Every finding on record at Saad Enterprises, Inc

Based on observation, the facility failed to maintain the stairway exit enclosure per the requirements of: 2012 NFPA 101, 19.2.2.3, and 7.2.2.5.3.1  This deficiency affects 1 of 2 stairwells. --- Findings include: During a tour of the facility, the surveyor observed 2 flatbed carts being stored in the basement level of the Back Stairwell of the North Wing. A member of the maintenance staff was present when this deficiency was identified. .

Based on observation, the facility failed to maintain the required means of egress per the requirements of: 2012 NFPA 101, 19.2.10.1, and 7.10.8.3 This deficiency affects 1 of 1 non exits. --- Findings include: During a tour of the facility, the surveyor observed on the 1st floor level of the Back Stairwell of the North Wing, a door leading to the Kitchen roof that could be mistaken for an exit and was not identified with a sign that reads, “No Exit”. A member of the maintenance staff was present when this deficiency was identified. .

Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.1.1, and 9.7.7       2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects all of the sprinkler system. --- .Finding Include:During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following:(1)  Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal   sensitivity, and pressure rating(2)  General description(3)  Quantity of each type to be contained in the cabinet(4)  Issue or revision date of the list A member of the maintenance staff was present when this deficiency was identified..

Based on review of documentation, the facility failed to maintain the private fire hydrant per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.82011 NFPA 25, 7.2.1, Table 7.1.1.2, 7.3.2, and 7.4.2.1  This deficiency affects 1 of 1 private fire hydrants. --- Findings include: During a tour of the facility, the facility failed to provide documentation of the yearly inspection and maintenance for the one private fire hydrant. A member of the maintenance staff was present when this deficiency was identified..

Based on observation, the facility failed to maintain a corridor door per the requirements of: 2012 NFPA 101, 19.3.6.3.10 This deficiency affects 1 corridor door. --- Findings include: During a tour of the facility, the surveyor observed one of the Conference Center corridor doors was impeded from closing by a kettlebell weight. A member of the maintenance staff was present when this deficiency was identified. .

Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 smoke barrier. --- Findings include: During a tour of the facility, the surveyor observed an unsealed penetration (the inside of the conduit) of a ¾” EMT conduit used as a chase for 2 blue cables, above the ceiling of the smoke barrier between the Bereavement Room/People Development Room 1 and the North Wing.  A member of the maintenance staff was present when this deficiency was identified. .

Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the comprehensive assessments were completed within five days. This deficient practice affected four of 27 MR reviewed including MR # 11, MR # 21, MR # 5, MR # 14, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Interdisciplinary Team Meeting ProcedurePolicy Number: 2A0225Reviewed: 6/25Section 1: Purpose/Objective1.1. To implement and maintain a process of coordinated patient communication to ensure continuity of care from admission through discharge/death...Section 4: Procedure4.1. A Care Plan and Assessment meeting will be completed within 5 days of admission...4.3. Patient information will include at a minimum:...b. Frequencies for all disciplinesc. Current issue/Concern/Problemd. MSW (Master of Social Work) Sectione. Chaplain Section...g. Volunteer Section --- 4. MR # 14 was admitted on 8/14/25 with a diagnosises of Parkinson's Disease without Dyskinesia, without mention of fluctuations and Ataxia, unspecified.Review of the HCPOC dated 8/14/25 revealed physician's orders for SN two visits per week for thirteen weeks, MSW one visit per week for one week, HHA two visits per week for twelve weeks.Review of the MSW VNR dated 8/20/25 revealed the MSW assessment was not completed until six days after admission. An interview was conducted on 9/18/25 at 4:23 PM with EI # 1 who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days.   3. MR # 5 was admitted to the agency on 7/29/25 with a primary diagnosis of Alzheimer's Disease, Unspecified.Review of the HCPOC dated 7/29/25 revealed physician's order for SN two visits a week for thirteen weeks, MSW one visit per week for one week, HHA one visit for one week then three visits for twelve weeks, and Chaplain one visit for one week. Review of the MR revealed the initial chaplain assessment dated 8/5/25 was not completed until eight days after admission.An interview was conducted on 9/18/24 at 3:19 PM with EI # 1 who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days.                                2. MR # 21 was admitted on 2/5/25 with a primary diagnosis Malignant Neoplasm of Rectum.Review of the HCPOC dated 2/5/25 revealed physician orders for SN three visits per week for one week and two visits a week for 12 weeks, and MSW one visit per week for one week.Review of the MSW VNR dated 2/11/25 revealed the MSW assessment was not completed until 6 days after admission. An interview was conducted on 9/18/25 at 4:06 PM with EI # 1, Clinical Director, who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days.  1. MR # 11 was admitted on 7/31/25 with a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery with Angina Pectoris. Review of the Hospice Certification and Plan of Care (HCPOC) dated 7/31/25 revealed physician orders for Skilled Nurse (SN) two visits per week for 13 weeks, MSW one visit per week for one week, Home Health Aide (HHA) two visits per week for 13 weeks, and Chaplain (CH) one visit per week for one week. Review of the CH Visit Note Report (VNR) dated 8/7/25 revealed the CH assessment was not completed until seven days after admission. Review of the MSW VNR dated 8/13/25 revealed the MSW assessment was not completed until 13 days after admission. An interview was conducted on 9/18/25 at 3:30 PM with Employee Identifier (EI) # 1, Clinical Director, who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days.

Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure volunteer services were offered as requested. This deficient practice affected four of 27 MR reviewed including MR # 14, Home Visit (HV) # 6, HV # 3, MR # 12, and had the potential to negatively affect all patients admitted to this agency.Findings include:Agency Policy: Volunteer ProgramPolicy Number: NoneReviewed: 7/21Purpose/Objective: 1.1 Saad Hospice Volunteer Program exists to place trained volunteer personnel as adjunct members to the hospice patient care team.Policy: Services of volunteers are provided on an as needed basis or by inclusion in the patient's plan of care. --- 4. MR # 12 was admitted to the agency on 5/2/25 and recertified for care on 7/26/25 with a primary diagnosis of Cerebral Infarction, Unspecified.Review of the Hospice Recertification Plan of Care Update dated 7/16/25 revealed physician's orders for SN three visits per week for one week, seven visits per week for twelve weeks, and three visits per week for one week. MSW one visit every month for three months and HHA two visits per week for one week, five visits per week for twelve weeks, and two visits per week for one week.Review of the MSW Client Coordination  Report dated 8/26/25 revealed MSW reviewed Volunteer Services with patient. Patient and caregiver  requested volunteer services and request was sent to Volunteer Coordinator. There was no documentation of a volunteer visit.An interview was conducted on 9/18/25 at 3:44 PM with EI # 1, who confirmed the staff failed to provide volunteer services. 3. HV # 3 was admitted on 9/5/25 with a primary diagnosis of Senile Degeneration of Brain. Review of the HCPOC dated 9/5/25 revealed physician's orders for SN two visits per week for 13 weeks then one visit per week for one week, MSW one visit for one week, and HHA three visits per week for 12 weeks then two visits per week for one week. Review of the MSW Client Coordination Note Report dated 9/8/25 revealed the MSW documented the patient/caregiver had requested volunteer services and the request had been sent to Volunteer Coordinator. There was no documentation volunteer services were provided. An interview was conducted on 9/18/25 at 4:00 PM with EI # 1 who confirmed volunteer services were not provided as requested.   1. MR # 14 was admitted on 8/14/25 with diagnoses including Parkinson's Disease without Dyskinesia, without mention of fluctuations and Ataxia, unspecified.Review of the Hospice Certification and Plan of Care (HCPOC) dated 8/14/25 revealed physician orders for Skilled Nurse (SN) two visits a week for thirteen weeks, Masters in Social Work (MSW) one visit a week for one week, and Hospice Aide (HA) two visits a week for twelve weeks, then one visit a week for one week.Review of the MSW Client Coordination Note Report dated 8/20/25, revealed patient/caregiver requested volunteer services.There was no documentation of a volunteer visit.An interview was conducted on 9/18/25 at 4:23 PM with Employee Identifier (EI) # 1, Clinical Director, (CD) who confirmed the staff failed to provide volunteer services.2. HV # 6 was admitted on 7/30/35 with diagnoses including Hypertensive Heart Disease without Heart Failure and Paroxysmal Atrial Fibrillation.Review of the HCPOC dated 7/30/25 revealed physician orders for SN two visits a week for thirteen weeks, then one visit a week for one week, MSW one visit a week for one week, HA three visits a week for one week, five visits a week for twelve weeks, then one visit a week for one week, and Chaplain (CH) one visit a week for one week.Review of the MSW Client Coordination Note Report dated 8/28/25, revealed patient/caregiver requested volunteer services.There was no documentation of a volunteer visit.An interview was conducted on 9/18/25 at 4:17 PM with EI # 1, who confirmed the staff failed to provide volunteer services.

