2:43 PM, an interview was conducted with S15. While reviewing the home visit, S15 confirmed he/she did not clean the stethoscope prior to exiting P3’s house. On 01/30/26 at 10:57 AM, an interview was conducted with S1, S3, and S5. A photograph of the disinfectant wipes taken after P3's home visit was reviewed with S5. This photo revealed an expiration date of 09/22.  S5 confirmed disinfectant wipes were expired and should not be used for equipment cleaning. S3 stated that reusable equipment is to be cleaned before and after use with all patients. 2.Facility policy titled, "Indection [sic] Control – Hand Hygiene," dated 11/12/25, stated, "… Procedures: 1. Hospice staff must wash their hands: … e. … after wearing gloves …"  Facility policy titled, "Infection Control – Bag Technique," dated 11/12/25, stated, "… Procedures: … 3 … hands are washed before removing other items from the bag …"  On 01/28/26 at 2:04 PM, S15 was observed providing care for P3.At 2:10 PM, S15, with gloves on, took P3’s vital signs (blood pressure, temperature, heart rate, and respirations). S15 was then observed removing his/her gloves and accessing his/her bag, without performing hand hygiene.At 2:36 PM, S15, with gloves on, was observed cleaning the thermometer, pulse oximeter, and automatic blood pressure cuff. S15, while still wearing his/her gloves, accessed his/her bag and returned the thermometer, pulse oximeter, and automatic blood pressure cuff. S15 was then observed removing his/her gloves and then later exiting P3’s house without performing hand hygiene following the removal of his/her gloves.At 2:43 PM, an interview was conducted with S15. While reviewing the home visit, S15 confirmed he/she accessed his/her bag and removed his/her gloves multiple times without performing hand hygiene.On 01/30/2026 at 10:57 AM, an interview was conducted with S1, S3, and S5. S3 stated that hand hygiene should be performed prior to accessing a bag and after removal of gloves.Cross reference:NJAC 8:42C – 10.2(b) Findings include:Facility policy titled, “Infection Control – Bag Technique” dated 11/12/25, stated, “…Procedures:…5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag…”On 01/28/26 at 12:46 PM, Staff (S)11 was observed conducting a home visit for P1.At 12:52 PM, S11 was observed disinfecting contaminated reusable equipment (stethoscope, blood pressure cuff, pulse oximeter, and measuring tape) with disinfectant wipes. After wiping the equipment with the disinfectant wipes, S11 placed the equipment directly into his/her bag without allowing the equipment to dry.At 1:16 PM, an interview was conducted with S11, regarding the disinfecting of equipment. S11 reported that he/she uses facility provided wipes to disinfect equipment, and it requires two minutes to dry. When asked about his/her process for allowing equipment to dry, S11 reported that he/she places items directly into the clinical bag. He/she said, “I thought I could let it dry in the bag because the bag is clean.”On 01/29/26 at 10:57 AM, an interview was conducted with S3, regarding staff expectations for disinfecting reusable equipment. S3 reported that after disinfecting reusable equipment, staff are expected to allow the equipment to air dry. S3 stated, “Items should not go directly back into their bag.”On 01/28/26 at 3:26 PM, S12 was observed conducting a home visit for P2.At 3:28 PM, S12 was observed removing items (stethoscope, blood pressure cuff, and pulse oximeter) from his/her clinical bag and placing them onto a clean barrier.At 3:32 PM, S12 performed an assessment on P2 using the stethoscope, blood pressure cuff, and pulse oximeter. After using this equipment, S12 returned these items to the same barrier, potentially contaminating the barrier.At 3:38 PM, S12 was observed disinfecting the reusable equipment using disinfecting wipes and returning the items to the potentially contaminated barrier.At 3:50 PM, S12 returned reusable items to his/her clinical bag.At 4:03 PM, an interview was conducted with S12 regarding his/her use of barrier pads. S12 was asked if the disinfected equipment was re-contaminated because it was placed on a potentially contaminated barrier, S12 responded, “It depends on the pathogen, but I don’t feel the equipment was on the barrier long enough to become re-contaminated. If the equipment was visibly soiled or the patient was isolated, I would have a different process.”On 01/29/26 at 10:57 AM, an interview was conducted with S3 regarding staff expectations for disinfecting reusable equipment. S3 reported that staff are taught to have a “clean” barrier and a “dirty” side. S3 explained that “clean” items should be kept separate from the “dirty.”  