Every finding on record at Great Lakes Caring Hospice C Il, LLC

Upon patient record review, 3 of 19 (Patient #6, 16, 19) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6 - Metamucil did not contain specific ounces of water to mix with one packet of Metamucil. Oxygen 2-10L/M per nasal cannula did not have titration specifics. Patient #16 - Hospice medication profile contained Nystatin and Methadone but not on ALF medication profile. ALF medication profile contained Tylenol 325mg 2 tabs every 6 hours PRN pain but not on hospice medication profile. Patient #19 - SNF medication profile contained Tylenol 500mg 1 tabs every 6 hours PRN pain and Nystatin Powder apply every shift under breast and abdominal fold but not on hospice medication profile.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #12 - The patient was admitted on 12/14/25. There was no evidence of a bereavement risk assessment at the time of the survey.

Upon patient record review, 2 of 19 (Patient #7,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7 - POC order for wound care to right forearm change daily and PRN did not have modifier for PRN. Patient #11 - The record indicated that the patient had a foley catheter. There was no evidence of an order for foley catheter changes.

Upon client record review, 1 of 19 (Patient #17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #17 - The record indicated that the patient had a volunteer visit on 01/28/26. There was no evidence of an order for volunteer.

Upon patient record review 5 of 19 (Patient #7, 10, 13, 16, 19) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #7 - The aide documented completion of a sponge bath; the aide plan of care indicated a shower on 02/10/26, 02/13/26 and 02/17/26. Patient #10 - Aide frequency 2 x week and only 1 visit was made the week of 02/08/26. Patient #13 - The aide plan of care indicated for ear care to be done 1x week, this was completed 2x week on 01/13/26 and 02/01/26. Patient #16 - The aide plan of care indicated for nail care, shaving and linen change to be done 1x week, the tasks were completed 2 x week 11/16/25 and 01/19/26. Patient #19 - The aide plan of care indicated for nail care to be done 1x week, this was completed 2x week 01/04/26 and 01/25/26.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency did not utilize at least 5% of the total patient care hours in 2025. The total usage of volunteers for 2025 was 2.09%.

Upon client record review, 2 of 19 (Patient #7, 11) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #7 - SNF resident admitted 12/23/25 with wound care to right forearm. There is no documented evidence of which provider is to provide wound care to the patient. Patient #11 - SNF resident admitted 10/29/25 with foley catheter. There is no documented evidence of which provider is to change foley catheter.

Upon patient record review, 3 of 13 (Patients #9,#10,#11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 9: The medical record contained nursing documentation upon recertification 2-14-22 identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site. Patient 10: The medication profile contained oxygen with no defined delivery method. Patient 11: The medication profile contained oxygen with no defined delivery method.

Upon patient record review, 1 of 13 (Patient #6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: The medical record contained nursing documentation since admission stating nursing facility management of chronic wound. There was no evidence of wound assessments since admission 2/23/22.

Upon patient record review, 2 of 13 (Patient #4 and 12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4: The medical record contained nursing documentation 12-14-22 identifying patient is high risk for aspiration. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 12: There was no evidence of the plan of care updated with information regarding discharge plans.

Upon patient record review, 3 of 13 (Patients #9,#10,#11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 9: The medical record contained nursing documentation upon recertification identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 10: The medical record contained an order for oxygen with no defined delivery method. Patient 11: The medical record contained an order for oxygen with no defined delivery method.

Upon patient record review, 1 of 13 (Patient #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of commode and walker. There was no evidence of the commode and walker included as DME on the plan of care. Corrected on site.

Upon patient record review, 1 of 13 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient 8: The aide care plan contained tasks for two bath types every visit, shower and bed bath. Corrected on site.

Upon client record review, 1 of 13 (Patient #6) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 6: The medical record contained nursing documentation since admission identifying facility management of patient's wound care. There was no evidence of an order for wound care in the medical record and who was responsible for the wound care. Corrected on site.

Upon patient record review, 1 of 13 (Patient #1) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Physician certification and recertification of the terminal illness specific to each patient Patient 1: Upon observation during the home visit, there was no evidence of the certification of terminal illness and updated plan of care in the hospice binder at the nursing home.

Upon personnel record review, 1 of 13 (Personnel #9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.