Based on observation, agency policies and procedures, Centers for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, and staff interviews, it was determined the agency failed to ensure staff: 1. Performed hand hygiene per agency policy, and CDC Guidelines. 2. Followed the agency's bed bath protocol. 3. Followed agency policy for medical equipment cleaning. 4. Followed agency policy for barrier protection/bag technique. These deficient practices did affect three of seven home visits (HV) conducted including HV # 1, HV # 4 and HV # 6, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Hand Washing IndicationsPolicy Number: 2B1230Date Reviewed: 01/25Section 1: Purpose/Objective 1.1. To prevent the spread of infection among the staff, visitors, and patients of Saad Hospice...Section 2: Policy 2.1. All employees will follow CDC hand washing recommendations for preventing the spread of infection...Section 4: Procedure 4.3. Employees should always sanitize their hands before and after touching wounds. 4.4. Employees should sanitize their hands before and after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood, or bodily fluids, secretions, excretions... 4.6. Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated...Agency Policy: Complete Bed Bath Procedure Policy Number: Not ListedDate Reviewed: 08/25Section 1: Purpose/ObjectiveTo remove dirt and odors...and help prevent skin breakdown in hospice patients...Section 4: Procedure 4.1. Use Universal Precautions... 4.3. Sanitize hands by washing...Apply gloves... 4.27. Wash patients back and buttocks...4.29. Wash Hands, and apply gloves...Agency Policy: Medical equipment CleaningPolicy Number: 2B1219Date Reviewed: 12/23 Section 1: Purpose/Objective 1.1. To provide clean equipment for patient use and reduce the risk of the spread of infection.Section 2: Policy 2.1. All equipment used for assessing patient vitals will be cleaned... between use on each patient...Agency Policy: Barrier Protection for Non-Disposable Medical SuppliesPolicy Number: 2A124Date Reviewed: 02/22Section 1: Purpose/Objective 1.1. To prevent and control infections in the home care setting.Section 2: Policy 2.1. All staff will be responsible for using recommended precautions... 2.5. Linen, laundry, or any other surface in direct contact with the patient or any other surface in the patient's home where contamination is possible should be considered contaminated...Section 4: Procedure...4.2. Prior to replacing any non-disposable medical equipment or storage container for medical supplies on a surface in the patient's home, the hospice staff member will place a fluid impermeable, disposable barrier material on the surface. The equipment can then be placed on top of the barrier. The barrier for the bag is divided into a clean half and a dirty half. The clean and dirty barrier equipment are not to be intermingled. 4.3. ...Once the non-disposable supplies have been used, they will be cleaned..., allowed to dry for the allotted time... and returned to the appropriate place within the work bag. CDC Clinical Safety: Hand Hygiene for Healthcare Workers.February 27, 2024Recommendations:Know When to Clean Your Hands: a. Immediately before touching a patient... c. Before moving from work on a soiled body site to a clean body site on the same patient. d. After touching a patient or patient's surroundings... e. After contact with blood, body fluids, or contaminated surfaces. f. Immediately after glove removal...Know When to Wear ( and change) Gloves.Gloves are not a substitute for hand hygiene. a. If your task requires gloves, perform hand hygiene  before donning gloves and touching the patient or patient's surroundings. b. Always clean your hands after removing gloves... --- 3. HV # 6 was admitted to the agency on 7/30/25 with a primary diagnosis of Hypertensive Heart Disease without Heart Failure and Paroxysmal Atrial Fibrillation.Review of the HCPOC dated 7/30/25 revealed physician's order for SN visits two per week for thirteen weeks, MSW visits one time per week for one week, HHA visits three times per week for one week, then five times per week for twelve weeks, and CH visits one time per week for one week.A HV was conducted on 9/17/25 at 8:47 AM to observe wound care provided by EI # 5, RN.EI # 5 placed a barrier on a bedside table and a second barrier on a chair.EI # 5 performed hand hygiene, donned gloves, and obtained HV # 6's blood pressure, temperature, oxygen saturation, and heart rate. EI # 5 placed the used equipment on the clean half of the barrier.EI # 5 then cleaned the blood pressure cuff, placed the used equipment back on the barrier with the dirty equipment, allowed the equipment to dry, and returned the equipment back to his/her bag.An interview was conducted on 9/18/25 at 4:17 PM with EI # 2, Inpatient Unit Director who confirmed staff did not follow the agency policies for cleaning of equipment or barrier protection/bag technique.  1. HV # 1 was admitted to the agency on 1/6/25 and recertified for care on 7/20/25 with the primary diagnosis Senile Degeneration of Brain, not Elsewhere Classified.Review of the Hospice Recertification Plan of Care Update (HRPOCU) dated 7/20/25 revealed physician's order for Skilled Nurse (SN) visits one per week for nine weeks, Master of Social Work (MSW) visits one per month for two months, Home Hospice Aide (HHA) visits five per week for eight weeks, Chaplain visits one per month for three months.A HV was conducted on 9/16/25 at 1:08 PM to observe care provided by Employee Identifier (EI) # 7, HHA , to provide a bed bath for HV # 1.EI # 7 washed and rinsed HV # 1's buttocks then his/her back and legs. Wearing the same pair of dirty gloves, EI # 7 dried his/her buttocks, back and legs with a towel, changed linen, Chux, and draw sheet, turned patient from side to side, dressed him/her with a clean shirt, pulled head of bed into a sitting position and pulled his/her sheet and blanket up to his/her chin without changing out of the dirty gloves.An interview was conducted on 9/18/25 at 4:02 PM with EI # 1, Clinical Director, who confirmed staff did not follow the agency's hand hygiene policy or bed bath protocol. 2. HV # 4 was admitted to the agency on 12/27/24 and recertified for care on 8/9/25 with a primary diagnosis of Cerebral Infarction, Unspecified.Review of the HRPOCU dated 8/9/25 revealed physician's order for SN visits two per week for eight weeks, MSW visits for one per month for two months.A HV was conducted on 9/17/25 at 9:27 AM to observe wound care provided by  EI # 8, Registered Nurse (RN).EI # 8 placed a barrier on a bedside table and his/her work bag at the end of the barrier, and a second barrier on a short stool. EI # 8 donned gloves without performing hand hygiene and obtained HV # 4's blood pressure. EI # 8 removed the used blood pressure cuff and placed it on the clean half of the barrier with the unused thermometer and pulse oximeter, contaminating the clean side of the barrier.During the HV, EI # 8 removed his/her dirty gloves five times and without performing hand hygiene, donned clean gloves, including before wound care was provided.EI # 8 cleaned the reusable equipment and placed them back on the now contaminated clean side of the barrier.An interview was conducted on 9/18/25 at 4:10 PM with EI # 1 who confirmed staff did not follow the agency policies for hand hygiene, cleaning of equipment or barrier protection/bag technique.

