Every finding on record at Hospice Inc

Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview on 09/09/25, it was determined the Hospice failed to provide a copy of its documented risk assessment as required under §418.113(d)(2), Emergency Preparedness – Risk Assessment and Planning. Although the facility had supporting documentation and tools indicating that a risk assessment had been conducted and reviewed by staff, the actual risk assessment could not be produced for review at the time of the survey. --- Findings Include:Review of the agency's Emergency Preparedness Program (EPP), last reviewed by the facility in January 2025, failed to include a copy of the documented risk assessment as required under §418.113(d)(2). Supporting materials and documentation indicated that the assessment was completed and reviewed; however, the assessment itself could not be located or provided during the survey.During an interview on 09/09/25 between 9:00 AM and 2:00 PM, the Administrator confirmed that the risk assessment had been completed, but the document could not be found or made available for review.

Based on policy review, observation, document review, record review, and interview the Hospice failed to ensure the plan of care (POC) included all durable medical equipment (DME) needed for the care of 2 (Patient 2 and 4) of 30 patients sampled. Failure to ensure the POC includes all necessary DME places patients at risk for unmet care needs. --- Findings Include:Review of the Hospice policy titled, “Plan of Care,” last reviewed 05/29/24, showed, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family…”Review of the Hospice policy titled, “Plan of Care – Content,” last reviewed 05/29/24, showed, “The plan of care includes, but is not limited to: … medical supplies, equipment, and appliances necessary to meet the needs of the patient …”Review of the Hospice document titled, “Performance Improvement Project (PIP) Charter Correction of EMR … Compliance Reporting Errors and Clinical Documentation Processes,” last updated 08/25/25 showed, “Scope: This PIP includes EMR [electronic medical record] documentation workflows across all hospice disciplines … it focuses on compliance-sensitive data elements (plan of care, orders, IDG, visit documentation, QAPI events) and related reporting. … Implementation … Completed in July of 2025 … Care planning Education for RN Case Managers … training on constructing symptom-specific, measurable, and interdisciplinary hospice plans of care … Monitoring and Evaluation … Monthly compliance audits … Training effectiveness checks … Manager spot-audits with immediate feedback and coaching … Quarterly QAPI [quality assurance performance improvement] review to adjust protocols and training”. Patient 2Review of Patient 2’s medical record showed an 89-year-old admitted to hospice services on 04/07/25 with a primary diagnosis of malignant neoplasm (cancer) of the left breast.  Review of Patient 2’s POC dated 09/03/25 showed no rollator walker listed under the DME portion of the POC. During a home visit on 09/03/25 at 10:10 AM, Patient 2 was observed using a rollator walker to ambulate from the living room to the bedroom. Patient 4Review of Patient 4’s medical record showed a 95-year-old admitted to hospice services on 12/03/24 with a primary diagnosis of heart failure. Review of Patient 4’s POC dated 09/03/25 showed no rollator walker listed under the DME portion of the POC. During a home visit on 09/09/25 at 1:00 PM, Patient 4 was observed using a rollator walker to ambulate from the bedroom to the bathroom.During an interview on 09/09/25 at 3:00 PM, Staff G, Director of Clinical Education and Risk Management, stated that the POC accuracy was identified as a problem since changing to a new charting system at the end of 2024. Staff G stated that all DME a patient has should be entered on the POC and any additional DME added during care should be updated in the POC. Staff G stated that the new electronic medical record (EMR) has a different process to enter patient owned DME and that this different process has resulted in DME not being recorded in the patient’s POC.  Staff G stated that Patient 2 and Patient 4 did not have patient owned DME listed in their POC.  Staff G stated that as part of the QAPI program a PIP was created on 08/25/25 identifying a problem with clinical documentation process including the POC accuracy. Staff G stated that any errors identified in any patient’s POC are addressed with the registered nurse (RN) case manager and additional education is provided to reinforce compliance. The Hospice failed to ensure the requirement for activities of daily living (ADLs) was included on the POC for patients that required use of DME.

Based on policy review, record review, and interview the Hospice failed to update the plan of care (POC) with new problems, interventions, and goals for 5 (Patient 1, 4, 16, 20, and 26) of 30 patients sampled. Failure to update the plan of care with new problems, goals, and interventions, places patients at risk for unmet care needs and negative outcomes. --- Findings Include:Review of the Hospice policy titled, “PLAN OF CARE,” last reviewed 05/29/24, showed, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive, and updated assessment of the patient. The plan of care is reviewed and updated by the IDG [Interdisciplinary Group] every 15 days or more frequently if the patient’s condition warrants. … Reviews of, and changes to, the plan of care are documented and communicated to members of the IDG.”Review of the Hospice policy titled, “PLAN OF CARE – CONTENT,” last reviewed 05/29/24, showed, “The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive, and updated assessments. … The plan of care includes, but is not limited to: … interventions to manage pain and symptoms … measurable outcomes anticipated from implementing and coordinating the plan of care …”Patient 1Review of Patient 1’s medical record showed a 73-year-old admitted to hospice services on 01/28/24 with a primary diagnosis of malignant neoplasm (cancer) of the neck.Review of Patient 1’s skilled nursing note on 08/16/25 showed that Patient 1 had an unwitnessed fall and a mattress with bolsters was ordered as an intervention for fall prevention. Review of Patient 1’s interdisciplinary group (IDG) meeting note dated 08/28/25 showed clinical notes made on 08/16/25 when Patient 1 sustained an unwitnessed fall. The note further showed durable medical equipment (DME) of a bolster mattress on 08/16/25 but did not list a fall problem, goal, or intervention.  