Every finding on record at St Francis Hospice

Based on record review and interview, the facility failed to ensure that all smoke detectors were maintained and tested for sensitivity in accordance with NFPA 72 (2010): 14.4.5.3 as indicated by NFPA 101: 9.6.1.3. The deficient practice had the potential to delay or prevent residents of all out of 1 smoke compartments from safely accessing the exit stair enclosure during an emergency. --- On 02/12/2026 at 10:17 AM, during document review with the Inpatient Unit Manager and the Engineering Construction Manager, the facility was unable to produce documentation demonstrating that the required biannual smoke detector sensitivity testing had been conducted. According to NFPA 72 (2010), Section 14.4.5.3, smoke detector sensitivity must be tested within one year of installation and every alternate year thereafter. While the code permits this testing to be done manually or automatically via a self-testing panel, the facility must maintain records of the results for review during inspection. No records could be provided at the time of review. This finding was acknowledged by the Inpatient Unit Manager and the Engineering Construction Manager during the document review and confirmed at the exit conference.

Deficient Practice Statement: Based on observation and interview, the facility failed to ensure a sidewall sprinkler was positioned far enough away from an obstruction to allow its discharge pattern to fully develop in accordance with NFPA 13 (2010), Section 8.7.5.2.1.3, as required by NFPA 101 (2012), Sections 19.3.5.1 and 9.7.1.1(1). This deficient practice could affect any residents, staff, or visitors utilizing Room 105. --- Findings: On 02/18/2026 at 1:04 PM, during a facility tour with the Inpatient Unit Manager and the Engineering Construction Manager, the surveyor observed a standard spray sidewall sprinkler in Room 105 located approximately 4 inches horizontally from the side edge of a wall-mounted flat panel TV. The TV projected 3 inches from the adjacent wall. According to NFPA 13, sprinklers must be positioned away from obstructions a minimum distance of three times the maximum dimension of the obstruction to prevent blocking the spray pattern. A 3-inch deep obstruction requires a minimum horizontal clearance of 9 inches. This finding was verified with the Inpatient Unit Manager and the Engineering Construction Manager at the time of observation and acknowledged during the exit conference.

Based on observation, record review, and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25 (2011) by failing to conduct a 5-year internal inspection of piping (Section 14.2.1) and failing to maintain sprinklers free of foreign materials (Section 5.2.1.1.1), as required by NFPA 101 (2012), Sections 19.3.5.1 and 9.7.5. This deficient practice could affect all 11 residents, staff, and visitors. --- 1. On 02/18/2026 at approximately 10:30 AM, during a document review, the facility was unable to produce documentation demonstrating that a 5-year internal inspection of the sprinkler system piping had been conducted. NFPA 25 requires this inspection every 5 years to check for the presence of pipe blockages. 2. On 02/18/2026 at 12:56 PM, during a facility tour, the surveyor observed one sprinkler head located in the main corridor near the skylight by the nursing station that was heavily loaded with dust. NFPA 25 requires sprinklers to be free of foreign materials to ensure proper operation.  These findings were acknowledged by the Inpatient Unit Manager and the Engineering Construction Manager at the times of discovery and confirmed during the exit conference.

Based on observation and interview, the facility failed to ensure that 2 of 11 resident room corridor doors and 1 of 1 corridor doors serving the soiled linen room were maintained to provide positive latching and were free from impediments to closing in accordance with NFPA 101: 19.3.6.3.5 as indicated by NFPA 101: 19.2.2.2.1. The deficient practice had the potential to delay or prevent residents of all out of 1 smoke compartments from safely accessing the exit stair enclosure during an emergency. --- 1. On 02/12/2026 at 1:16 PM, during a facility tour with the Inpatient Unit Manager and the Engineering Construction Manager, a privacy curtain was observed obstructing the corridor door to Room 110. The resident room door was propped open. When attempting to close the door, the curtain fabric became caught between the door and the frame, preventing the door from closing and latching. The curtain had to be manually repositioned in order for the door to fully close and latch. 2. On 02/12/2026 at 1:22 PM, during the same facility tour, the surveyor observed that the corridor door to a single-occupancy resident room was obstructed by a mobile overbed table. The table extended into the door's swing path, preventing the door from fully closing and latching unless the table was manually repositioned by staff. 3. On 02/12/2026 at 1:31 PM, during the same facility tour, the surveyor observed that the corridor door to the soiled linen room would not latch. A paper towel had been intentionally stuffed into the strike plate in the door frame, preventing the latch bolt from engaging. Upon interview at the time of observation, staff stated that they intentionally placed the paper towel in the strike plate "so it can be pushed open easily." These findings were acknowledged by the Inpatient Unit Manager and the Engineering Construction Manager at the times of discovery and confirmed during the exit conference.

