Every finding on record at Crown Health Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 06/11/2026, 06/12/2026, and 06/15/2026. Active Census: 7 At this Emergency Preparedness survey, Crown Health Services LLC was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 6/16/2026.

This visit was for an Initial Federal Certification for Medicare and Medicaid enrollment survey for a Home Health provider. Survey Dates: 06/11/2026, 06/12/2026, and 06/15/2026. 12 Month Unduplicated Admissions: 18 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to the State Form for additional State Findings. Abbreviations: CNA Certified Nursing Assistant DME Durable Medical Equipment RN Registered Nurse CM Clinical Manager POC Plan of Care SOC Start of Care SN Skilled Nursing QR completed by Area 3 on 6/16/2026.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patients’ current health, psychosocial, and functional status in 3 of 7 active records reviewed. (Patients: # 5, 6, and 7) Findings Include: 1. A review of an undated agency policy titled “Comprehensive Client Assessment” indicated, but was not limited to, “ … The assessment identifies facilitating factors and possible barriers to the client reaching his or her goals, including presenting problems … a. The Comprehensive Assessment must accurately reflect the client’s status, and must include at a minimum, the following information: The client’s current health, psychosocial, functional, and cognitive status … ” 2. A review of Patient #5’s active clinical record, with a Start of Care date of 04/24/2026, showed an agency document titled “OASIS‑E2 Start of Care” dated 04/24/2026 and electronically signed by the Administrator/CM. The comprehensive initial assessment sections titled “Psychosocial Assessment,” “Safety Measures,” “Elimination Status,” “Genitourinary Assessment,” and “Gastrointestinal Assessment” were left blank and unanswered. During an interview on 06/15/2026 at 2:52 PM, when asked about the comprehensive assessment being completed, upon review of the comprehensive assessment for Patient #5,the Administrator/CM stated, “No blanks should be there.” 3. Observed on 06/12/2026 at 3:59 PM during a home visit at Patient #6’s residence: CNA 1 assisted Patient #6 from a seated position in a recliner to standing, then assisted with ambulating Patient #6 to the bathroom toilet. When Patient #6 stood, a brief was observed above the waistband of Patient #6’s shorts. During ambulation, Patient #6 demonstrated a shuffling, unsteady gait, with hand tremors, requiring CNA 1 to use both hands to guide and steady the patient. A review of Patient #6's active clinical record with a SOC date of 12/17/2025, contained an agency document titled “OASIS -E2 Recertification” dated 06/10/2026, and electronically signed by the Administrator/CM. The comprehensive reassessment section titled “Genitourinary Assessment” noted Patient #6 received hemodialysis treatments on Tuesdays, Thursdays, and Saturdays, but failed to list Patient #6 had been incontinent and required briefs. The section titled “Functional Status Musculoskeletal Assessment” noted Patient #6 had poor balance, weak hand grips, high risk for falls, muscle weakness, and an unsteady gait. The functional status failed to address Patient #6 had a shuffling gait, and hand tremors. During an interview on 06/15/2026 at 3:06 PM, when asked about Patient#6’s shuffling gait, tremors, and incontinence documentation in the comprehensive assessment, the Administrator/CM stated, “Yes, he does have a shuffling gait and tremors, and it should had been documented in the assessment.” 4. A review of Patient #7's active clinical record with a SOC date of 04/15/2026, contained an agency document titled “OASIS -E2 Start of Care” dated 04/15/2026, and electronically signed by the Administrator/CM. The comprehensive initial assessment sections titled “Genitourinary Assessment” and “Gastrointestinal Assessment” had been left blank. During an interview on 06/15/2026 at 3:20 PM, when asked about the comprehensive assessment being completed, upon review of the comprehensive assessment for Patient #7, the Administrator/CM stated, “All the sections should be completed in the assessments.” 