Review of Patient 1’s POC dated 09/03/25 did not show a fall problem, goal, or intervention for the fall that occurred on 08/16/25.Patient 4Review of Patient 4’s medical record showed a 95-year-old admitted to hospice services on 12/03/24 with a primary diagnosis of heart failure.Review of Patient 4’s skilled nursing note on 07/09/25 showed that Patient 4 had a fall on 07/08/25 resulting in a skin tear to the left forearm. The note did not show a fall intervention. Review of Patient 4’s IDG meeting note on 07/09/25 showed a quality assurance performance improvement (QAPI) event of a fall that occurred on 07/08/25. The note did not list a fall problem, goal, or intervention.Review of Patient 4’s POC dated 09/03/25 did not show a fall problem, goal, or intervention for the fall that occurred on 07/08/25. Patient 16Review of Patient 16’s medical record showed an 83-year-old admitted to hospice services on 04/10/25 with a primary diagnosis of malignant neoplasm (cancer) of the kidney. Review of Patient 16’s skilled nursing note on 09/05/25 showed an upper respiratory infection and Azithromycin (antibiotic medication) 250 mg by mouth 2 tabs on day 1, then 1 tab daily for 4 days was ordered.Review of Patient 16’s POC dated 09/10/25 showed no respiratory infection problem, goal, or intervention. Patient 20Review of Patient 20’s medical record showed an 88-year-old admitted to hospice services on 10/05/22 with a primary diagnosis of malignant neoplasm (cancer) of the ovaries. Review of Patient 20’s skilled nursing note on 06/08/25 showed that the patient had a back injury while making the bed and was transported to the hospital for evaluation. Further review of Patient 20’s clinical notes from 06/13/25 showed a diagnosis of a fracture in the patient’s lumbar spine.Review of Patient 20’s IDG meeting note on 06/25/25 showed no spinal fracture problem, goal, or intervention. Review of Patient 20’s POC dated 09/03/25 showed no spinal fracture problem, goal, or intervention. Patient 26Review of Patient 26’s medical record showed a 78-year-old admitted to hospice services on 11/10/23 with a primary diagnosis of senile degeneration of the brain (a state of physical, emotional, and social decline of brain).Review of Patient 26’s skilled nursing note on 02/05/25 showed an oral abscess and Amoxicillin (antibiotic medication) 500 mg by mouth, 1 tab every 8 hours for 7 days was ordered. Review of Patient 26’s IDG meeting note on 02/14/25 showed no oral infection or abscess problem, goal, or intervention. Review of Patient 26’s POC dated 09/03/25 showed no oral infection or abscess problem, goal, or intervention. During an interview on 09/03/25 at 4:00 PM, Staff A, Vice President of Clinical Services, stated that the POC for each patient should be updated with any new problems, goals, and interventions. Staff A, stated that the Hospice adopted a new EMR (electronic medical record) within the last year. The new EMR requires input of a coded diagnosis to generate a problem, goals, and interventions to the POC. Staff A, went on to state that instead of inputting individual diagnosis codes for each identified problem (such as the diagnosis code for UTI), staff had been directed to enter everything under the primary diagnosis (such as cancer.) This failure prevented specific problem areas such as wounds, infections, and falls from being identified in the patient’s POC. Staff A, confirmed that a review of patient POCs reflected this concern. During an interview on 09/03/25 at 4:00 PM, Staff G, Director of Clinical Education and Risk Management, stated that a QAPI performance improvement project (PIP) was created in April of 2025 to improve wound documentation and integration of wound care into the POC. Staff G stated that after several months of auditing, integration of information into the POC continued to be problematic. A new PIP was created on 08/25/25 to focus on integrating tracked QAPI events (such as falls, infections, and wounds) into the POC. The Hospice failed to ensure routine updates to the POC.

Based on policy review, document review, record review, interview and observation, the Hospice failed to ensure that Registered Nurse (RN) and Home Health Aide (HHA) scheduled visit frequencies were provided as written on the plan of care (POC) for 3 (Patient 13, 17, and 18) of 30 patients sampled. Failure to ensure that POC frequencies are followed as written places patients at risk for unmet care needs. --- Findings Include:Review of the Hospice policy titled, “Hospice Aide Supervision,” last reviewed 05/29/24, showed, “A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG [interdisciplinary group] and provided by the hospice aide are meeting the patient’s need.”Review of the Hospice policy titled, “PLAN OF CARE,” last reviewed 05/29/24, showed, “The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family … Reviews of, and changes to, the plan of care are documented and communicated to members of the IDG.”Review of the Hospice policy titled, “PLAN OF CARE – CONTENT,” last reviewed 05/29/24, showed, “The plan of care includes, but is not limited to: … a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs…”Review of the Hospice policy titled, “COORDINATION OF SERVICES,” last reviewed 05/29/24, showed, “All members of the IDG, volunteers, and contracted personnel have access to the patient’s plan of care and are expected to provide care in accordance with it.”Review of the Hospice document titled, “Performance Improvement Plan: Visit Frequency & Aide Supervisory Documentation Compliance,” created 02/26/25, showed, “Internal audits revealed clinicians were not consistently documenting visit frequencies in the EMR [electronic medical record] … July 2025 and Beyond: Target for full compliance and sustained monitoring through monthly reviews, updated training as needed, and continued recognition of staff performance. … Expected Outcomes … Compliance: 100% adherence to Medicare visit frequency … Accuracy: Elimination of incomplete or missing documentation … Enhanced Patient Care: Improved continuity of services through accurate scheduling …”Patient 13Review of Patient 13’s medical record showed an 84-year-old admitted to hospice services on 05/19/25 with a primary diagnosis of malignant neoplasm (cancer) of the left breast.Review of Patient 13’s POC dated 09/03/25 showed an HHA visit frequency of two times weekly.Review of Patient 13’s IDG meeting note dated  08/29/25 showed an HHA visit frequency of two times weekly. Review of Patient 13’s record from 06/01/25 - 06/07/25 showed only one HHA visit was completed on 06/03/25. The record failed to show documented evidence that a second weekly visit was completed as required.Patient 17Review of Patient 17’s medical record showed a 91-year-old male admitted to hospice services on 06/19/24 with a primary diagnosis of malignant neoplasm (cancer) of the ascending colon.Review of Patient 17’s POC dated 09/03/25 showed a skilled nursing visit frequency of one time weekly and six PRN (as needed) visits. Review of Patient 17’s IDG meeting note dated 07/09/25 showed a skilled nursing visit frequency of one time weekly and six PRN visits. Review of Patient 17’s clinical notes for skilled nursing showed an RN visit completed on 06/20/25 and a subsequent RN visit completed on 07/11/25. Further review failed to show documented evidence of weekly skilled nursing visit for the week of 06/22/25 and 06/29/25 as required. Patient 18Review of Patient 18’s medical record showed an 88-year-old admitted to hospice services on 02/25/25 with a primary diagnosis of senile degeneration of the brain (a state of physical, emotional, and social decline of brain)Review of Patient 18’s POC dated 09/03/25 showed an HHA visit frequency of one time weekly. Review of Patient 18’s IDG meeting note dated 07/18/25 showed an HHA visit frequency of one time weekly. Review of Patient 18’s clinical notes for the HHA showed a visit made on 07/16/25 and a subsequent HHA visit made on 07/31/25. Further review failed to show documented evidence of a HHA visit for week of 07/20/25. During an interview on 09/09/25 at 3:00 PM, Staff G, Director of Clinical Education and Risk Management stated that visit frequency and scheduling for clinical staff was identified as problem since changing to a new charting system at the end of 2024.  