Every finding on record at Horizon Homecare and Hospice

Based on observation and interview, the facility failed to properly store oxygen cylinders in accordance with NFPA 101, 2012 edition, Section 19.3.2.4; NFPA 99, 2012 edition, Sections 11.3.4.1, 11.3.4.2. This deficient practice had a potential to affect all patients receiving care in the facility. --- Findings includeOn 12/09/2025 at 9:40 A.M., observation revealed there was no precautionary sign posted on door of the attached, conditioned Garage where “E” size oxygen cylinders and Kitchen supplies were stored.          CAUTION:OXIDIZING GAS(ES) STORED WITHIN     NO SMOKING The above deficiency was confirmed by observation and interview with Staff M1 and M2 at the time of discovery, and with Staff B (Hospice Manager) at exit interview on 12/10/2025 at 10:30 A.M.  Findings include1.      On 12/10/2025 at 12:55 P.M., observation revealed that 2 empty and 2 full oxygen cylinders of “E” size were stored in the same cart; empty oxygen cylinders were not segregated from full cylinders.2.      On 12/10/2025 at 12:56 P.M., observation revealed there was no precautionary sign posted on door of the oxygen storage room where “E” size oxygen cylinders were stored. The storage was located across the Patient Room 201.               CAUTION:OXIDIZING GAS(ES) STORED WITHIN           NO SMOKING The above findings were confirmed by observation and interview with Staff M3 and M4 at the time of discovery, and Staff B (Hospice Manager) at exit interview on 12/10/2025 at 2:30 P.M.

Based on observation, staff interviews, and review of maintenance records on December 12,022 the facility did NOT construct, install and maintain the building systems to ensure the physical environment for inpatients. 42 CFR 418.110(c) Condition of Participation: Life Safety Physical Environment was NOT MET --- Findings include: The facility Kathy House located at West Bend, Wisconsin was found to contain the following deficiencies: K 0354 Sprinkler Systems - Out of ServiceK 0712 Fire Drills The facility Lawliss Family House located at Mequon, Wisconsin was found to contain the following deficiencies: K 0281 Illumination of Means of Egress Refer to the full description of the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice's inability to ensure a safe environment for the inpatients.

Based on observation, staff interviews, and a review of maintenance records on December 12, 2022, the facility did NOT construct, install and maintain the building systems to ensure the physical environment for inpatients. 42 CFR 418.110(d) Fire Protection was NOT MET --- Findings include: The facility Kathy House located at West Bend, Wisconsin was found to contain the following deficiencies: K 0354 Sprinkler Systems - Out of ServiceK 0712 Fire Drills The facility Lawliss Family House located at Mequon, Wisconsin was found to contain the following deficiencies: K 0281 Illumination of Means of Egress Refer to the full description of the cited K tags. The cumulative effect of the environmental deficiencies results in the Hospice's inability to ensure a safe environment for the inpatients.

Based on record review and interview, the agency failed to ensure that patients were given written information regarding its policies on advance directives as well as the applicable State law in one of one admission packet reviewed. Findings include: Review of policy "Advance Directives" last reviewed 3/22/1017 revealed in part, "B. If an advance directive has been completed by the patient the clinician will: 1)Provide and explain information on the advance directive educational tool provided in admission packet which explains the three types of advance directives." Review of the agency's admission packet revealed no written information regarding advance directives, including the agency policy, applicable State law and educational tool. An interview was conducted with Hospice Director D on 9/13/2022 at 1:00 p.m. When asked how patients are informed of advance directives D stated that if a patient does not have an advanced directive then they are educated and materials are given to them. When asked what materials were given to patients D stated "I'm not quite sure." An interview was conducted with Chief Operations Officer C on 9/13/2022 at 1:30 p.m. When reviewing the policy and admission packet with C he/she was asked where the advanced directives information could be found, C stated "The hospice booklets had been redone and that section must have been left out."