Findings include: 1. Facility policy titled, "Infection Control – Bag Technique," dated 11/12/25, stated, "… Procedures: … 5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag …" On 01/28/26 at 12:46 PM, Staff (S)11 was observed conducting a home visit for P1.At 12:52 PM, S11 was observed cleaning disinfecting contaminated reusable equipment (stethoscope, blood pressure cuff, pulse oximeter, and measuring tape) with disinfectant wipes. After wiping the equipment with the disinfectant wipes, S11 placed the equipment directly into his/her bag without allowing the equipment to dry.  you have to say what S11 used the equipment on prior to disinfecting. instead say,  At 12:52 PM, S11 was observed using the stethoscope, blood pressure cuff, pulse ox (measures oxygen level in blood), and a measuring tape on P1. After use, S11 used a disinfectant wipe to clean the stethoscope, blood pressure cuff, pulse oximeter, and measuring tape and immediately placed the stethoscope, blood pressure cuff, pulse oximeter, and measuring tape into his/her bag without allowing the equipment to dry. At 1:16 PM, an interview was conducted with S11, regarding the disinfecting of equipment. S11 reported that he/she uses the facility provided wipes to disinfect the equipment, and that it requires two minutes to dry. When asked about his/her process for allowing equipment to dry, S11 reported that he/she places the items directly into the clinical bag after disinfection. He/she said, “I thought I could let it dry in the bag because the bag is clean.” S11 confirmed he/she does not allow the equipment to dry for two minutes prior to placing it back into his/her clinical bag. On 01/29/26 at 10:57 AM, an interview was conducted with S3, regarding staff expectations for disinfecting reusable equipment. S3 reported that after disinfecting reusable equipment, staff are expected to allow the equipment to air dry. S3 stated, “Items should not go directly back into their bag.”On 01/28/26 at 3:26 PM, S12 was observed conducting a home visit for P2.At 3:28 PM, S12 was observed removing items (stethoscope, blood pressure cuff, and pulse oximeter) from his/her clinical bag and placing them onto a clean barrier.At 3:32 PM, S12 performed an assessment on P2 using the stethoscope, blood pressure cuff, and pulse oximeter. After using this equipment, S12 returned these items to the same barrier, potentially contaminating the barrier.At 3:38 PM, S12 was observed disinfecting the reusable equipment using the disinfecting wipes and returning the items to the potentially contaminated barrier. Thus, potentially contaminating the equipment. At 3:50 PM, S12 returned the potentially contaminated equipment to his/her clinical bag.At 4:03 PM, an interview was conducted with S12 regarding his/her use of barrier pads. S12 was asked if the disinfected equipment was re-contaminated because it was placed on a potentially contaminated barrier, S12 responded, “It depends on the pathogen, but I don’t feel the equipment was on the barrier long enough to become re-contaminated. If the equipment was visibly soiled or the patient was isolated, I would have a different process.” Do you have a policy that speaks about the barriers? On 01/28/26 at 2:04 PM, S15 was observed providing care for P3.At 2:10 PM, S15 took P3’s vital signs (blood pressure, temperature, heart rate, and respirations) and then placed the potentially contaminated vital signs equipment (thermometer, pulse oximeter, and automatic blood pressure cuff) on P3’s hospital bed. S15 placed his/her potentially contaminated stethoscope around his/her neck.At 2:14 PM, S15 removed the disinfectant wipes from his/her bag and was observed using a wipe to clean his/her stethoscope. S15 was then used the stethoscope to listen to P3’s heart and lungs and then, without cleaning and disinfecting the stethoscope, placed the potentially contaminated stethoscope around his/her neck. At 2:36 PM, S15 was observed using a disinfectant wipe to clean the thermometer, pulse oximeter, and automatic blood pressure cuff but did not clean and disinfect the stethoscope that was around his/her neck.  At 2:41 PM, S15 was observed exiting P3’s house with the potentially contaminated stethoscope around his/her neck.At 2:43 PM, an interview was conducted with S15. While reviewing the above findings with S15, S15 confirmed he/she did not clean the stethoscope prior to exiting P3’s house. On 01/30/26 at 10:57 AM, an interview was conducted with S1, S3, and S5. A photograph of the disinfectant wipes taken after P3's home visit was reviewed with S5. This photo revealed an expiration date of 09/22.  