410 IAC 17-14-1(a)(1)(A)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC included all required DME and supplies, omitted prescribed nutritional needs, and documented incorrect SN visit frequencies for 3 of 7 active clinical records reviewed. (Patients: #1, 3, and 5) Findings Include: 1. A review of an undated agency policy titled "Plan of Care" indicated, but was not limited to, " … 2. The Plan of Care shall be completed in full to include: … c. Type, frequency, and duration of all visits and services ... l. Specific dietary or nutritional requirements or restrictions ... n. Medical supplies and equipment required … v. All of the above items must always be addressed on the Plan of Care. …" 2. A review of Patient #1's active clinical record, SOC date of 12/10/2025, contained a POC for the recertification period of 06/08/2026 to 08/06/2026, signed by the Administrator/CM and dated 06/04/2026. The POC in the section titled “Orders For Disciplines and Treatment” listed Patient #1 had orders for SN two times a week for one week and two visits as needed (PRN) for a change in condition. During an interview on 06/15/2026 at 2:47 PM, when asked if Patient #1 is discharged this week due to frequency, the Administrator/CM reviewed the POC for Patient #1 and stated, “No, I see him twice a week for LVAD dressing changes. The frequency of SN is wrong. I don’t know why it is like that.” 3. During a home visit at Patient#3’s residence on 06/12/2026 at 11:05 PM, observed Patient #3 in the living area lying in a hospital bed. Observed a Hoyer lift beside the hospital bed\, a wheelchair in the living area, and one in the kitchen area. Further observed a suction machine on the floor beside Patient #3’s bed. The Alternate Administrator/Alternate CM communicated Patient #3’s caregiver provided g-tube feedings and medication administration through Patient #3’s g-tube. Patient #3 takes nothing by mouth (NPO) and does not speak. A review of Patient #3's active clinical record, SOC date of 03/04/2026, contained a POC for the recertification period of 05/03/2026 to 07/01/2026, signed by the Administrator/CM and dated 04/29/2026. The POC in the section titled “Nutritional Requirements” listed enteral nutrition and nothing by mouth, but failed to list the kind of enteral nutrition, the amount, how it was received, and water. The section titled “DME and Supplies” listed a hospital bed, foam dressings, gauze bandages, saline, gloves, and masks, but failed to list wheelchairs, Hoyer lift, suction machine, g-tube supplies, and all wound care supplies. During an interview on 06/15/2026 at 2:47 PM, when asked about the wound care supplies, g-tube feedings, suction, Hoyer, and wheelchairs used for Patient #3, the Administrator/CM reviewed Patient #3’s POC and stated, “Everything should be on there. I missed it.” The Administrator further communicated Patient #3 received 500 milliliters (ml) of water with every 250 ml of Peptamen AF 1.2 kilocalorie (kcal) (a unit of energy commonly used in nutrition to measure the energy content) 5 times a day bolus feeding provided by the caregiver. 4. A review of Patient #5's active clinical record, SOC date of 04/24/2026, contained a POC for the initial certification period of 04/24/2026 to 06/22/2026, signed by the Administrator/CM and dated 04/24/2026. The POC in the section titled “Orders for Discipline and Treatment” noted Patient #5 had orders for SN one week two and two visits for a change in condition. During an interview on 06/15/2026 at 2:52 PM, when asked about Patient #5’s frequency on the POC, the Administrator/CM reviewed the patient’s POC and stated, “It should be every other week. No, that frequency is not right. I thought I had it every other week for visits. I review all the POCs I do not know how it was missed.” 