Based on observation, Centers for Disease Control (CDC) Injection Safety: Preventing Unsafe Injection Practices, and staff interviews, it was determined staff failed to date multidose vials (MDV) of medication when opened.This deficient practice had the potential to negatively affect all patients served by this agency.Findings include:CDC Injection Safety: Preventing Unsafe Injection PracticesDate: March 26,2024Key PointsUnsafe injection practices put patients and healthcare providers at risk. This harm is preventable...Why it mattersSafe injection practices are every provider's responsibility...Key Points for MDVOnce a MDV is opened (ergo, needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial... --- A tour of the Saad Hospice inpatient hospice facility at Providence Hospital was conducted on 9/16/25 at 9:16 AM.An observation of the medication room revealed the following open MDVs without a date when medication was opened and available for patient use: a. One 10 milliliter (ml) vial of Versed 5 milligrams (mg). b. One 10 ml vial of Lorazepam 20 mg.Employee Identifier (EI) # 2, Inpatient Unit Coordinator, confirmed at the time of the observation staff failed to date the MDVs when opened, and were available for patient use.

Based on observations and interviews with staff during a tour of the inpatient hospice unit by Life Safety Code surveyors, it was determined the inpatient hospice facility was not constructed, arranged and maintained to ensure patient safety.This had the potential to affect all patients served by this hospice.Findings include:Refer to tags: K-0225, K-0293, K-0351, K-0353, K-0363, and K-0372.