During an interview on 09/10/25 at 4:05 PM Staff A, Vice President of Clinical Services, stated that visit frequencies should be followed as written on the POC. Staff A confirmed that review of Patient 13’s medical record failed to show evidence of a second HHA visit for the week of 06/01/25 and no missed visit note. Staff A confirmed that review of Patient 17’s medical record failed to show evidence of skilled nursing visit notes for the week of 06/22/25 and the week of 06/29/25. Staff A stated that Staff M, RN Case Manager, was on vacation during those 2 weeks and communication of visit coverage for Patient 17’s skilled nursing visits was missed. Staff A confirmed that review of Patient 18’s medical record failed to show an HHA visit for the week of 07/20/25 and no missed visit note.  The Hospice failed to ensure that all visit frequencies listed on the POC were accounted for and fulfilled.

Based on policy review, record review, and interview, the Hospice failed to communicate medication changes with non-hospice caregivers for 1 (Patient 2) of 30 patients sampled. Failure to provide an accurate medication list with non-hospice caregivers places these patients at risk for unmanaged symptoms and negative outcomes. --- Findings Include:Review of the Hospice policy titled, “COORDINATION OF SERVICES,” last reviewed 05/29/24, showed, “An assigned hospice RN coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers furnishing services unrelated to the terminal illness.”Patient 2Review of Patient 2’s record showed an 89-year-old admitted to hospice services on 04/07/25 with a primary diagnosis of malignant neoplasm of the left breast.Review of Patient 2’s medications showed the following:1.    Review of Patient 2’s plan of care (POC) medication list and “Patient Medication List” dated 09/03/25 showed that Miralax (laxative medication) was to be administered once every day.Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed that the medication was only to be administered daily AS NEEDED. 2.    Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 showed Levsin (medication used to reduce oral secretions) was to be administered in a quantity of one tablet every six hours as needed. Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed the medication was to be administered in a quantity of two tablets every six hours as needed. 3.    Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 showed Miebo ophthalmic solution (medication for dry eyes) was to be administered three times daily. Review of Patient 2’s residing facility’s medication record dated 09/03/25 did not list Miebo ophthalmic solution.4.    Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 showed Refresh Optive ophthalmic gel (medication for dry eyes) was to be administered two times daily. Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed the medication was to be administered three times daily. 5.    Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed Fiber-Lax (laxative medication) tablet to be administered daily. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 failed to show Fiber-Lax tablet. 6.    Review of Patient 2’s residing facility’s medication record dated 09/03/25 showed Montelukast Sodium (medication to treat allergies) to be administered one time daily. Review of Patient 2’s POC medication list and “Patient Medication List” dated 09/03/25 failed to show Montelukast Sodium 10mg tablet. During an interview with on 09/03/25 at 4:00 PM, Staff A, Vice President of Clinical Services, stated that each patient medication list is entered at the time of admission, reviewed by the medical director and pharmacy, and updated with any changes and during interdisciplinary group (IDG) every 2 weeks. Staff A stated that the registered nurse case manager (RNCM) is responsible for communicating and updating any changes to the patient POC or medication list.

Based on policy review, observation, and interview the Hospice failed to ensure standard practices of infection control were followed. Failure to follow appropriate infection control practices places patients at risk for exposure to communicable diseases and infections. --- Findings Include:Review of the Hospice policy titled, “INFECTION CONTROL – PROGRAM,” last reviewed on 05/29/24, showed, “…maintains and documents an effective, organization-wide infection control program that includes active monitoring, surveillance, identification, prevention, and control … The hospice’s infection control program includes, but is not limited to the following components: … education and training for staff … a written bloodborne pathogen exposure control plan”.Review of the Hospice policy titled, “INFECTION CONTROL - BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN,” last reviewed on 05/29/24, showed, “A written Bloodborne Exposure Control Plan (ECP) is maintained in accordance with OSHA standard 29 CFR 1910.1030 to prevent and control diseases caused by bloodborne pathogens or other potentially infectious materials. … Methods of compliance: … proper clean up and decontamination practices and handling regulated waste.”Review of the Hospice policy titled, “INFECTION CONTROL - STANDARD AND TRANSMISSION - BASED PRECAUTIONS,” last reviewed 05/29/24, showed, “Hospice staff are required to use standard precautions in the care of all hospice patients … Standard precautions include, but are not limited to: … Cleaning and disinfecting contaminated surfaces, equipment, and other objects in accordance with Centers for Disease Control and Prevention (CDC) standards. A tour of Location 3 (L3) on 09/04/25 at 1:55 PM showed a biohazard waste (potentially infectious materials that could pose a threat to public health or the environment) receptacle was stored between shelves of supplies in the clean supply room. The biohazard receptacle was open without a lid. During an interview on 09/04/25 at 1:55 PM, Staff E, Vice President of Clinical Services, stated that the biohazard receptacle is used for disposal of biohazard materials and is picked up by a contracted company one time a month.Patient 17 Review of Patient 17’s medical record showed a 91-year-old male admitted to hospice services on 06/19/24 with a primary diagnosis of malignant neoplasm (cancer) of the ascending colon.During a home visit for Patient 17 on 09/09/25 at 11:00 AM, Staff M, Registered Nurse Case Manager (RNCM), was observed using a blood pressure cuff on Patient 17. After use, Staff M failed to disinfect the cuff and placed it back into its storage container and then into his/her bag of clean equipment and supplies.  During an interview on 09/09/25 at 3:00 PM, Staff G, Director of Clinical Education and Risk Management, stated that the expectation for clinical staff is to follow nationally recognized infection control practices. Staff G, stated all staff receive initial orientation and annual education for all clinical standards of practice including infection control.The Hospice failed to ensure appropriate infection control practices were maintained placing patients at risk for transmission of infections.

