Every finding on record at Prestonwood Home Healthcare LLC

A complaint investigation survey was conducted for Complaint 2808384 on 03/20/2026. Licensed and certified home health services census was 174. Abbreviations and Acronyms: Admin-Administrator Alt. Admin-Alternate Administrator DON-Director of Nurses POC- Plan of Care SOC- Start of Care CG-Caregiver (homemaker/home health aide) Registered Nurse (RN) SN- Skilled Nursing OASIS -outcome and assessment information set CMS-Center for Medicare and Medicaid Services

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 record review, observation, and interview the agency failed to ensure that the individualized plan of care (POC) included the required elements in three of three patient records reviewed, in that: for (Patients # 1, 2, and 3) the POC failed to include all pertinent diagnoses, the patient's psychosocial status (refers to the interaction between an individual’s thought, emotions, behavior, their relationships, culture, and society), neurological status (includes assessing mental status, nervous system, movement status, reflexes, sensations), activities permitted, all medications, and safety measures to protect against injury. The failure placed the patient at increased risk of having poor physical health and safety outcomes, increased mental health decline, and social isolation due to not having a detailed plan of care. Findings include: Patient # 1: Review of Patient # 1’s clinical record revealed a POC with a SOC date of 11/25/2025 and a treatment period of 11/25/2025 to 05/23/2026. Review of the POC revealed that RN B signed and dated the POC on 12/01/2025. Continued review of the POC revealed that there was no assessment for psychosocial status, neurological status, or safety measures to protect against injury included in the POC. Further review of the POC revealed that it included orders for SN visits one time a week for nine weeks. Review the Patient # 1’s medication list revealed the patient used oxygen continuously to assist with maintaining consistent oxygen levels in the blood (which required safety measures i.e., no smoking, keeping oxygen tanks away from open flames). Continued review of Patient # 1’s record revealed an “Approval Referral For Medical Care” form dated 11/24/2025 from the client’s payor source (Payor Source A). Review of the approval form revealed that the agency was authorized to provide seven to six hours of home health aide (homemaker services) to assist with activities of daily living (household tasks, i.e., laundry, cleaning; personal care tasks i.e., assisting with bathing and shaving) and SN visits for oversight of homemaker/home health aide services. Patient # 2: Review of Patient # 2’s clinical record revealed a POC with a SOC date of 11/27/2025 and a treatment period of 11/27/2025 to 05/25/2026. Review of the POC revealed that RN B signed and dated the POC on 12/04/2025. The POC included a primary diagnosis of congestive heart failure (a condition where the heart muscle cannot pump enough blood to meet the needs of the body, effectively). Continued review of the POC revealed that there was no assessment of the patient’s psychosocial status or neurological status included in the POC. Further review of the POC revealed that it included orders for SN visits one time a month for eight months. Continued review of the record revealed that Patient # 2 had a diagnosis of stroke (a neurological condition that occurs when blood flow to a part of the brain is interrupted by blood vessel bursting or getting blocked; the interruption causes brain cells to die due to lack of oxygen, this condition requires safety measures) with right side paralysis. Continued review of Patient # 2’s record revealed an “Approval Referral For Medical Care” form dated 11/25/2025 from the client’s payor source (Payor Source A). Review of the approval form revealed that the agency was authorized to provide 12 to 16 hours of home health aide (homemaker services) to assist with activities of daily living (household tasks, i.e., laundry, cleaning; personal care tasks i.e., assisting with bathing and shaving) and SN visits for oversight of homemaker/home health aide services. Patient # 3: Review of Patient’s # 3’s clinical record revealed a POC with a SOC date of 10/28/2025 and a treatment period of 10/28/2025 to 04/25/2026. Review of the POC revealed that RN A signed and dated the POC on 10/28/2025. Continued review of the POC revealed that there were no diagnoses included, psychosocial status, activities permitted, any medications, or safety measures to protect against injury included in the POC. Further review of the POC revealed that it included orders for SN visits one time a month for eight months and home health aide (homemaker) services for 10 hours weekly to assist with activities of daily living (household tasks, i.e., laundry, cleaning; personal care tasks i.e., assisting with bathing and shaving). During a home visit, observation and interviews with Client # 3 and CG A on 03/24/2026 at 9:30 AM, the surveyor asked Client # 3 his age and birth date. Client # 3 stated an incorrect age and the correct date of birth. The surveyor pointed to (CG A) and asked who she was. The surveyor observed that Client # 3 could not identify (CG A) without her prompt. During an interview with RN B on 03/24/2026 at 1:40 PM, the surveyor asked how long RN B had worked for the agency. RN B stated that she started working for the agency early last year (2025). The surveyor asked RN B to explain her process for conducting patient assessments. RN B stated that she called the patient. She asked if the patient had dogs. When she arrived at the home she explained the reason for the admission. She obtained their consent to receive services from the agency. She provided the admission paperwork and discussed patient rights information. She stated that she informed the patient if they have a complaint, they could call the agency and the state. She left copies of the paperwork with the patient. She had them sign an authorization to keep the doctor informed and updated. She stated that the last thing that she did was the OASIS assessment (is a group of standard data elements home health agencies include in their comprehensive