Every finding on record at Heritage Crossing Fresno, Inc.

Observed in Emergency Management Session. In 4 of 4 drills, The hospice nurse surveyor noted that the emergency response drills conducted in 2021 and 2022 did not include documentation of the identification of deficiencies and opportunities for improvement. This was confirmed with the administrator. Observed in Emergency Management Session. The hospice nurse surveyor noted that there was no evidence that three of four disaster drills were evaluated by management and staff, as there was no written scenario or documented participation and response or after action plan. This was confirmed with the administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the chaplain had visited the patient five times a month in both December and January; however the plan of care did not include spiritual or psycho-social goals and the frequency orders were not individualized to the needs of the patient. Also, in (RR#3),and (RR#5), the surveyor noted that the chaplain visits were more frequent than orders; however, the plan of care did not indicate the individual needs of the patient by frequency or in the plan of care goals and interventions. The surveyor noted that in 11 of 11 records reviewed the frequency orders were all the same for all disciplines and were not individualized to meet the needs of the patient, even when the patient's condition changed. The surveyor also, noted that 11 of 11 care plans did not include outcomes goals or interventions for either spiritual or psycho-social needs. This was confirmed with the administrator.

Observed in Individual Tracer. In 6 of 6 patient records with home health aide, The hospice nurse surveyor noted (HV#1) that the aide care plan did not include instructions for providing a hydro-bath. The surveyor noted that the care plan indicated a shower twice a week; however, in conversation with the inpatient unit nursing director, the aide is instructed to perform a hydro-bath. The instructions are not included on the plan of care. The surveyor noted the same had occurred in the care plans for (HV#2), (HV#3), (RR#1-RR#4). This was confirmed with the administrator.

Observed in Record Review. In 1 of 2 discharge records, The hospice nurse surveyor noted (RR#8) that the patient was transferred to another hospice; however, there was no evidence in the patient record that confirmed a transfer/discharge summary was provided to the receiving agent. This was confirmed with the alternate administrator.

Observed in Building Tour. In 3 of 6 storage areas, The hospice nurse surveyor noted that there were boxes and supplies stored on top shelves leaving less than 18 inches or more of open space maintained below the sprinkler to the top of storage. This was noted in three (3) storage areas. This was corrected on-site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. In 6 of 6 doors to closed patio, The hospice nurse surveyor noted that Signs reading NO EXIT are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may be mistaken for an exit. This was corrected on site and signage confirmed as attached to all doors. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The hospice nurse surveyor noted that the Fire-rated door in the main entry did not have functioning hardware, including positive latching devices and self-closing or automatic-closing devices (either kept closed or activated by release device complying with NFPA 101-2012: 7.2.1.8.2). Also, the gap between meeting edges of door pairs was more than 1/8 of an inch wide (measured at 3/4 of an inch), Also, the surveyor noted that the door was wedged open with kick plate stops on both doors. The surveyor noted that the door did not have a magnetic fire release option. The door stops were removed, the hardware was repaired and the door gap was repaired on site and the door was maintained closed with signage that instructed to keep door closed, attached. This was corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The hospice nurse surveyor noted that the exits, exit accesses, and exit discharges (means of egress) were not clear of obstructions or impediments to the public way, such as clutter and included a large ramp device that obstructed half- of the hallway, several storage bins near patient doorways and unsecured furniture obstructing the hallway clearance. The ramp and bins were removed and the surveyor noted that the furniture did not protrude into the eight foot clearance; however, it was not secured. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. In 3 of 8 kitchen and laundry areas, The hospice nurse surveyor noted that the hospice failed to obtain, store, prepare, distribute, and serve all food under sanitary conditions. There were several cans and containers of food stored in the pantry that had expired, and several opened packages of cereal and bread, flour and barley. The surveyor also noted that there was debris scattered under pantry shelves and the floor was not clean in the pantry area. Also, the dishwasher racks were crusted with debris, the storage racks were crusted and the stove was greasy and crusted with debris. Also, brooms and mops were stored in the pantry. The expired food and open packages were discarded on site and the pantry area was cleaned. This was confirmed with the facilities manager.

Observed in HR File Review. In 4 of 9 HR files reviewed, The hospice nurse surveyor noted that the file of the medical director , alternate medical director, director of nursing and a registered nurse did not include evidence that their licenses were verified with the primary source when hired. Also, the file of a registered nurse whose license renewed in July of 22, did not include evidence that a verification was performed when it was renewed. This was confirmed with the COO.