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Based on record review and interview with staff member, the facility failed to document the facility informed and distributed written information to the patient concerning its policies on advance directives for one of 16 patients sampled (Patient (P) 14). Findings Include: On 04/08/22 at 08:30 AM reviewed P14's "Advance Health Care Directives Assessment" dated and signed by the patient's representative on 02/10/22 in Section 1, Advanced Health Care Directive (AHCD) was not checked off. The following were not completed and signed by a Registered Nurse in the assessment, "Reviewed Advance Care Planning document(s) with patient/representative; Patient given information on AHCD; Patient chooses not to provide copy of ACP document(s) ..." In Section 2, for patients who do not have an AHCD, documentation that written materials about the patients' rights to make decisions about their medical treatments was not completed and signed by P14's representative or Registered Nurse. On 04/08/22 at 09:17 AM interview and concurrent review of P14's "Advance Health Care Directives Assessment" with Quality Manager (QM) was done. QM stated P14 does not have a AHCD only a Physician Order for Life Sustaining Treatment (POLST). On 04/08/22 at 02:00 PM, QM provided a copy of the policy and procedures for "Advance Directives" with an issuance date of 01/16/19. Section IV. Procedure, documents "During the referral visit and during the start of care visit (the admission visit), a...[facility]...associate will explain the patient's right to make health care decisions...if a patient lacks capacity at the time of admission or start of care, advance directive information will be provided to patient's surrogate. B. Each patient will be asked at the point of admission to hospice if he/she has executed an advance directive and his/her responded documented in the medical record. If a patient does not have an Advance Directive, general information will be provided to the patient or surrogate."

Based on record review and interview with staff members, the facility failed to obtain the patients' or representatives' signature to confirm receipt of the notice of rights and responsibilities for 16 (Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 20) of 16 patients. Findings include: Record review during the survey period for Patients (P)4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P20 found no documentation of patients' or representatives' signature(s) to attest they received notice of their rights and responsibilities. The survey team requested documentation of patients' or representatives' attestation(s) that the notice of their rights and responsibilities were provided. On 04/07/22 at 01:51 PM, the facility provided copies of the "Patient/Family Bill of Rights" and "Election of Hospice Care" forms which has the patients' name printed on the documents, however, there are no signatures to confirm receipt of their rights. Interview with Quality Manager (QM) and Hospice Manager (HM)1 on 04/07/22 at 02:54 PM confirmed the facility's form does not have a place for the patients' or representatives' signature. QM and HM1 reported the facility is in the process of updating their "Election of Hospice Care" form and the updated form does not include a signature attesting to receipt of their rights.

Based on record reviews and interviews, the facility failed to ensure that a thorough pain assessment of Patient (P)4's leg pain was done by the interdisciplinary team. This deficient practice robs P4's right to effective pain management and can affect all patients with pain. Findings include: On 04/07/22 at 09:00 AM, P4's electronic health record (EHR) was reviewed for the initial certification period of 11/20/21 to 02/17/22. P4's diagnoses include cancer of the lung, heart failure, right hip fracture and falls. P4's "IDG [Interdisciplinary Group] Meeting" documented on 01/11/22 was read. P4 complained of occasional leg pain that was relieved with Acetaminophen. A social work "Routine visit" on 01/20/22 documented by the social worker stated P4 was having "some pain in R [right] thigh/hip area. Pt [patient] had hx [history] of surgery in the area. Reports when she steps, sometimes it hurts. Using...[a methyl salicylate medication patch applied to the skin] and...[acetaminophen, a pain reliever medication] for pain management. RN [registered nurse] aware." Nurse visits from 12/29/21 to 02/02/22 were reviewed, and there were no thorough, nursing pain assessments of P4's leg pain found. Care plan reviewed revealed that P4's leg pain was not identified as a problem. (Cross reference to L546) On 04/08/22 at 08:10 AM, a concurrent EHR review and interview were done with Hospice Manager (HM)1 and the Quality Manager (QM) in HM1's office. HM1 and QM agreed that there were no thorough assessments done of P4's leg pain and one should have been completed. They also agreed that P4's care plan should have been individualized to manage her pain. On 04/08/22 at 2:17 PM, QM was queried about pain assessment training the facility's staff receive. QM stated that the staff received a pain assessment competency training on 01/20/22 and that three trainings are done per year. On 04/08/22 at 2:30 PM, the training material, "Talking to Patients and Families About Pain, used in the facility's pain assessment competency trainings, was reviewed. Under "Interdisciplinary Pain Assessment" it stated, "Optimal pain management should always start with a thorough assessment." A detailed "Pain Interview" was also described. It included assessing the cause of the pain, what does it feel like, if it radiates to other areas, how sore the pain is, and how long it lasts.