S5 confirmed disinfectant wipes were expired and should not be used for equipment cleaning. when was this noted that they were expired. This should be mentioned above also. Do not indicate that you took a photograph.  S3 stated that all reusable equipment including the stethoscope. blood pressure cuff, pulse oximeter, and the thermometer should be cleaned before and after use with all patients. S3 reported that staff are taught to have a “clean” barrier and a “dirty” side. S3 explained that “clean” items should be kept separate from the “dirty.”Facility policy titled, "Indection [sic] Control – Hand Hygiene," dated 11/12/25, stated, "… Procedures: 1. Hospice staff must wash their hands: … e. … after wearing gloves …"  Facility policy titled, "Infection Control – Bag Technique," dated 11/12/25, stated, "… Procedures: … 3 … hands are washed before removing other items from the bag …"  2. On 01/28/26 at 2:04 PM, S15 was observed providing care for P3.At 2:10 PM, S15, while wearing gloves, took P3’s vital signs (blood pressure, temperature, heart rate, and respirations). S15 then removed his/her gloves and entered his/her bag without performing hand hygiene.At 2:36 PM, S15, while wearing gloves, used a disinfectant wipe to clean and disinfect the thermometer, pulse oximeter, and automatic blood pressure cuff. S15, while still wearing the potentially contaminated gloves, entered his/her bag and returned the thermometer, pulse oximeter, and automatic blood pressure cuff. S15 removed his/her gloves and did not perform hand hygiene (what did they do after removing gloves?) later exiting P3’s house without performing hand hygiene following the removal of his/her gloves.At 2:43 PM, an interview was conducted with S15. While reviewing the above findings, S15 confirmed he/she entered his/her bag and removed his/her gloves multiple times without performing hand hygiene.On 01/30/2026 at 10:57 AM, an interview was conducted with S1, S3, and S5. S3 stated that hand hygiene should be performed prior to accessing a bag and after removal of gloves. Did anyone look at the education of these staff members for bag technique, cleaning of equipment, hand hygiene?  Cross reference:NJAC 8:42C – 10.2(b)

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure a bereavement plan of care is developed for one of four bereavement records reviewed (Patient (P)24). --- Findings include:Facility policy titled, “Bereavement – Care Planning," dated 11/12/25, stated, “…Procedures: …3. The chaplain is notified of all deaths and initiates the bereavement discussion and care planning at the first interdisciplinary team meeting following the patient’s death. At this time, the bereavement care plan is developed. 4. The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind of bereavement services to be provided and the frequency of delivery. 5. The bereavement coordinator ensures that the bereavement plan of care is followed for thirteen (13) months following the patient’s death, appropriate to the level of need assessed.”Facility policy titled, “Bereavement – Mailings," dated 11/12/25, stated, “Policy Statement: Bereavement mailings are sent to identified family members and significant others of deceased hospice patients. These mailings are sent at regular intervals (one month, three months, six months, nine months and thirteen months)…”On 01/29/26 a review of P24’s medical record was conducted and revealed the following:On 06/16/25, a Visit Note Report, written by S32, documented P24’s admission to the facility and start of care.On 06/17/25, a Visit Note Report, written by S33, documented P24’s death at home.The facility was unable to provide evidence that a bereavement assessment was conducted for P24’s family member after P24’s death. The facility was unable to provide evidence that a bereavement plan of care was created for P24’s family member.On 01/29/26 at 2:20 PM, an interview was conducted with Staff (S) 10. S10 stated that P24’s family member had not been flagged for bereavement services. S10 was unable to provide evidence that P24’s family member had refused bereavement services. S10 stated that an initial sympathy card was sent to P24, but there was no documentation of the one-month, three-month, or six-month letters being sent to the patient’s family member.On 02/04/26 at 12:20 PM, an interview was conducted with S1 and S5. S1 and S5 confirmed the facility was unable to provide evidence of a bereavement assessment following P24’s death or a bereavement plan of care for P24’s family member.