Based on policy review, record review, and interview the Hospice failed to ensure a registered nurse (RN) performed a home health aide (HHA) supervisory visit at least every 14 days for 3 (Patient 1, 2, and 8) of 30 patients sampled. Failure to ensure an HHA supervisory visit is performed every 14 days places patients at risk for unmet care needs. --- Findings Include:Review of the Hospice policy titled, “HOSPICE AIDE SUPERVISION,” last reviewed 05/29/24 showed, “Hospice aides are supervised by a registered nurse in a manner and frequency that assures the safety of patients and the quality of aide services provided. … A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need. … The supervisory visits are documented in the patient’s clinical record every two weeks and include notation regarding the aide’s competency, whether the aide is following the patient’s plan of care, and is satisfactory to the patient/family.”Patient 1Review of Patient 1’s record showed a 73-year-old admitted to hospice services on 01/28/24 with a primary diagnosis of malignant neoplasm (cancer) of the neck. Review of Patient 1’s RN supervisory notes showed an RN supervisory visit performed on 06/09/25 and a subsequent RN supervisory visit performed 07/01/25 for a gap of 22 days between supervisory visits for the HHA.Patient 2Review of Patient 2’s record showed an 89-year-old admitted to hospice services on 04/07/25 with a primary diagnosis of malignant neoplasm of the left breast. Review of Patient 2’s RN supervisory notes showed an RN supervisory visit performed on 05/13/25 and a subsequent RN supervisory visit performed 05/28/25 for a gap of 15 days between supervisory visits for the HHA.Patient 8Review of Patient 8’s record showed a 83-year-old admitted to hospice services on 04/25/25 with a primary diagnosis of Alzheimer’s disease (a progressive disease, causing decline in memory loss and mental function). Review of Patient 8’s clinical notes showed an RN admission note performed on 04/25/25 establishing initial patient HHA frequency of 2 times weekly. The first RN supervisory visit was performed on 05/23/25 a gap of 28 days without an RN supervisory visit for the HHA. During an interview on 09/10/25 at 4:05 PM Staff A, Vice President of Clinical Services, stated that RN supervisory visits of an HHA should occur at least every 14 days. Staff A stated that review of Patient 1’s medical record failed to show an RN supervisory visit from 06/09/25 to 07/01/25. Staff A stated that review of Patient 2’s medical record failed to show an RN supervisory visit from 05/13/25 to 05/28/25. Staff A stated that review of Patient 8’s medical record failed to show an RN supervisory visit from 04/25/25 to 05/23/25. The Hospice failed to ensure RN supervisory visits were performed to oversee HHA’s at least every 14 days.

Based on policy review, observation, document review, contract review, and interview the Hospice failed to ensure a sanitary environment was maintained on the in-patient unit (IPU). Failure to maintain a sanitary environment places all patients in the IPU at risk for infection or communicable diseases. --- Findings Include: Review of the Hospice policy titled, “INFECTION CONTROL – PROGRAM,” last reviewed on 05/29/24 showed, “…maintains and documents an effective, organization-wide infection control program that includes active monitoring, surveillance, identification, prevention, and control …”Review of the Hospice policy titled, “INFECTION CONTROL – BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN,” last reviewed on 05/29/24, showed, “A written Bloodborne Exposure Control Plan (ECP) is maintained in accordance with OSHA standard 29 CFR 1910.1030 to prevent and control diseases caused by bloodborne pathogens or other potentially infectious materials. … Methods of compliance: … proper clean up and decontamination practices and handling regulated waste.”Review of the Hospice policy titled, “INFECTION CONTROL - STANDARD AND TRANSMISSION - BASED PRECAUTIONS,” last reviewed 05/29/24, showed, “Hospice staff are required to use standard precautions in the care of all hospice patients … Standard precautions include, but are not limited to: … Cleaning and disinfecting contaminated surfaces, equipment, and other objects in accordance with Centers for Disease Control and Prevention (CDC) standards."Review of the Hospice document titled, “Work Order,” dated 09/03/25, showed a second request for a repair of the sink in the dirty utility room with an additional comment on 09/02/25 a technician noted “I plunged sink several times without success.”Review of the Hospice lease contract with the hospital for the IPU dated 07/12/04 showed, “Landlord shall keep the Premises, and all the equipment located therein (except equipment provided by Tenant) in good order, condition and repair, and in compliance with all applicable federal, state, and local laws and regulations.” A tour of the IPU on 09/03/25 at 8:40 AM showed a clogged sink located in the dirty utility room with approximately 4 inches of dirty foul-smelling water. During a revisit of the IPU on 09/05/25 at 2:15 PM the clogged sink in the dirty utility room had been taped off with blue masking tape that read, “Do Not Use.” The standing water remained in the sink. During an interview on 09/03/25 at 9:00 AM, Staff C, Support Services Coordinator, confirmed the presence of standing water in the sink located in the dirty utility room on the IPU and stated that the sink was not draining properly. During an interview on 09/03/25 at 4:00 PM, Staff A, Vice President of Clinical Services, stated that the sink located in the dirty utility room on the IPU was not working properly. The Hospice failed to maintain a sanitary environment on the IPU due to failure to drain, clean, and repair of a sink in the dirty utility room that had standing dirty water from 09/02/25 through 09/05/25.