Based on record reviews and interview, the facility failed to provide an initial comprehensive assessment done by the physician for Patient (P)4. This deficient practice does not provide a thorough evaluation of the patient's physical status related to their terminal illness and related conditions and can affect hospice care and services provided to P4. All patients admitted to the facility can be affected by this deficient practice. Findings include: On 04/07/22 at 09:00 AM, P4's electronic health record (EHR) was reviewed for P4's initial certification period of 11/20/21 to 02/17/22. P4's initial benefit election date was 11/20/21. A documented initial comprehensive assessment and visit were found by the registered nurse for 11/20/21. The social worker's initial visit and comprehensive assessment were completed on 11/21/21, and the clergy's visit and assessment were documented for 11/22/21. No physician comprehensive assessment was found documented within the five day deadline from the election date of 11/20/21, which ended on 11/24/21. On 04/08/22 at 08:10 AM, concurrent EHR review and interview were done with the Hospice Manager (HM)1 and Quality Manager (QM) in HM1's office. QM verified that an initial comprehensive assessment by the physician was not completed for P4 and that one should have been done within five days of the election date of 11/20/21, which was by 11/24/21. On 04/08/22 at 2:10 PM, the facility's "ASSESSMENT, PATIENT/FAMILY" policy issued on 01/16/19, was reviewed. It stated, "...A comprehensive assessment must be completed by members of the Interdisciplinary (sic) Group [IDG] within five (5) calendar days of the effective date of admission...The IDG must include ...1. A doctor of medicine ..."

Based on record review, interview with staff members, and review of the facility's policy and procedures, the facility failed to ensure an initial bereavement assessment was done for 4 of the 16 patients in the active sample (Patients 14, 7, 10 and 16). Findings include: On 04/06/22 at 09:25 AM, Quality Manager (QM) provided a copy of the policy and procedure for "Bereavement Support Services" with an issuance date of 10/16/19. Section III. Procedure, A. Bereavement Assessment notes, "Bereavement assessment captures the strengths, stress factors, and coping abilities of the griever. This includes physical, emotional, social, and spiritual aspects of how one has responded to grief and loss in the past and currently. Bereavement assessment starts at he time of admission as part of the Psychosocial Comprehensive Assessment, continues while receiving hospice care, and throughout bereavement support. It is a continuous process." 1) On 04/07/22 at 07:45 AM record review was done for Patient (P)10. P10's start of care was 06/01/21. There was no documentation of an initial bereavement assessment for P10. On 04/06/22 at 09:14 AM interview and concurrent record review was done with QM. QM reported the bereavement assessment is completed by the social worker. Concurrent review with QM found the facility's software will initiate a bereavement assessment when the assessor checks a specific box. QM reported the social worker did not check this box, therefore, the tab to complete a bereavement/grief risk factors was not activated for completion. On 04/08/22 at 09:15 AM, Hospice Manager (HM)1 confirmed an initial bereavement assessment was not done. 2) On 04/07/22 at 09:12 AM record review was done for P16. P16's start of care was 01/13/22. A review of the initial social worker assessment found no initial bereavement assessment. On 04/08/22 at 09:23 AM, interviewed HM1 regarding an initial bereavement assessment. HM1 was agreeable to further review P16's record. On 04/08/22 at 09:37 AM, HM confirmed an initial assessment was not done. 3) On 04/08/22 at 09:17 AM interview and concurrent review of P14's medical chart was completed with Quality Manager (QM). P14's start of care was 02/14/22. QM confirmed there was no documentation that an initial bereavement assessment for P14 was done. 4) On 04/08/22 at 09:20 AM interview and concurrent review of P7's medical chart was completed with QM. P7's start of care was 03/30/22. QM confirmed there was no documentation that an initial bereavement assessment for P7 was done.

Based on record reviews and interview, the facility failed to individualize Patient (P)17's care plan to include her insomnia (difficulty sleeping), confusion, and wandering behavior. This deficient practice fails to recognize P17's problems and associated safety issues and can affect the deliverance of hospice care and services. All patients with the facility can be affected by this deficient practice. Findings include: On 04/07/22 at 2:00 PM, P17's electronic health record (EHR) was reviewed for the second certification period of 12/17/21 to 03/16/22. P17 was initially admitted to the facility on 09/18/21 with end stage kidney disease caused by high blood pressure. An on-call physician telehealth visit was documented for 01/26/22. P17 had difficulty sleeping at night and frequently got up during the night with confusion and wandered. P17 was prescribed an antipsychotic medication as a treatment for this problem. P17's "Team Care Plan" as of 04/07/22 was reviewed. P17's problems of insomnia, confusion, and wandering and associated interventions to address these problems were not documented. On 04/08/22 at 08:10 AM, concurrent EHR review and interview were done with Hospice Manager (HM)1 and the Quality Manager (QM) in HM1's office. QM agreed that P17's problems of insomnia, confusion, and wandering, which she needs to take an antipsychotic medication for treatment, should have been included in her care plan for safety issues. On 04/08/22 at 2:10 PM, the facility's policy, "ASSESSMENT, PATIENT/FAMILY" issued on 01/16/19, was reviewed. It stated, "...K. Revising the Care Plan Hospice will revise the care plan, goals, for care and treatment based upon the patient's/family's needs."

