Passages Hospice

Inspection history (21)

Records from June 2022 to May 2025.

• May 5, 2025 · Standard

  Citation L0647

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0647 (CFR 418.78(e)) for Level of activity. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0524

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0524 (CFR 418.54(c)) for Content of comprehensive assessment. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0629

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0629 (CFR 418.76(h)(1)(i)) for Supervision of hospice aides. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0531

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0531 (CFR 418.54(c)(7)) for Content of comprehensive assessment. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0591

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0591 (CFR 418.64(b)(1)) for Nursing services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0523

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0523 (CFR 418.54(b)) for Timeframe for completion of assessment. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0585

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0585 (CFR 418.62(b)) for Licensed professional services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• May 5, 2025 · Standard

  Citation L0678

  Federal surveyors cited this hospice in a survey that ended on 2025-05-05 under CMS tag L0678 (CFR 418.104(a)(7)) for Content. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-05.GOV

• August 10, 2022 · Standard

  Citation L0671

  Federal surveyors cited this hospice in a survey that ended on 2022-08-10 under CMS tag L0671 (CFR 418.104) for Clinical records. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-08-10.GOV

• August 10, 2022 · Standard

  Citation L0663

  Federal surveyors cited this hospice in a survey that ended on 2022-08-10 under CMS tag L0663 (CFR 418.100(g)(3)) for Training. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-08-10.GOV

• August 10, 2022 · Standard

  Citation L0555

  Federal surveyors cited this hospice in a survey that ended on 2022-08-10 under CMS tag L0555 (CFR 418.56(e)(2)) for Coordination of services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-08-10.GOV

• June 10, 2022 · Standard

  Citation K0916

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0916 for Essential Electrical Systems – Alarm Annunciator. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation L0585

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag L0585 (CFR 418.62(b)) for Licensed professional services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation K0712

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0712 for Fire Drills. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation K0761

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0761 for Maintenance, Inspection & Testing - Doors. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation K0133

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0133 for Multiple Occupancies - Construction Type. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation L0524

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag L0524 (CFR 418.54(c)) for Content of comprehensive assessment. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation K0345

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0345 for Fire Alarm System - Testing and Maintenance. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation K0353

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0353 for Sprinkler System - Maintenance and Testing. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

• June 10, 2022 · Standard

  Citation K0918

  Federal surveyors cited this hospice in a survey that ended on 2022-06-10 under CMS tag K0918 for Essential Electrical Systems – Generator or Alternate Source. CMS recorded this at the standard level, which sits under a condition of participation. K tags cover the Life Safety Code requirements, which apply to hospices that operate an inpatient facility. CMS recorded the survey type as Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-06-10.GOV

Penalties

CMS publishes its civil money penalty and payment denial file for certified nursing homes only. No hospice appears in it, including this one. Enforcement here runs through the state licensing agency instead.

Staffing

Staffing hours are published for nursing homes and for no other kind of provider. Federal law requires Medicare- and Medicaid-certified nursing homes to file payroll-based nurse hours with CMS every quarter, and no agency collects the same return from hospices.

Ownership

For-Profit

Recent changes to this listing

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Each line is a difference between two readings of a government file. It says what the source reported, not what the provider did.

1. Sep 1, 2026Ownership changed

   The source now records ownership as "For-Profit".

   Reported by CMS home health hospice (hospice)

2. Jul 23, 2026First appeared in our data

   This listing first appeared in the government file we read. That is usually when it entered the file, not the day it opened.

   Reported by CMS home health hospice (hospice)