Based on review of medical records (MR), agency policies and procedures, observation, and staff interviews, it was determined the agency failed to ensure: 1.The skilled nurse (SN) assessed, measured, and documented all wounds weekly as directed per policy. 2.The SN provided wound care as ordered by the physician... These deficient practices affected two of two home visits (HV) with wounds, including HV # 1 and HV # 2 and had the potential to negatively affect all patients admitted to the agency with wounds. Findings include: Facility Policy: Wound Documentation Review Date: 10/19 Section 2: Policy: 2.2 Wound assessments and reassessments will be completed weekly on skilled nursing visit and documented in the integumentary wound record. 2.3 A deteriorating wound status, wound size increase, or non-healing wound status always requires notification and documentation of the physician's response. Section 4: Procedure 4.1 The integumentary Command Center will be completed as part of the Admission, Significant Change, Recertification process and every skilled nurse visit. 4.2...Wound measurements and photos are done on admit, on a weekly basis, change in wound status or new wounds... 4.3 The following documentation will be recorded in the Integumentary Command Center: a. Location of the wound b. measurement of Length, Width, and Depth of wound... 5.2 Documentation of any Nursing Supervisor or Physician contact will be indicated in a Coordination Note. 5.3 Documentation should be clear, concise and accurate and reflect the actual status of the wound at the time of the assessment. --- 2. HV # 2 was admitted to the agency on 9/23/22 with an admitting diagnosis of Malignant Neoplasm of Brain, Unspecified. Review of the VNR dated 10/20/22 revealed the skilled nurse documented under the Integumentary section of the note the patient has a stage II to the coccyx. Further review of the VNR dated 10/20/22 revealed no documentation the physician was notified and no documentation the wound was measured. Review of the IDG (Interdisciplinary Group) Report dated 10/26/22 revealed the nurse documented new onset Stage II to sacrum medicating appropriately... Wound care and interventions provided by hospice services include: Stage II to sacrum. Medicating with Calmoseptine Cream and left open to air. An interview was conducted on 10/27/22 at 3:50 PM with EI # 1 who confirmed the nurse failed to document the physician was notified and failed to complete measurements per agency policy. 1. HV # 1 was admitted to the agency on 12/23/21 and recertified for care 8/20/22 to 10/18/22 with diagnoses Alzheimer's Disease, Unspecified and Unspecified Dementia. Review of the Hospice Recertification Plan of Care (POC) Update dated 8/5/22 revealed SN visits once a week for nine weeks effective 8/21/22. SN visits increased to twice weekly for wound care effective 10/11/22. Review of the Visit Note Report (VNR) dated 9/12/22 revealed wounds "not measured". Review of the VNR dated 9/19/22 revealed "unable" to measure wounds. Review of the VNR dated 9/26/22 revealed wounds "not due" to be measured. Review of the Visit Note Report (VNR) dated 10/17/22 revealed an onset of a new wound- Wound Assessment: # 5- mid upper arm, right, skin tear, no measurements taken, acute state, bloody exudate scant, irregular shape, no odor. Review of the Hospice Physician Order dated 10/17/22 revealed SN will clean wound using wound cleanser, pat dry, using four by four (4x4) gauze, apply transparent skin barrier film over affected area, protect with rolled gauze. A HV was conducted on 10/26/22 at 8:50 AM to observe wound care with EI # 3 Licensed Practical Nurse (LPN). EI # 3 provided wound care to wound # 5 but neglected to protect the wound with rolled gauze as ordered. An interview conducted on 10/27/22 at 2:01 PM with Employee Identifier (EI # 1), Clinical Director, confirmed that wounds should be measured weekly per agency policy and wound care should be provided as physician ordered.