Based on record reviews and interview, the facility failed to individualize Patient (P)4's care plan for complaints of her leg pain and associated management. This deficient practice fails to recognize one of the attributes of a good death, in which pain management is a core principle. All patients with the facility can be affected by this deficient practice. Findings include: On 04/07/22 at 09:00 AM, P4's electronic health record (EHR) was reviewed for the initial certification period of 11/20/21 to 02/17/22. P4's diagnoses include cancer of the lung, heart failure, right hip fracture and falls. P4's "IDG [interdisciplinary group] Meeting" documented on 01/11/22 was reviewed. P4 complained of occasional leg pain that was relieved with Acetaminophen. A social work routine visit on 01/20/22 documented that a methyl salicylate medication patch applied to the skin was used to treat her pain. "Team Care Plan" of 02/17/22 was read. P4's leg pain was not documented as a problem and there were no associated interventions to manage her pain. On 04/08/22 at 08:10 AM, concurrent EHR review and interview were done with Hospice Manager (HM)1 and the Quality Manager (QM) in HM1's office. HM1 and QM both stated that P4's care plan should have been individualized for her leg pain and included individualized interventions for its management. On 04/08/22 at 2:10 PM, the facility's policy, "ASSESSMENT, PATIENT/FAMILY" issued on 01/16/19, was reviewed. It stated, " ...K. Revising the Care Plan Hospice will revise the care plan, goals, for care and treatment based upon the patient's/family's needs."

Based on observation, record review, and interview with staff members, the facility failed to ensure that care and services were provided in accordance with the patients' plan of care for 4 of 16 patients (Patients 11, 8, 10, and 6) in the active sample. Findings include: 1) On 04/07/22 at 07:45 AM a record review for Patient (P)10 was done. A review of the recertification period of 01/27/22 to 03/27/22 found visit frequency for skilled nursing (once a week for 9 weeks and six PRN [as needed] visits), social worker (once a month for three months and three PRN visits), and cleric (once a month for three months with four PRN visits). A review of the clinical notes found documentation of volunteer visits on 03/01/22, 03/15/22, 03/16/22, 03/21/22, and 04/01/22, however, volunteer services were not included in P10's plan of care (frequency of visits and interventions). On 04/08/22 at 09:15 AM interview was conducted with Hospice Manager (HM)1. HM1 confirmed although volunteer services were provided, this service is not included in P10's plan of care. 2) On 04/05/22 at 02:28 PM a record review for P8 was done. P8's start of care was 03/12/22. The certification period of 03/12/22 to 06/09/22 was reviewed. P8's plan of care as of 04/05/22 included hospice aide services. The visit frequency included, three PRN visits (start date of 03/12/22) and twice a week for 13 weeks (start date of 03/13/22). A review of the clinical notes found only one visit was made for the weeks of: 03/13/22 to 03/19/22, 03/20/22 to 03/26/22, and 03/27/22 to 04/02/22. On 04/06/22 at 01:54 PM concurrent record review and interview was done with the Quality Manager (QM). QM confirmed only one visit was made for the aforementioned weeks. QM noted documentation of the following on the patient's calendar, 03/18/22 - tried, 03/23/22 - tried, and 03/30/22 - unmade. QM was agreeable to follow-up on documentation. On 04/07/22 at 10:14 AM, QM provided hospice aide documentation of the visits done on 03/16/22 and 03/26/22, however, there was no documentation related to the missed visits. On 04/06/22 at 02:19 PM interview was done with Hospice Manager (HM)1. HM1 confirmed the documentation of 03/18/22 - tried, 03/23/22 - tried, and 03/30/22 - unmade. Inquired where does the hospice aide document why the visit was not made and whether the patient was offered another time for the visit? HM1 provided hospice aide documentation of the visits made, however, there was no documentation related to the missed visits and an offer to re-schedule the visit. On 04/06/22 at 09:00 AM, a record review for Patient (P)11 was done for the certification period of 12/28/21 to 03/24/22. During the review, it was noted that Hospice Aide (HA) services had been ordered twice a week for thirteen weeks plus three as needed visits. A review of the HA visit frequency revealed that for the week of 02/20/22 to 02/26/22, there had been only one HA visit documented. On 04/07/22 at 03:39 PM, during a concurrent P11 record review and interview with the Quality Manager in the Conference Room, the QM stated that on 02/21/22, there was an "unsuccessful [HA] visit" documented with the reason of "Other." After communicating with the Hospice Manager assigned to P11, the QM reported that P11's family had asked for HA visits on Mondays and Thursdays only, and because 02/21/22 had been a holiday, the HA scheduled for that day did not conduct the visit. The QM confirmed that there was no documentation of the family's request for specific days included in the care plan, nor was there any documentation that a make-up day had been offered, planned, or discussed with P11 or his/her representative, either in anticipation, or even after the holiday had passed. 4) On 04/05/22 at 02:36 PM a record review for P6 was done. P6 resided at a long term care facility and received hospice outpatient services. P6's start of care was 02/04/22. The certification period of 02/04/22 to 05/04/22 included hospice aide services. The visit frequency included, twice a week visits for 13 weeks and four PRN visits for personal care. A review of the clinical notes found only one visit was made for the weeks of: 02/27/22, 03/06/22, and 03/30/22. No visits were made for the week of: 02/13/22, 02/20/22, 03/13/22, and 03/20/22. On 04/06/22 at 9:17 AM reviewed P6's care plan. The care plan documents the hospice aide to provide interventions for personal hygiene, showering. On 04/06/22 at 11:07 AM interview with P6's family member (F) 1 stated, " ...hospice aide doesn't come really. I don't remember seeing an aide ..." According to F1, the long term care facility gives P6 a shower three times a week. On 04/08/22 at 09:17 AM, concurrent record review and interview was done with Quality Manager (QM) . QM confirmed hospice aide services were not provided at least twice a week. QM noted documentation of the following on P6's calendar, 03/11/22-unmade (other), 02/16/22-unmade (patient request), 02/18/22-unmade (patient request), 02/23/22 -unmade (patient request), 02/25/22-unmade (other), 03/04/22-unmade (other), 03/11/22- unmade (other), 03/16/22- unmade (other), 03/18/22- unmade (other), 03/23/22- unmade (other), 03/15/22- unmade (other) and 04/01/22- unmade (other). QM confirmed there was no documentation related to the missed visits.