Based on interviews, record review, and policy review, the facility failed to report an allegation of abuse to the state agency that involved 1 (Patient 1) of 4 sampled patients reviewed for abuse. --- Findings included: Review of a facility policy titled, ";Assessment of Possible Abuse/Neglect," revised October 2019, revealed, ";The organization will report all suspected cases of abuse, neglect, or exploitation, in compliance with applicable state statutes to appropriate protection organizations." A review of undated state statute titled, ";Adult Mandatory Reporters 39-1431," revealed ";Abuse, neglect or exploitation of certain adults; reporting abuse, neglect or exploitation or need of protective services; persons required to report; penalty of failure to report, posting notice of requirements of act. (a) Any person who is licensed to practice any branch of the healing arts, a licensed psychologist, a licensed master level psychologist, a licensed clinical psychotherapist, the chief administrative officer of a medical care facility, a teacher, a licensed social worker, a licensed professional nurse, a licensed practical nurse, a licensed dentist, a licensed marriage and family therapist, a licensed clinical marriage and family therapist, licensed professional counselor, licensed clinical professional counselor, registered alcohol and drug abuse counselor, a law enforcement officer, a case manager, a rehabilitation counselor, a bank trust officer or any other officers of financial institutions, a legal representative, a governmental assistance provider, an owner or operator of a residential care facility, and independent living counselor and the chief administrative officer of a licensed home health agency, the chief administrative officer of an adult family home and the chief administrative officer of a provider of community services and affiliates thereof operated or funded by the department for children and families or licensed under K.S.A. 75-3307b and amendments thereto who has reasonable cause to believe that an adult is being or has been abused, neglected or exploited or is in need of protective services shall report, immediately from receipt of the information, such information or cause a report of such information to be made in any reasonable manner. An employee of a domestic violence center shall not be required to report information or cause a report of information to be made under this subsection. Other state agencies receiving reports that are to be referred to the department for children and families and the appropriate law enforcement agency, shall submit the reports to the department and agency within six hours, during normal workdays, of receiving the information. Reports shall be made to the department for children and families during the normal working weekdays and hours of operation. Reporters shall be made to law enforcement agencies during the time social and rehabilitation services are not in operation. Law enforcement shall submit the report and appropriate information to the department for children and families on the first working day that department for children and families is in operation after receipt of such information." A review of Patient 1s ";Combined Discipline Comprehensive Assessment," dated 10/26/23, revealed the facility admitted Patient 1 on 03/07/19, with diagnoses that included neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), Parkinsons disease, and heart failure. A review of Patient 1s ";Nurse Progress Note Routine Visit," dated 10/30/23 and electronically signed by Registered Nurse Case Manager (RNCM) 3, revealed Paid Caregiver (PCG) 1 reported after she viewed home camera videos related to how Patient 1 sustained a skin tear to the right hand while being cared for by a nightshift caregiver, who no longer was employed by the facility due to patient abuse. Per the Nurse Progress Note Routine Visit, PCG 1 verbalized the paid caregiver hit, taunted, and mocked the patient when the patient cried. Per the Nurse Progress Note Routine Visit, PCG 1 reported the caregiver laid the patient in bed and fed the patient a dark colored liquid by wat of a syringe which caused the patient to cough, choke, and become short of breath. The Nurse Progress Note Routine Visit indicated the caregiver laughed, mocked, and turned the television volume up louder. The Nurse Progress Note Routine Visit revealed the office manager, social worker, and physician were notified of the reported abuse. A review of Patient 1s ";Interdisciplinary Note," dated 10/30/23, electronically signed by Licensed Medical Social Worker (LMSW) 4, revealed the social worker placed a phone to Patient 1s residence to follow up regarding the alleged abuse of the patient by another paid caregiver. During an interview on 11/09/23 at 2:58 PM, PCG 1 stated that on 10/27/23 another PCG who was not affiliated with the agency (PCG 2) contacted her and reported Patient 1 had sustained an injury to their right hand. PCG 1 stated she notified RNCM 3 of the injury. According to PCG 1, RNCM 3 visited the Patient 1, assessed and treated the injury on Patient 1s right hand, and suggested they watch the video of the 10/26/23 overnight shift due to the appearance of the skin on Patient 1s hand. PCG 1 stated while watching the video, she observed and heard Patient 1 loudly cry out while PCG 2 grabbed and pulled on Patient 1s hand. Per PCG 1, PCG 2 leaned over Patient 1 and used ";a mocking tone" said ";go ahead and cry some more." PCG 1 stated, Patient 1 shouted ";my hand," and PCG 2 left Patient 1 alone in the room to cry. According to PCG 1, on the video, PCG 2 returned with a syringe filled with an unknown dark liquid and administered the fluid orally to Patient 1, who began to gasp and make. PCG 1 stated on 10/30/23 or 10/31/23 she told RNCM 3 what she had observed on the video and RNCM 3 told PCG 1 she would discuss this information with LMSW 4. On the afternoon of 10/30/23 or 10/31/23, PCG 1 stated she spoke with LMSW 4 and described what she observed on the 10/26/23 overnight shift video, and her concerns that PCG 2 had abused Patient 1. PCG 1 stated LMSW 4 texted her information on how to report allegations to Adult Protective Services (APS). During an interview on 11/10/23 at 12:50 PM, RNCM 3 stated that PCG 1 reported Patient 1 had a skin tear that occurred during an overnight shift. According to RNCM 3. PCG 1 later reported she watched the video from the overnight shift of 10/26/23 and observed another PCG abuse Patient 1. RNCM 3 stated PCG 1 asked how to report the alleged abuse and RNCM 3 provided instruction on who to contact. RNCM 3 stated she then notified the Vice President of Clinical Services (VPCS), LMSW 4 and the patients physician. RNCM 3 stated she did not report the abuse allegation to any state agencies because it was ";hearsay," she did not have proof of the abuse happening. RNCM 3 stated the agency policy was the nurse reported allegations of abuse to the clinical supervisor and notified an agency social worker who would then contact Adult Protective Services (APS). During an interview on 11/10/23 at 1:15 PM, LMSW 4 stated that on 10/30/23, RNCM 3 told her that PCG 1 had shared an allegation that PCG 2 injured Patient 1s hand. LMSW 4 stated she provided education to PCG 1 on how to report an allegation of abuse to APS. LMSW 4 stated she did not report the abuse allegation to any state agencies as she had no suspicions that abuse had occurred, she did not see any proof that abuse happened, and considered the allegation ";hearsay." LMSW 4 defined an allegation of abuse as when she witnessed the event or believed that abuse had happened. During an interview on 11/13/23 at 9:45 AM, the VPCS stated that on 10/30/23, PCG 1 reported she viewed the video of Patient 1s care and reported the overnight PCG abused Patient 1. Per the VPCS, the facility did not report the allegation of abuse to APS because the patients family had already reported the incident.