Based on observation, agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff followed the agency's policies for infection control. This deficient practice affected three of four home visits (HV) including HV # 1, HV # 2, HV # 4, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Barrier Protection For Non-Disposable Medical Supplies Date revised: 02/22 Purpose/Objective: To prevent and control infections in the home care setting. Policy: ...2.1 All staff will be responsible for using recommended precautions... Procedure: ...4.3...Once the non-disposable supplies have been used, they will be cleaned with a Saad Hospice approved germicidal wipe, allowed to air dry for the allotted time, in accordance with the germicidal wipe manufacturers guidelines and returned to the appropriate place within the work bag. General Guidelines for Use: Sani-Cloth Germicidal Disposable Wipe Date Revised/Update: 08/2021 ...4. Allow treated surface to remain wet for two minutes. Let air dry... Agency Policy: Hand Washing Indications Date Reviewed: 01/22 Section 2: Policy 2.1 All employees will follow CDC (Centers for Disease Control) hand washing recommendations for preventing nosocomial infections. 2.2 All employees involved in patient contact/care will sanitize hands with antimicrobial containing products before and after removing gloves/gown. Section 4: Procedure 4.6 Employees should sanitize their hands before and after touching inanimate sources... 4.7 Employees should sanitize their hands before and after removing gloves/gown... 4.8 Employees should wash hands with soap and running water after removing gloves that are visibly soiled...Dry hands on a paper towel. --- 3. Home Visit (HV) # 4 was admitted to the agency on 3/29/21 and recertified on 9/20/22 with diagnoses including Heart Failure and Ascites. Review of the Hospice Recertification Plan of Care Update dated 9/5/22 revealed the SN was to visit twice a week for one week, then three times each week for eight weeks. The Aide was to visit four times a week for one week and five times a week for eight weeks to provide HHA (Home Health Aide) services for assistance with personal care and Activity of Daily Living (ADL) secondary to functional limitation which prevent self-care. A HV was conducted on 10/26/22 at 9:10 AM with EI # 4, Aide to observe care provided to the patient. During the HV, hand hygiene of EI # 4 was observed. EI # 4 washed his/her hands in the patients bathroom sink. He/she used the patients hand soap to wash his/her hands. He/she turned off the water with the back of his/her wet hands and dried hands on the patients bath towel and applied gloves. Upon completion of bed bath and vital sign taken EI # 4 wipe the used equipment with a Santi Cloth. The wrist blood pressure cuff was wiped with a Sani-cloth and placed immediately into the equipment bag without allowing the allotted dry time of two minutes. The thermometer was wiped with a Sani-cloth and placed immediately into the equipment bag without allowing allotted dry time of two minutes. In an interview conducted on 10/27/22 at 2:26 PM with EI # 1, confirmed the staff failed to follow the agency's hand hygiene policy and allow the equipment to air dry per the agencys policy. 2. HV # 2 was admitted to the agency on 9/23/22 with an admitting diagnosis of Malignant Neoplasm of Brain, Unspecified. Review of the physician order dated 9/29/22 at 12:15 PM revealed the following order as Physical Therapy evaluation with six sessions for ROM (Range of Motion) exercises R/T (related to) stiffness... A HV was conducted on 10/26/22 at 9:41 AM with EI # 5, Physical Therapist, to observe care provided to the patient. After EI # 5 completed exercises with the patient EI # 5 began to clean the re-usable equipment. EI # 5 used the Sani-Cloth wipes and cleaned the blood pressure cuff and the thermometer and failed to let the re-usable equipment dry for the specified time of 2 minutes per the instructions before placing the wet equipment back into the bag. An interview was conducted on 10/27/22 at 3:50 PM with EI # 1, who confirmed EI # 5 failed to follow agency policy and allow the equipment to dry the 2 minutes prior to placing the equipment in the bag. 1. HV # 1 was admitted to the agency on 12/23/21 and recertified for care 8/20/22 to 10/18/22 with diagnoses Alzheimer's Disease, Unspecified and Unspecified Dementia. Review of the Hospice Recertification Plan of Care (POC) dated 8/5/22 revealed skilled nurse (SN) frequency one time a week for nine weeks effective 8/21/22. A HV was conducted on 10/26/22 to observe wound care provided by Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN). Upon completing wound care and patient's vital signs, EI # 3 wiped used equipment with a Sani Cloth. The blood pressure cuff was wiped with the Sani Cloth, immediately wrapped up onto itself and placed in the equipment bag without allowing the allotted time to dry. The stethoscope was wiped and knotted up and immediately placed into the equipment bag without the allotted time to dry. The pulse oximeter, thermometer, and tablet were wiped and immediately placed into the equipment bag without the allotted time to dry. An interview was conducted on 10/27/22 at 2:01 PM with EI # 1,Clinical Director, who confirmed the staff failed to allow the equipment to air dry according to the agency's policy.