Based on record review and interview with staff members, the facility failed to ensure that bereavement services reflected the needs of the bereaved. Specifically, the hospice provider failed to provide bereavement services to the bereaved spouse (SP), including a needs assessment, in his/her preferred language, for over a month. As a result of this deficient practice, the bereaved family had needs that were not met, and were placed at risk of psychosocial decline. Findings include: On 04/07/22 at 02:00 PM, a bereavement record review was done for Patient (P)2, who had expired on hospice services on 02/15/22. The following was noted in the documentation of a bereavement call made to the bereaved family by Licensed Social Worker (LSW)1 on 03/01/22: " ...[daughter of deceased] returned phone call stating she is doing well but is concerned for ...[SP] as ...[SP] has been "really down." Asked if ...[SP] could receive bereavement services over the phone or virtually from someone who is Ilocano-speaking [a dialect of the Filipino language]. This LSW informed that we do not have bereavement social workers who are Ilocano-speaking but will see if there are any options we could provide." There was no assessment found of SP's bereavement needs at the time, nor was there any documentation that LSW1 had spoken to SP. Further review of bereavement documentation noted bereavement translation services were not located and offered to the family until 04/07/22, again by LSW1: "Follow up call to pt's [patient's] daughter ...this LSW left message stating translation services can be provided by one of our LSW's if ...[SP] is still interested ..." It was also noted that although the LSW Initial Assessment done on 02/10/22 identified SP as the person most at risk for grief, it did not identify a potential need for translation services. On 04/08/22 at 01:41 PM, a phone interview was done with the Social Work Lead (SWL) regarding the availability of translation services. The SWL stated that she was able to locate an Ilocano-speaking staff member and informed LSW1 on 04/01/22. SWL could not explain why the bereaved family was not notified of the availability until 04/07/22. When asked, SWL confirmed that translation services are also immediately available by phone, stating that "we usually go through ...[translation services company] if needed." SWL acknowledged that without an assessment of SP's bereavement needs in the requested language, the hospice provider could not say for certain if the immediately available phone translation services were needed at the time, or if SP could wait for 4-5 weeks. A review of the hospice provider's policy titled Bilingual/Sign Language Interpreter, issued 08/25/15, revealed the following: "III.B.2.d. When no in-house or caregiver resources are available, contact the ...[Bilingual Access Line services company] and request a qualified bilingual interpreter for the specific foreign language needed."

Based on observation, record review, and interview with staff members the facility failed to ensure the hospice aide provided services that were included in the plan of care for one of four patients (Patient (P) 6) observed. Findings include: On 04/05/22 at 02:36 PM a record review for P6 was done. P6 resided at a long term care facility and received hospice outpatient services. P6's start of care was 02/04/22. The certification period of 02/04/22 to 05/04/22 included hospice aide services twice a week visits for 13 weeks and four PRN [as needed] visits for personal care. On 04/06/22 at 9:17 AM reviewed P6's care plan. The care plan documents the hospice aide to provide the following interventions for personal hygiene: Provide skin care, provide as needed bed linen change, provide bath in shower, maintain clean, safe environment assist with transfer, assist with dressing/undressing with bathing, provide perineal hygiene care with bathing, assist with shampooing hair, access skin every visit and report any changes, maintain dry linens if patient diaphoretic [sweaty], maintain standard and universal precautions, and provide bed bath if unable to shower. On 04/06/22 at 11:27 AM observed Hospice Aide (HA) 1 offer to apply lotion on P6 after P6 declined HA1 to give her a shower. While HA1 applied lotion on P6's right arm HA1 inquired if P6 can bend her arm at the elbow. HA1 was observed to provide Range of Motion (ROM) to P6's right arm, physically bending P6's right arm at the elbow. HA1 proceeded to lotion and provide ROM to P6's left arm, physically bending P6's left arm at the elbow. HA1 stated P6's left arm is stiff. On 04/08/22 at 09:17 AM, concurrent record review and interview with Quality Manager (QM) was done. QM confirmed P6's plan of care does not include ROM. QM stated ROM is not usually an intervention hospice provides and is considered a rehabilitation task. If ROM services is needed or requested, it would be in the plan of care. On 04/08/22 at 02:00 PM, QM provided a copy of the policy and procedures for "Hospice Aide Supervision" with an issuance date of 09/18/19. Section III, Procedure B. documents "Hospice aides provide services that are ordered by the interdisciplinary group. Written instructions are patient care prepared in the plan of care by the RN utilizing the Hospice Aide Task List in the electronic medical record (EMR)..."