410 IAC 17-13-1(a)(i-xiii)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure staff adhered to established infection prevention and control practices, including hand hygiene, gloving, and wound care, during 2 of 3 home visits. (Employees: Alternate Administrator/Alternate CM, and CNA 1) Findings Include: 1. A review of an undated agency policy titled “Handwashing/Hand Hygiene” indicated, but was not limited to, “Policy: In an effort to reduce the risk for infection in clients and staff … The agency will establish guidelines for all staff and will provide education and direction … 3. Indications for handwashing and hand antisepsis: … d. Between tasks on the same client. e. Before touching a wound. F. After removing gloves. g. After touching objects that are potentially contaminated … ” 2. A review of an agency policy effective date of 10/01/2025, titled “Wound Care Policy and Procedure” indicated but was not limited to, “Crown Health Services LLC shall provide safe, evidence-based wound care services to patients … implementing infection prevention measures … ” 3. During a home visit at Patient #3’s residence on 06/12/2026 at 1:04 PM, observed the Alternate Administrator/Alternate CM performing wound care and gastrostomy tube (g-tube) (a surgically placed feeding tube used to give direct access to the stomach) site care for Patient #3. The Alternate Administrator/Alternate CM removed the old dressing from around the g-tube site and discarded the dressing in the trash. Then the Alternate Administrator/CM obtained a washcloth, washed around the site, obtained another washcloth, rinsed around the site, obtained a third washcloth, and dried the site. The Alternate Administrator failed to discard their gloves, perform hand hygiene, and don new gloves after removing the old dressing before cleaning the g-tube site. The Alternate Administrator/Alternate CM then discarded their gloves and donned new gloves without performing hand hygiene either before donning new gloves or after discarding the old gloves. The Alternate Administrator/CM obtained a drainage sponge and applied it around the g-tube site. The Alternate Administrator/Alternate CM then performed wound care to Patient #6’s left heel, cleansed the wound with wound wash and 4 x 4 gauze, removed their gloves, and donned new gloves without performing hand hygiene. While observing the Alternate Administrator/CM performing wound care to Patient #6’s left hip wound, the Alternate Administrator/Alternate CM used a sterile cotton-tip applicator and applied Medihoney gel (a wound gel used for wound care treatment) from the tube to Patient #6’s hip wound. The Alternate Administrator/Alternate CM then touched the applicator back to the opening of the Medihoney tube, obtaining more gel, and reapplied it to Patient #6’s left hip wound. The Alternate Administrator/Alternate CM failed to obtain a new applicator after the first applicator had touched Patient #6’s wound, resulting in contamination risk to the Medihoney tube. During an interview on 06/12/2026 at 2:14 PM, when asked about infection control and prevention with the use of hand hygiene and using the cotton-tip applicator, the Alternate Administrator/Alternate CM stated, “I should use hand sanitizer every time gloves are removed and don new gloves. No, the cotton-tip applicator should not touch the tube after it is used on the patient.” 4. During the home visit at Patient #6’s residence on 06/12/2026 at 3:59 PM, observed CNA 1 washing their hands at the bathroom sink before and after assisting Patient #6 with a shower. On both occasions, CNA 1 turned off the faucet handles with their bare hands and then dried their hands with a paper towel. CNA 1 did not use a paper towel to turn off the contaminated faucet handles and did not perform hand hygiene after touching them. During an interview on 06/12/2026 at 4:30 PM, when asked about hand hygiene and touching the dirty faucet handles, CNA 1 stated, “I knew it. I just knew it. No don’t touch the handles of the faucet off.” 5. A review of the Personnel record for the Alternate Administrator/Alternate CM with a date of hire 11/01/2024, contained an agency document titled “Hand Hygiene Test” dated 04/06/2025, which had been completed and signed by the Alternate Administrator/Alternate CM. 6. A review of the Personnel record for CNA 1, with a date of hire 01/06/2025, contained an agency document titled “Infection Control: Guidelines for Standard and Additional Precautions Test” dated 01/06/2025, which had been completed and signed by CNA 1. On 06/15/2026 at 10:09 AM, when reviewing the home visit observations with concerns of infection control, gloving, and hand hygiene, the Administrator/CM stated, “We talk about this all the time. I even go on visits with them to ensure infection control practices are being completed.” 410 IAC 17-12-1(m)