Based on review of Medical Records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure physician wound care orders were complete and included the location of the wound and frequency for the dressing change. This deficient practice affected two of eight MR records reviewed with wounds, including MR # 1, MR # 3, and one of two home visits (HV) with wounds including HV # 1, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Physician Notification and Physician Orders Date Reviewed and Revised: 01/2019 Section 1: Purpose/Objective ...To ensure that all disciplines follow all orders, to include the 485/487 and Physician change orders in their entirety... Section 4: Procedure/Documentation Any changes in the Plan of Care will be addressed by completion of a new order in the Electronic Medical Record... Reasons to obtain a new order... A new wound/skin lesion or any alteration in skin integrity... --- 3. HV # 1 was admitted to the agency on 12/23/21 and recertified for care 8/20/22 to 10/18/22 with diagnoses Alzheimer's Disease, Unspecified and Unspecified Dementia. Review of the Hospice Recertification Plan of Care (POC) Update dated 8/5/22 revealed SN visits once a week for nine weeks effective 8/21/22. SN visits increased to twice weekly for wound care effective 10/11/22. Review of the Hospice Physician Order dated 10/17/22 revealed SN will clean wound using wound cleanser, pat dry, using four by four (4x4) gauze, apply transparent skin barrier film over affected area, protect with rolled gauze. There was no documentation on the order for the location of the wound or the frequency of wound care to be performed. An interview conducted on 10/27/22 at 2:01 PM with EI # 1 confirmed the order was incomplete. 1. MR # 1 was admitted to the Hospice Inpatient Unit (IPU) on 9/27/22 with a primary diagnoses of Unspecified Systolic (Congestive) Heart Failure. Review of the Hospice Certification and Plan of Care (POC) dated 9/27/22 revealed orders for the Skilled Nurse (SN) to perform wound care, cleanse with wound cleanser, apply Dakins soaked gauze wet to dry, cover with dressing using aseptic technique. There was no documentation on the order or in the POC the location of the wound or the frequency to be performed. Review of the Hospice RN (Registered Nurse) Start of Care note dated 9/27/22 revealed an assessment of a wound to the anterior medial post-inguinal, right surgical incision. Review of the Physician Order dated 10/6/22 revealed orders for wound care to right groin to be performed as needed. In an interview conducted on 10/27/22 at 2:42 PM, Employee Identifier (EI) # 1, Clinical Director, confirmed the order for the wound on the Hospice Certification and POC was not complete and did not include the location of the wound. 2. MR # 3 was admitted to the IPU on 10/17/22 with a primary diagnoses of Malignant Neoplasm of Bladder, Unspecified. Review of the Hospice Certification and POC dated 10/17/22 revealed Orders of Discipline and Treatments included orders for SN to perform procedure of skin tear wound care every 3 days or as needed if soiled. Cleanse with wound cleanser, apply xeroform, cover with abdominal pad, and wrap with Kerlix. There was no description on the orders to indicate the location of the wound. Review of the Hospice RN Start of Care Note dated 10/17/22 revealed a description of a skin tear to the left mid forearm. In an interview conducted on 10/27/22 at 2:40 PM, EI # 1 confirmed the order for wound care was not complete and did not include a description of the location of wound.

Based on review of documentation and observation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1) 2010 NFPA 13, 8.5.6.1 This deficiency affects 1 of 5 smoke compartments. --- Findings include: On 10/25/2022, during a tour of the facility from 10:45 am to 4:00 pm, the surveyor observed boxes were stored within 10 inches of a sprinkler head in the Kitchen Storage/Mechanical Room. A member of the maintenance staff was present when this deficiency was identified..

Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of: 2012 NFPA 101, 19.3.6.2.4 This deficiency affects 1 of 5 smoke compartments. --- Findings include: On 10/26/2022, during a tour of the facility from 8:30 am to 1:45 pm, the surveyor observed three 1' x 2' ceiling tiles missing in the Basement Floor Supply Room. A member of the maintenance staff was present when this deficiency was identified..

Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 19.5.1.1, and 9.1.22011 NFPA 70, 110.26 This deficiency affects 1 of 5 smoke compartments. --- Findings include: On 10/25/2022, during a tour of the facility from 10:45 am to 4:00 pm, the surveyor observed stored material (shelf and boxes) blocking the designated work space for the electrical panels located in the Main Floor Main Electrical/Mechanical Room. A member of the maintenance staff was present when this deficiency was identified.