Based on record reviews and interview, the facility failed to ensure that Patient (P)5's complaint of not feeling well to Hospice Aide (HA)2 was relayed to Registered Nurse (RN)4. This deficient practice failed to provide P5 with appropriate and timely palliative care and all patients in the facility can be affected. Findings include: On 04/06/22 at 08:30 AM, P5's electronic health record (EHR) was reviewed for the initial certification period of 03/25/21 to 06/22/21. P5 is an 84-year-old patient with respiratory failure. A "Visit Record" documented on 04/22/21 and signed by HA2 at 1:08 PM revealed, " ...patient not feeling well." A "Visit record" and "Routine visit" documented on 04/22/21 and signed by RN4 at 2:07 PM revealed that P5's complaint of not feeling well was received from HA2 and no follow up assessment was made. On 04/08/22 at 08:10 AM, a concurrent EHR review and interview were done with Hospice Manager (HM)1 and QM in HM1's office. HM1 stated that HA2 should have communicated to RN4 that P5 was not feeling well and a follow up assessment by RN4 should have been done with P5. On 04/08/22 at 2:10 PM, the facility's policy, "ASSESSMENT, PATIENT/FAMILY" issued on 01/16/19, was reviewed. Revealed under " ...I. Reassessment: 2. ...upon significant change in patient's condition/family situation requiring symptomatic management or other services ...Staff will make appropriate referral to members of the IDG [interdisciplinary group] as needed." The facility's policy, "MEDICAL CARE AND SERVICES" issued on 10/02/19, was also read. It stated, " ...B. Communication between the attending physician/APRN [advanced practice registered nurse] and other members of the interdisciplinary group is ongoing, timely, and documented."

Based on policy and procedure, record review and interview with staff members, the facility did not ensure two physicians initially certified patients with a terminal diagnosis for admission to hospice care for 2 (Patients 10 and 13) of 16 patients in the active sample. Findings include: On 04/08/22 at 02:00 PM, the Quality Manager (QM) provided the facility's policy and procedure titled, "Interdisciplinary Plan of Care" (date issued 10/02/19) which includes procedure of "two physicians certify that the patient is eligible for hospice". QM reported certification is signed by two physicians which would include: the hospice Medical Director and attending physician, the hospice Medical Director and hospice physician, or the hospice Medical Director and hospitalist (acute hospital). 1) On 04/07/22 at 07:45 AM a record review was done for Patient (P)10. P10's start of care was 06/01/21. Review found no documentation of initial certification statement that the patient has a terminal illness with life expectancy of less than six months. On 04/07/22 at 09:33 AM interview with QM, it was reported based on the patient's insurance type, an initial certification of terminal illness is not required. On 04/08/22 at 09:15 AM, further review was done with Hospice Manager (HM)1. HM1 provided a copy of a clinical note dated 05/12/21 by the facility's Medical Director certifying P10 with life expectancy of less than six months and certified P10 at hospice level of care. P10 is diagnosed with severe coronary artery disease, endstage ischemic cardiomyopathy, and chronic obstructive pulmonary disease. The Medical Director notes the patient's prognosis is poor with life expectancy of less than six months. HM1 confirmed there is only one signature by the Medical Director.

Based on record reviews and interview, the facility failed to ensure that the electronic health record (EHR) for two patients, (P)4 and P17, out of a sample of 20 patients, contained their advance health care directive (AHCD). This deficient practice failed to depict a complete and accurate picture of P4 and P17 and of their desired medical care outlined in their AHCD and if it was in alignment with their hospice care and services. All patients may be affected by this deficient practice. Findings include: 1) On 04/07/22 at 09:00 AM, P4's EHR was reviewed for the initial certification period of 11/20/21 to 02/17/22. P4's diagnoses include cancer of the lung, heart failure, right hip fracture and falls. No AHCD was found and a request to the facility was made for P4's document at 10:00 AM. On 04/07/22 at 1:55 PM, no AHCD was received, but the document "Advance Health Care Directives Assessment" dated 11/20/21 was given and reviewed. The document revealed that P4 had an AHCD and that a copy would be provided to the facility. The document was signed by P4's daughter. On 04/08/22 at 08:10 AM, concurrent EHR review and interview were done with Hospice Manager (HM)1 in HM1's office. HM1 stated that if a patient had an AHCD, the facility would obtain the copy. HM1 looked in another database for P4's AHCD, but none was found. 2) On 04/07/22 at 10:00 AM, P17's AHCD was requested from the facility. At 1:51 PM, the "Advance Health Care Directives Assessment" document dated 11/18/21, was received. It revealed that P17 had an AHCD, and it was signed by P17's son. On 04/07/22 at 2:00 PM, P17's EHR was reviewed for the second certification period of 12/17/21 to 03/16/22. P17 was initially admitted to the facility on 09/18/21 with end stage kidney disease caused by high blood pressure. An "Initial visit" by the social worker documented on 09/22/21, revealed that P17 had an AHCD and that a copy of it was "on file." No AHCD was found in P17's EHR. P17's care plan as of 04/07/22 was reviewed. There was no entry regarding P17's AHCD. At 3:21 PM, a follow up query about P17's AHCD was made with HM1. HM1 stated that P17 did not have an AHCD on file with the facility. On 04/08/22 at 08:10 AM, a concurrent EHR review and interview were done with HM1 and the Quality Manager (QM) in HM1's office. It was confirmed that the facility's database did not have P17's AHCD. HM1 stated that if a patient had an AHCD, the facility would obtain the copy. On 04/08/22 at 2:15 PM, the facility's "Advance Directives" issued on 01/16/19, was reviewed. It revealed, "IV. PROCEDURE ...C. If a patient has an advance directive, every reasonable effort will be made to obtain a copy, which will be placed in the medical record of the patient. The social worker or nurse will follow up with the patient/family to obtain a copy of an existing advance directive when there is none on file. If a copy cannot be obtained, this will be documented in the appropriate section of the patient's plan of care, and care will be rendered as if an advance directive does not exist."