Based on interviews, record review, and policy review, the agency failed to provide needed services for one (Patient 6) of two patients reviewed for the provision of care and services based on all assessments when the agency failed to ensure that Patient 6 received mental health services. This failure resulted in a lack of necessary mental health support for Patient 6 and potentially contributed to Patient 6's discharge from the agency. Findings Include: Review of an agency policy titled, "The Plan of Care," copyrighted in 1995, showed that patients' plans of care (POCs) would be based on initial and ongoing assessments of patients' needs and goals and would be revised as needed based on outcomes of interventions. Review of Patient 6's "Patient Face Sheet," undated, showed that Patient 6 was admitted to the agency on 10/26/21 with diagnoses that included stage 5 chronic kidney disease (CKD - a condition characterized by a loss of kidney function that required dialysis or a kidney transplant) and schizoaffective disorder, bipolar type (a mental health disorder with symptoms that may include delusions, hallucinations, paranoia, depression, and mood changes). Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 10/26/21, showed that Patient 6 was anxious and had a goal that Patient 6's mental health disorder would be managed without compromising Patient 6's care. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 10/28/21, showed that Patient 6 appeared disheveled, was anxious, had a history of mental health hospitalizations, was estranged from all but one family member, and was fearful of living alone. Further review indicated that Patient 6 had recently terminated community-based mental health services, was refusing to return to the community-based provider, was open to receiving private practice mental health services, was interested in eye movement desensitization and reprocessing (EMDR - a type of therapy that used eye movement to alleviate anxiety), and that Social Worker (SW) A would look for local mental health provider resources. Further review indicated that SW A also identified a goal that the agency would assist in managing Patient 6's mental health disorder so that it would not interfere with Patient 6 receiving hospice care. Review of Patient 6's clinical record did not show that SW A followed up on Patient 6's need for private practice mental health services or EMDR therapy. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 11/05/21, showed that Patient 6 was anxious and was repeating stories "over and over." Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/05/21, showed that Patient 6 was very anxious during the visit, in constant movement, requested the door be locked due to fears of people entering the home, and was worried about the relationship with their primary contact/caregiver who was also their significant other. Review of Patient 6's "Combined Disciplinary Plan of Care," dated 11/09/21, showed that one of Patient 6's goals was to manage mental health disorders without compromising care and that Patient 6 was to continue involvement with existing mental health care providers. Further review did not show any documentation of a discussion or review of SW A's assessment on 10/28/21 that showed Patient 6 was no longer receiving mental health services. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/09/21, showed that Patient 6 expressed feelings of anxiety and loneliness and asked the provider to end the visit early. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 11/15/21, showed that Patient 6 reported a high level of anxiety but refused medications for anxiety. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/19/21, showed that Patient 6 was screaming, crying, yelling, and repeatedly stating that their significant other was in town but not spending time with Patient 6. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 11/23/21, showed that Patient 6 had constant anxiety and was taking medications for the anxiety. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/23/21, showed that Patient 6 was "in better emotional condition at this visit than the previous." Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 11/30/21, showed that Patient 6 had increased anxiety and had not taken routine daily medications for two days due to increased anxiety. Review of Patient 6's "Spiritual Counselor Note Comprehensive Assessment," dated 11/30/21, showed that Patient 6 appeared confused, repeated stories, and was distressed due to the relationship with their significant other. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/10/21, showed that Patient 6 had a fear of being committed to a mental health facility, and declined any further social work or spiritual counseling services. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/13/21, showed that Patient 6 had missed a call to their significant other and became agitated, shouted, told the care provider to shut up and to not move, "appeared and spoke like a different person," and threw their phone at the care provider during the visit. Further review showed that these behaviors were reported to the Vice President of Clinical Services (VPCS). Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/21/21, showed that Patient 6 became agitated when speaking about feeling abandoned by their family over the holidays, issues with their significant other, and fear that the hospice staff would have them committed to a mental health facility. Further review indicated that Patient 6 frequently repeated topics, yelled at the nurse, but then stated that talking to the nurse was helpful. Review of Patient 6's "Combined Disciplinary Plans of Care," dated 11/23/21, 12/07/21, 12/23/21, showed that one of Patient 6's current goals was to manage mental health disorders without compromising care and that Patient 6 was to continue involvement with existing mental health care providers. Further review did not show any documentation of a discussion or review that Patient 6 was no longer receiving mental health services. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/28/21, showed that Patient 6 became agitated, was rocking back and forth, yelling at staff, repeatedly talking about a lost key, refused care, and shouted at staff to leave. Further review showed that the nurse had felt it was unsafe for staff to provide services to Patient 6 due to these behaviors and had reported that information to the VPCS. Review of Patient 6's "Interdisciplinary Note," dated 12/28/21, showed that the VPCS called Patient 6 to discuss services and that Patient 6 had refused services, but would not sign revocation documentation at that time. Further review indicated that VPCS discussed concerns about staff safety due to Patient 6's behaviors. Review of Patient 6's "Transfer/Death/Discharge Summary," dated 12/29/21, showed that Patient 6 was discharged due to their "erratic and unpredictable behaviors." During an interview on 06/16/22 at 1:14 PM, Spiritual Counselor (SC) B, stated that SC B did not recall if Patient 6's behaviors were discussed during the interdisciplinary group meetings (IDG meeting - a meeting to develop a hospice patient's POC that