Based on record review, staff interview, and review of facility policy, it was determined the facility failed to ensure the Registered Nurse supervises the home health aides every 14 days, in four of the 13 active medical records reviewed (Patient (P) 6, P7, P10, and P20). --- Findings include:Facility policy titled, "Home Health Aide Supervision," dated 11/12/25, stated, "… Procedures: 1. The hospice RN [Registered Nurse] supervises home health aides that are employed by the hospice and those that work for the hospice under contract at least every 14 days. 2. The hospice RN documents the supervision of the home health aide’s services in the patient’s clinical record. …"  A review of P6’s medical record was conducted and revealed the following: Staff (S) 16 completed an Aide Supervisory Visit on 01/12/26. No additional Aide Supervisory Visits were conducted as of 01/30/26, 18 days since the previous Aide Supervisory Visit.A review of P7’s medical record was conducted and revealed the following: S31 completed an Aide Supervisory Visit on 10/22/25. The next Aide Supervisory Visit was conducted by S31 on 11/08/25, 17 days after the previous Aide Supervisory Visit.S31 completed an Aide Supervisory Visit on 11/08/25. The next Aide Supervisory Visit was conducted by S31 on 12/10/25, 32 days after the previous Aide Supervisory Visit.A review of P10’s medical record was conducted and revealed the following: Home Health Aide (HHA) visits began on 01/04/26. No Aide Supervisory Visits were conducted as of 01/30/26, 26 days since HHA visits began. On 02/04/26 at 11:07 AM, an interview was conducted with S5. S5 confirmed that the time between aide supervisory visits for P6, P7, P10, and P20 were greater than 14 days. S5 stated that aide supervisory visits should occur every 14 days.Cross reference:NJAC 8:42C – 7.5(a) Findings include:A review of P20’s medical record was conducted and revealed the following:S16 completed an Aide Supervisory Visit on 12/15/25. The next Aide Supervisory Visit was conducted by S16 on 1/05/26, 21 days after the previous Aide Supervisory Visit.S16 completed an Aide Supervisory Visit on 1/05/26. The next Aide Supervisory Visit was conducted by S16 on 1/21/26, 16 days after the previous Aide Supervisory Visit.

Based on observation, medical record review, staff interview, and review of facility policy, it was determined the facility failed to ensure the appropriate disposal of a controlled drug in a patient’s home, according to facility policy, in one of three home visits observed (Patient (P) 3). --- Findings include:Facility policy titled, "Medication – Disposing of Controlled Drugs in the Patient’s Home," dated 11/12/25, stated, "… Procedures: … Disposal 1. Controlled drugs no longer needed … are disposed of in compliance with State and Federal regulations and disposal instructions and activities are documented. 2. A hospice nurse, accompanied by a witness, is responsible for disposing of the patient’s controlled substance by utilizing a Pill Terminator [sealed container used to deactivate unused medications before disposal] or mixing medication with an undesirable substance like coffee ground or kitty litter … 3. At the time of destruction, the following information is documented in the patient’s clinical record: a. name and dose of the medication; b. amount or quantity of the medication … destroyed … c. date of destruction and signature of the nurse and witness …" On 01/28/26 at 2:04 PM, Staff (S) 15 was observed providing care for P3.At 2:13 PM, S15 was observed picking up a fentanyl (controlled pain medication) transdermal patch (adhesive patch which allows medication to slowly absorb into patient) off the floor next to P3’s hospital bed. S15 was then observed folding the fentanyl transdermal patch onto itself and placing it on a bed next to the patient's hospital bed. At 2:22 PM, S15 was observed handing the discovered fentanyl transdermal patch to P3’s family member. S15 was not observed asking for the patch back and did not dispose of the patch by utilizing the Pill Terminator, as per policy. It is unknown what P3’s family member did with the patch. P3's family member stated the patch was applied on 01/26/26, approximately 48 hours prior to the patch being discovered on the floor. On 01/30/26 at 10:57 AM, an interview was conducted with S1, S3, and S5. S1 stated that Pill Terminators are supplied to hospice nurses to be utilized for the destruction of controlled substances, which includes fentanyl transdermal patches. S1 