Based on record review and interview with facility staff, the facility did not assure documents requested were readily available on request. As a result of this deficient practice, the survey process was impeded. Findings include: 1) During the survey, copies of patients' advance directives were not found in the software (NetSmart). This software is utilized by direct caregivers. A request was made for copies of the advance directives. Interview with Quality Manager (QM), it was reported that the advance directives are located in another system which is not "contiguous" with the software utilized by staff members. QM also reported the patients' history and physical is not located in the software and can only be accessed by himself and the Medical Director. On 04/07/22 at 03:21 PM, Hospice Manager (HM)1 reported an advance directive could not be found for Patients 15, 10, and 16. However, the facility later was able to provide copies of the advance directive, medical durable power of attorney, and/or documentation patients without an advance directive were provided with information related to executing an advance directive. 2) Cross Reference to L555. On 04/05/22 at 02:28 PM record review for Patient (P)8 was done. Review found missing hospice aide visits and no documentation of why the visits were missed and whether the patient/caregiver was offered another time for the visit. Requested documentation of the aide visits, the facility provided hard copies of the aide visits from another system which included duration of visit and the tasks performed during the visit. Documentation was requested twice, the facility was unable to provide documentation of communication with patient/caregiver regarding the missed appointments. On 04/08/22 at 03:30 PM, during an interview with the Vice-President of Client Services (VPCS), it was revealed that the hospice provider had previously identified the record retrieval challenges and was searching for a workable solution. The VPCS stated that staff in the field (visiting patients in the home) have spotty internet coverage depending on geographic location of the patient. When asked how staff retrieve necessary documents in the field, the VPCS admitted that they cannot, however, several work-arounds have been implemented as they search for a more permanent solution, such as staff use paper documents that get uploaded later, or staff download necessary documents prior to heading out in the field.