used a multidisciplinary team approach) but remembered that staff (unknown) discussed Patient 6's behaviors outside of the IDG meetings. During an interview on 06/16/22 at 1:33 PM, SW A, stated that Patient 6 was not receiving any active mental health treatment at the time of their admission to the agency as Patient 6 had "fired" the mental health providers prior to admission. SW A stated that Patient 6 was interested in receiving EMDR therapy and that SW A attempted to obtain this service but had been unable to locate EMDR therapy services in the area and Patient 6 did not have transportation to other areas to receive the services. SW A stated that there was no documentation of the agency attempting to locate therapy services for Patient 6 and stated that SW A should have documented the attempts. SW A did not recall if Patient 6's behaviors or mental health issues were discussed in IDG meetings or by staff outside of IDG meetings. During an interview on 06/16/22 at 2:23 PM, Registered Nurse (RN) D stated that the VPCS was notified on 12/13/21 that Patient 6 had thrown a phone at RN D but was unaware of any follow up. RN D stated that Patient 6's escalating behaviors were discussed in several IDG meetings, but no interventions or changes to the plan of care were discussed. RN D stated that the agency sent a different nurse to provide care to Patient 6 on 12/28/21, and that when Patient 6 demonstrated angry behaviors toward that nurse, the agency decided to discharge the patient. During an interview on 06/16/22 at 3:05 PM, the VPCS stated that the VPSC participated in Patient 6's IDG meetings and the agency was aware of Patient 6's mental health issues prior to Patient 6's admission. The VPCS stated that Patient 6's behaviors were discussed in IDG meetings, but that the discussions were not documented. The VPCS stated that the outcome of these discussions was that RN D was the target of Patient 6's anger and that the agency decided to send a different nurse to provide care for Patient 6. The VPCS stated that RN D notified the VPCS on 12/13/21 that Patient 6 had thrown a phone at RN D, and there was a discussion to send a different nurse to provide care to Patient 6, but that the VPCS did not document the report or any follow-up actions. The VPCS stated that, on 12/28/21, after Patient 6 had demonstrated unsafe behaviors toward a different nurse and social worker, the IDG team decided to discharge Patient 6 due to concerns for staff safety. The agency was unable to provide documentation of IDG team meeting discussions of Patient 6's behaviors as detailed in provider assessments, or any updates to Patient 6's POC based on the escalation of Patient 6's behaviors. During a concurrent record review and interview on 06/20/22 at 11:14 AM the Quality Assurance Director (QAD), stated that the agency expectation was for staff to communicate patient needs as identified in assessments during IDG POC planning meetings, document these communications, and update patient POCs as needed and acknowledged that the agency was not following its policy.

Based on interviews, record review, and policy review, it was determined that the agency failed to provide needed services for one (Patient 6) of two patients reviewed for medical social services when Social Worker (SW) A failed to follow up on Patient 6's need for therapy services. This failure resulted in Patient 6 not receiving necessary mental health support and potentially contributed to Patient 6's discharge from the hospice. Findings Include: Review of an agency policy titled, "Psychosocial Services," revised 04/2021, showed the agency would provide psychosocial services (counseling and casework services which addressed the social, economic, psychological, and emotional needs of patients and families) to patients, including referrals to community support services. Review of Patient 6's undated "Patient Face Sheet," showed the agency admitted Patient 6 on 10/26/21 with diagnoses that included stage 5 chronic kidney disease (CKD - a condition characterized by loss of kidney function that required dialysis or a kidney transplant) and schizoaffective disorder, bipolar type (a mental health disorder with symptoms that may include delusions, hallucinations, paranoia, depression, and mood changes). Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 10/26/21, showed that Patient 6 was anxious and a goal that Patient 6's mental health disorders would be managed without compromising Patient 6's care. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 10/28/21, showed Patient 6 appeared disheveled, was anxious, had a history of mental health hospitalizations, was estranged from all but one family member, and was fearful of living alone. Further review indicated that Patient 6 had recently terminated community-based mental health services and was refusing to return to the community-based provider, but was open to receiving private practice mental health services and was interested in eye movement desensitization and reprocessing therapy (EMDR - a type of therapy that used eye movement to alleviate anxiety). The review indicated that SW A would look for local mental health provider resources for Patient 6. Further review indicated that SW A had also identified a goal that the agency would assist in managing Patient 6's mental health disorder so that it would not interfere with Patient 6 receiving hospice care. Review of Patient 6's clinical record did not show that SW A or any agency staff member had followed up on Patient 6's need for private practice mental health services or EMDR therapy. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/05/21, showed that Patient 6 was very anxious during the visit, in constant movement, requested that the door be locked due to fears of people entering the home, and was worried about the relationship with their primary contact/caregiver who was also their significant other. Review of Patient 6's "Combined Disciplinary Plan of Care," dated 11/09/21, showed that one of Patient 6's goals was to manage mental health disorders without compromising care and that Patient 6 was to continue involvement with existing mental health care providers. Further review did not show any documentation of a discussion or review of SW A's assessment on 10/28/21 that showed Patient 6 was no longer receiving mental health services or Patient 6's interest in receiving mental health services from a private practice. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/09/21, showed that Patient 6 expressed feelings of anxiety and loneliness and had asked the provider to end the visit early. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/19/21, showed that Patient 6 was screaming, crying, yelling, and repeatedly stating that their significant other was in town but not spending time with Patient 6. Review of Patient 6's "Social Worker Progress Note Comprehensive Assessment," dated 11/23/21, showed that Patient 6 was "in better emotional condition at this visit than the previous." Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 11/30/21, showed that Patient 6 had increased anxiety and had not taken routine daily medications for two days due to increased anxiety. Review of Patient 6's "Spiritual Counselor Note Comprehensive Assessment," dated 11/30/21, showed that Patient 6 appeared confused, repeated stories, and was distressed due to the relationship with their significant other. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/10/21, showed that Patient 6 had a fear of being committed to a mental health facility, and declined any further social work or spiritual counseling services. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/13/21, showed that Patient 6 had missed a call to their significant other and became agitated, shouted, told the care provider to shut up and to not move, "appeared and spoke like a different person," and threw their phone at the care provider during the visit. Further review showed that these behaviors were reported to the Vice President of Clinical Services (VPCS). Review of Patient 6's "Combined Disciplinary Plans of Care," dated 11/23/21, 12/07/21, and 12/23/21, showed that one of Patient 6's current goals was to manage mental health disorders without compromising care and that Patient 6 was to continue involvement with existing mental health care providers. Further review did not show any documentation of a discussion or review that Patient 6 was no longer receiving mental health services. Review of Patient 6's "Nurse Progress Note Comprehensive Assessment," dated 12/28/21, showed that Patient 6 became agitated, was rocking back and forth, yelling at staff, repeatedly talking about a lost key, refused care, and shouted at staff to leave. Further review showed that the nurse felt that it was unsafe for staff to provide services to Patient 6 due to these behaviors and reported that information to the VPCS. Review of Patient 6's "Interdisciplinary Note," dated 12/28/21, showed that the VPCS called Patient 6 to discuss services and that Patient 6 had refused services, but would not sign revocation documentation that time. Further review indicated that the VPCS discussed concerns about staff safety due to Patient 6's behaviors. Review of Patient 6's "Transfer/Death/Discharge Summary," dated 12/29/21, showed that Patient 6 was discharged due to their "erratic and unpredictable behaviors." During an interview on 06/16/22 at 1:33 PM, SW A, stated that Patient 6 was not receiving any active mental health treatment at the time of their admission to the agency as Patient 6 had "fired" the mental health providers prior to admission. SW A stated that Patient 6 was interested in receiving EMDR therapy and that SW A attempted to obtain this service but was unable to locate EMDR therapy services in the area and that Patient 6 did not have transportation to other areas to receive the services. SW A stated that there was no documentation of the agency attempting to obtain therapy services for Patient 6 and stated that SW A should have documented the attempts. The agency was unable to provide documentation that any referrals had be made to mental health providers while Patient 6 was receiving agency services. During a concurrent record review and interview on 06/20/22 at 11:14 AM, Quality Assurance Director (QAD), stated that the agency expectation was for staff to attempt to complete referrals for patients when needed and to document those attempts. The QAD acknowledged that the agency was not following its policy.

Based on observation and staff interview, the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 15 residents in one smoke zone. The facility has a capacity of 15 and a census of 5. Findings Include: During the survey on June 14, 2022 between the hours of 8:30 AM and 10:30 AM the following is observed: 1. At 9:00 AM, it is noted that the laundry room in the corridor is not provided with an automatic door closure. The Clinical Manager was present and acknowledged the findings. Review of the following National Fire Protection Association (NFPA) Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1 Review of the following NFPA Standard revealed: The doors shall be self-closing or automatic-closing. 2012 NFPA 101, 19.3.2.1.3

Based on observation, interview and record review, the facility failed to install smoke detectors in accordance with National Fire Protection Association (NFPA) 72. Failure to maintain smoke detectors and smoke alarms decreases the possibility of detection of smoke and smoke products in the facility delaying the notification of residents, visitors, and staff in the event of a fire affecting all residents, visitors, and staff in 1 of 1 smoke zone. The facility has a capacity of 15 with a census of 5 at the time of this survey. Findings Include: During the survey on June 14, 2022, between the hours of 8:30 AM and 10:30 AM, the following observations were made: 1. It was observed at 9:45 AM that smoke detectors were mounted closer than 36" to the Heating, Ventilation, and Air Conditioning (HVAC) supply or return vents in Room 8156, at three locations in the corridor to the elevator, and in the corridor outside of Room 8504. The Clinical Manager was present during the survey and acknowledged the findings. Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 Review of the following NFPA Standard revealed: Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted by one of the following: (1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met: (a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. (2) In smoke compartments protected throughout by an ap proved, supervised automatic sprinkler system in accordance with 19.3.5.8, waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met: (a) The aggregate waiting area in each smoke compartment does not exceed 600 ft2 (55.7 m2). (b) Each area is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or each area is arranged and located to allow direct supervision by the facility staff from a nursing station or similar space. (c) The area does not obstruct access to required exits. (3)*This requirement shall not apply to spaces for nurses' stations. NFPA 101, 2012 19.3.6.1

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of National Fire Protection Association (NFPA) 25 This deficient practice fails to ensure that the sprinkler system is properly prepared, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system, affecting all residents, patients, visitors and staff in 1 of 1 smoke zone. The facility has a capacity of 15 with a census of 5 at the time of this survey. Findings Include: During the survey conducted on June 14, 2022, between the hours of 8:30 AM and 10:30 AM, the following is observed: 1. At approximately 10:00 AM., it is observed that the Administrator/Staff Corridor and offices and restrooms within the space, have a combination of quick response (QR) and standard response sprinkler heads in a common space. The patient area has QR sprinkler heads within the corridor but no smoke barrier, smoke/fire wall, or suite boundary is found at the transition to standard response sprinkler heads in the administration area. The Clinical Manager was present and acknowledged these findings. NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5. NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1 NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1