stated that the fentanyl transdermal patch would be cut and placed into the Pill Terminator to be destroyed. S1 stated that controlled substances should be destroyed per facility policy and that a clinical note must be placed in the patient’s electronic medical record (EMR). S1 stated that it is not recommended, but that family members are allowed to destroy the controlled substance if they refuse to allow the clinicians to destroy the medication, which must also be documented in the patient’s EMR. S1 stated that the disposing of controlled medications policy is utilized during all visits and not only when a patient expires.On 02/04/26, one week after the visit, P3's medical record was reviewed. The medical record lacked evidence of how the fentanyl patch was disposed of during the 1/28/26 visit. On 02/04/26 at 11:43 AM, an interview was conducted with S15. While discussing the disposal of a controlled substance, S15 stated that we let family dispose of the controlled medication if the patient has not expired. When asked about the process of documenting this information, S15 stated that he/she does not typically place a note in the patient’s EMR regarding the disposal of a controlled substance by a family member. S15 confirmed that during P3’s visit on 01/28/26, S15’s family member disposed of the fentanyl transdermal patch.Cross reference:NJAC 8:42C-8.1(2)(c)

Based on review of three of four medical records of patients receiving home health aid services (Patient (P)11, P15, and P17), staff interviews, and a review of facility documents, it was determined the facility failed to ensure that patient care services are provided in accordance with the plan of care. --- Findings include: Reference: Facility document titled, "Protocol for Missed Visits" (last updated: 11/17/2022) states, "... If a visit is missed a physician order needs to be entered for the missed visit. A communication note should be entered to explain efforts made to complete the scheduled visit. If staff unable [sic] to be scheduled, were there alternative care methods provided (RN, LPN)." 1. A review of P11's plan of care for the certification period 3/2/23 - 5/30-23 conducted on 4/12/23 at 9:30 AM, revealed the following: The HHA (Home Health Aide) visit frequency orders for the recertification period beginning 3/2/23 stated, "... 1-3 wk 1 wk [1-3 times per week for 1 week]; 5-7 wk 12 wk [5-7 times per week for 12 weeks] ... begin 3/2/23 - 5/30/23." During the week of 3/2/23, there were no HHA visits provided. During the review, P11's medical record lacked evidence that the facility protocol for the missed visit was implemented. This finding was confirmed with S1 and S2 during the exit conference. 2. A review of P15's plan of care for the certification period 1/9/23-4/8/23 conducted on 4/11/23 at 10:37 AM, revealed the following: The HHA visit frequency orders for the certification period beginning 1/9/23 stated, "... 2-4 wk 1 wk [2-4 times per week for 1 week]; 3-5 wk 12 wk [3-5 times per week for 12 weeks] begin 1/10/23 - 4/18/23" During the week of 1/9/23, there were no HHA visits provided. During the week of 1/15/23, there were no HHA visits provided. During the week of 1/22/23, the HHA made one visit on 1/26/23. During the review, P15's medical record lacked evidence that the facility protocol for the missed visit was implemented. This finding was confirmed with Staff (S)1 upon discovery and with S2 during the exit conference. 3. A review of P17's plan of care for the certification period 2/14/23 - 5/14/23 conducted on 4/11/23 at 2:09 PM, revealed the following: The HHA visit frequency orders for the certification period beginning 2/14/23 stated, "... 2-4 wk 1 wk [2-4 times per week for 1 week]; 3-5 wk 12 wk [3-5 times per week for 12 weeks] begin 2/14/23 - 5/13/23" During the week of 2/14/23, there were no HHA visits provided. During the week of 2/19/23, the HHA made one visit on 2/24/23. During the review, P17's medical record lacked evidence that the facility protocol for the missed visit was implemented. This finding was confirmed with S1 and S2 during the exit conference. N.J.A.C. 8:42C-6.3(a)(6)