Based on interviews and record review, the facility failed to provide one patient ((P)20) with appetizing meals in the inpatient unit (IPU), and failed to ensure the inpatient kitchen stored and prepared food for patients under sanitary conditions. This deficient practice has the capability to make the last stages of life for all the patients in the IPU less comfortable. Findings include: 1) On 04/08/22 at 8:00 AM, P20's electronic health record (EHR) was reviewed. P20 is an 80- year-old patient admitted from an acute hospital to the IPU on 03/13/22 with heart failure caused by high blood pressure. The "Initial visit" documented on 03/13/22 by the Registered Nurse (RN) revealed that P20 was alert and oriented four times (person, place, time, and situation). On 04/08/22 at 11:03 AM, an interview with P20 was done at her bedside. P20 stated the meals served in the IPU were "the same," "institutional," "not healthy," "near frozen" or "lukewarm." She stated that she was served unhealthy items like bacon, spam, and Vienna sausage. She was provided alternative items, but no one had assessed her food likes and dislikes. P20 stated she had complained to the facility staff regarding the food. On 04/08/22 at 11:40 AM, RN8 was interviewed at the IPU's nursing station. RN8 stated that P20 had complained about the food and the staff heats up her food in the microwave if it is cold and provide her with meal alternatives. On 04/08/22 at 12:30 PM, P20's care plan was reviewed. There was no problem and associated interventions to manage P20's dislike for the meals served in the IPU. On 04/08/22 at 1:00 PM, a query was made with Hospice Manager (HM)1 regarding P20's complaints about the meals in the IPU. He stated that that he was aware of her complaints, but staff heats up her meals if it needs to be warmed, and breakfast is made in the facility. The meals are on a five week cycle and lunch and dinner are contracted to be made by an outside company. On 04/08/22 at 2:10 PM, the facility's policy, "ASSESSMENT, PATIENT/FAMILY" issued on 01/16/19, was reviewed. It stated, " ...K. Revising the Care Plan Hospice will revise the care plan, goals, for care and treatment based upon the patient's/family's needs." 2) On 04/08/22 at 10:50 AM, during observations and a concurrent interview with the Dietary Aide (DA) in the inpatient kitchen, the following was observed: Observed a cluster of small (the size of sand) unidentifiable black debris on the bottom shelf of an opened cabinet located above the countertops near the kitchen window and sink. A red, ant bait trap was above the unidentifiable black debris. Inquired with DA what the black debris were, DA stated it could be rust from the hinges of the cabinets. Rust was not observed to be on the hinges of the cabinets. Inquired what is stored in the cabinet, DA stated plastic containers used to prepare patients food. On the inpatient kitchen countertops, observed an unlabeled, undated, and unsealed Styrofoam cup identified as mashed potato by DA and two unlabeled and undated Styrofoam bowls identified as a bowl of mashed potato and a bowl of gravy by DA. DA stated the mashed potatoes and gravy were from breakfast and is to be thrown away later. Review of the policy and procedure for "Dietary Sanitation" documents in section III. Procedure 4., "After portioning foods, they will be returned to the refrigerator immediately." In the inpatient kitchen cabinet that stored dry goods, observed an opened unsealed box of cream of wheat. The top side of the box had a flap, DA confirmed the flap was open and it should be sealed. DA stated he was not done with the cream of wheat. Observed the digital temperature located outside and on top of refrigerator 2 read 43 degrees Fahrenheit (F). Concurrent observation of the thermometer inside of refrigerator 2, DA stated the temperature was 44 degrees F. Requested two more times with DA what the temperature was inside refrigerator 2, DA continue to state 44 degrees F. Observed the thermometer inside of refrigerator 2 as 42 degrees F and the outside digital temperature drop to 42 degrees F from initial observation. Inquired with DA what temperature the refrigerators should be kept at, DA stated 40 degrees F or below. From 11:06 AM to 11:17 AM, a total of 11 minutes, continued observation of the digital temperature located outside and on top of refrigerator 2 read 43 degrees F. At 11:17 AM the inside thermometer of refrigerator 2 read 43 degrees F. From 11:06 AM to 11:17 AM refrigerator 2 was not opened. Review of the policy and procedure for "Dietary Sanitation" documents in section III. Procedure 7., "The refrigerated temperature for food storage shall be either at or below 5 degrees Celsius/41 degrees Fahrenheit." On 04/08/22 at 11:17 AM, concurrent observation and interview with Hospice Manager (HM)1 was done of the inpatient kitchen air conditioner. Observed a substantial amount of dust on the air conditioner vents, the kitchen ceiling, and light fixtures directly in front of the air conditioner vents. HM1 stated he believes a contractor cleans the air conditioners and if not, the facility staff should be cleaning them. On 04/08/22 at 12:26 PM, HM1 provided a copy of the policy and procedures for "Dietary Sanitation" with an issuance date of 12/12/17. Section I. Purpose, documents "To maintain a food operation which will be sanitary by following current standards of practice, including nationally recognized infection control precautions, and which will avoid sources and transmission of food-borne illnesses."

K-293 Exit Signage This STANDARD is not met as evidenced by: Based on record review and staff interview with facility manager, the facility failed to produce documentation for a monthly 30 second test for the battery backed up exit signs in the facility in accordance with NFPA 101, 2012 edition, and section 7.9.9.1.1 (1). This deficiency could affect all residents, staff, and visitors during an emergency requiring evacuation during a power outage. Findings include: During record review on 4/7/22 at approximately 11:30 am revealed that the facility failed to provide documentation for the monthly exit sign test. These findings were verified at the exit conference with the facility manager and Administrator on 4/7/22 at 12:45 pm.

K-353 Sprinkler System-Inspection and Testing This standard is not met as evidenced by: Based on record review and staff interview with facility manager, the facility failed to produce documentation for a monthly and quarterly fire sprinkler system inspection and testing in accordance with NFPA 101, Life Safety Code, 2012 edition, section 9.7.5, and NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems 2011 edition, section 5.2. This deficiency could affect all residents, staff, and visitors during a fire due to the lack of monthly and quarterly inspections to ensure proper fire sprinkler operations during fire conditions within the facility. Findings include: During record review on 4/7/22 at approximately 12:15 pm revealed that the facility failed to provide documentation for a monthly and quarterly fire sprinkler inspection and testing. These findings were verified at the exit conference with the facility manager and Administrator on 4/7/22 at 12:45 pm.

K-761 Maintenance, Inspection and testing-Doors This STANDARD is not met as evidenced by: Based on record review and staff interview with facility manager, the facility failed to produce documentation for an annual inspection for the fire doors in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, sections 5.2, and 5.2.3. This deficiency could affect all residents, staff, and visitors during a fire due to the lack of an annual inspection to ensure proper protection from fire and smoke extension within the facility. Findings include: During record review on 4/7/22 at approximately 11:30 am revealed that the facility failed to provide documentation for the annual fire door inspection. These findings were verified at the exit conference with the facility manager and Administrator on 4/7/22 at 12:45 pm.