Based on observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that patient pain is assessed, documented in the medical record, and communicated to the physician. --- Findings include: Reference: Facility Policy titled, "Pain and Symptom Management," last reviewed on 7/22, states " ... Procedures: ... 4. Pain is reassessed during every home visit, any time a patient states that his/her pain level has changed, ... This information is documented in the patient's clinical record. 5. If the patient is not receiving relief from the current pain medication or dosage, the nurse notifies the contracted pharmacy, the hospice medical director, and/or attending physician, and carries out the recommended action(s) ordered by the physician. ..." On 4/10/23 at 12:20 AM, during a nursing visit in the home of Patient (P)1, the patient notified Staff (S)16 that he/she was having stomach cramps. S16 did not respond verbally to the patient. At 12:28 PM, P1 notified S16 again that he/she was having stomach cramps. S16 stated, "is it hurting you?" P1 stated, "It's very annoying." S16 stated, "I'll call the doctor and then I'll call your daughter." On 4/12/23 at 9:20 AM, a review of P1's medical record was conducted. In the "Skilled Nursing Visit Note" from 4/10/23, S16 documented for "Symptom Assessment" the following: "Pain: 0." There was no documentation found in the medical record of the patient's report of stomach cramps. There was no documentation found in the medical record that the patient's doctor had been notified. At 1:43 PM, these findings were confirmed by S1. N.J.A.C. 8:43E-6.4(b) N.J.A.C. 8:43E-6.4(e)

Based on observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure: 1) all staff perform hand washing for at least 15 seconds. 2) the facility policy regarding the cleaning of equipment using approved disinfectants is implemented. --- Findings include; Reference: Facility policy titled, "Infection Control - Hand Hygiene," last approved 7/22, states, "... Procedures: ...5. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, ..." On 4/10/23 at 12:23 AM, during a home visit with Patient (P)1, Staff (S)16 was observed entering the patient's bathroom and removing his/her gloves. S16 was observed washing his/her hands for 10 seconds. At 12:27 PM, S16 was observed washing his/her hands in the bathroom sink for 6 seconds. The above findings were reviewed with SMARY on 4/12/23 at 1:48 PM. N.J.A.C 8:42C-10.2(b) Findings include: Facility Policy titled ";INFECTION CONTROL- BAG TECHNIQUE" (reviewed July 2022) states ";...PROCEDURES: ... 5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag. ..." Facility Policy titled ";PROTOCOL FOR Disinfectant" updated March 2021 states ";...Grace only provides disinfectant wipes that are on the approved EPA N list. The wipes we provide to our nurses are from Medline- Micro-Kill One Germicidal Alcohol Wipes, EPA Reg No. 88494-2. ..." 2. On 4/10/23 at 1:40 PM during an observation of a hospice home visit, Staff #6 was observed cleaning items used on a patient (stethoscope, blood pressure cuff, thermometer, pulse oximeter and measuring tape) with Lysol Disinfectant wipes, which is not a facility approved disinfectant. On 4/11/23 at 8:43 AM during an observation of a hospice home visit, Staff #7 was observed cleaning items used to render patient care (stethoscope, blood pressure cuff, thermometer, and pulse oximeter) with Hand Sanitizer, which is not a facility approved disinfectant. Prior to cleaning the items Staff #7 stated ";we use alcohol wipes to clean equipment, but I prefer hand sanitizer because it cleans better." On 4/12/23 at 2:45 PM, Staff #1 confirmed that the facility does provide the Medline Micro-Kill One Germicidal Alcohol wipes to all staff. Staff #1 explained that the wipes can be mailed to the staffs home, or the wipes can be delivered to the staff at the bi-weekly Interdisciplinary Team meetings. 8:42C-7.2

Based on observation, medical record review, and staff interview, it was determined that the facility failed to ensure that patient assessment information is accurately documented in the medical record. --- Findings include: On 4/10/23 from 12:18 PM until 12:32 PM, Staff (S)16 was observed during a nursing visit in the home of Patient (P)1. S16 was not observed measuring P1's mid-arm circumference during the home visit. On 4/12/23 at 9:20 AM, a review of P1's medical record was conducted. In the "Skilled Nursing Visit Note" from 4/10/23, S16 documented the following: "Anthropometric Measurements a. Time: 12:30 EDT [Eastern daylight time] Mid-Arm Circumference 14.5 Centimeters Left Arm." At 1:48 PM, during an interview, S1 revealed that mid-arm circumference measurement information is not carried over in the nursing note from prior assessments, but has to be entered on the flowsheet every time it is measured. The above findings were reviewed with S1. N.J.A.C. 8:42C-7.4(a)