assessment, to collect and report quality data to CMS) and comprehensive assessment information. She asked about their medications and conducted a head-to-toe assessment of the patient. The surveyor asked if RN B completed the plan of care. RN B stated that the plan of care populated (patient information was filled in) from the OASIS assessment. The surveyor asked if she completed the OASIS for the skilled and non-skilled patients the same. RN B stated that she did not know there was any difference. The surveyor asked why the plan care was not completed with all the required elements (psychosocial status, neurological status, and safety measures) for Clients # 1 and 2. She replied, “I can’t answer that I don't have the information in front of me.” She stated if the patient had not had a stroke and there was nothing to address, then there would be nothing documented under that area. “I only see them one time, to do the initial assessment.” The surveyor asked if the nurse did supervisory visits for the home maker/home health aide caregiver. She replied, “No, I just do admission.” During an interview with RN A on 03/24/2026 at 1:50 PM the surveyor asked how long RN A had worked for the agency. RN A stated that she started in September of 2025. The surveyor asked if RN A remembered doing the initial assessment for Client # 3. RN A stated that she did remember doing the initial visit and (OASIS) initial assessment with Client 3. The surveyor asked what RN A remembered about Client # 3. RN A stated that he lived with family members, he had dementia (memory loss, confusion, and behavioral changes that interfere with daily life) and high blood pressure. RN A stated that his family member was his provider (paid caregiver). The surveyor asked if there were any safety concerns that she remembered. RN a stated that she remembered that Client # 3’s family member said he liked being at home, so there wasn't much of a risk with falls. The surveyor asked if the client had any medication. She stated that he did have medication, but she did not remember what kind of medication because she did not have access to the record at that time. The surveyor asked RN A to explain her process for conducting patient assessments. RN A stated that she introduced herself, explained the purpose of the visit, answered questions, and explained the reason for the home health referral. RN A stated that during initial assessment visits with patients she asked them if they approved of being admitted to the agency. RN A completed a health assessment and reviewed their health history. The surveyor asked if RN A completed the OASIS and comprehensive for the skilled and non-skilled patients the same. RN A stated that the assessments were completed the same, and that she did not know anything about doing a non-skilled assessment differently. The surveyor asked if RN A remembered doing the OASIS assessment for Client # 3. RN A stated that she did remember doing the initial visit and initial assessment with Client #3. The surveyor reviewed the findings of the OASIS and plan of care not being completed with all required elements (no diagnosis on POC, no medications listed on POC, no psychosocial status, no safety measures, and no activities permitted on POC). The surveyor asked why OASIS and POC did not include the required elements. RN A stated that it sounded like to her that she got interrupted and just submitted it incomplete.” During an interview with the Admin/DON and Alt Admin on 03/24/2026 at 2:44 PM, the Surveyor reviewed the findings. The surveyor asked what processes the agency had in place to ensure that RNs had completed the OASIS and comprehensive assessment with all required elements (so that the POC included all required elements). Admin/DON stated that there was an OASIS check (in the software), the software would not let the RN submit the OASIS if they had not completed it. Admin/DON stated that the RN would notify the agency if the OASIS did not submit. Admin/DON stated that she did not know that the OASIS for Client # 3 and the POC (s) for Clients # 1, 2, and 3 did not include the required elements; and that she would have to look at them. Admin/DON stated that she was responsible for ensuring OASIS assessments and POC were completed. Review of agency policy titled, “Plan of Care” last reviewed 01/01/2026 read in part, “Purpose [:] To ensure that care provided is appropriately planned in a timely manner to meet the patients/clients. specific needs and problems... Policy [:] I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs… A. A registered nurse (RN) initiates the Plan of Care for skilled nursing care and for personal hygiene/activities of daily living care… III. Each patient/client must receive an individualized written Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the Plan of Care. The individualized Plan of Care will indicate if the patient/client has an advance directive(s) and if so, what type(s) of advance directive(s) exists. If the patient does not have an advance directive, this should also be listed on the individualized Plan of Care. The individualized Plan of Care must also specify the patient/client and caregiver education and training. A. The individualized Plan of Care must include the following: 1. All pertinent diagnoses; 2. The patient’s/client’s mental, psychosocial, and cognitive status; 3. The types of services, supplies, and equipment required; a. The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care. 4. The frequency and duration of visits to be made; 5. Prognosis; 6. Rehabilitation potential; 7. Functional limitations; 8. Activities permitted; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 12. A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors. 13. Patient/client and caregiver education and training to facilitate timely discharge; 14. Patient/client-specific interventions and education; 15. Measurable outcomes and goals identified by the Agency and the patient/client; 16. Information related to any advance directives; and 17. Any additional items the Agency or physician or allowed practitioner may choose to include…”

An on-site investigation was conducted for ID IQ97259/Intake 415372 on 04/21/2023. L & C census was 74. Acronyms/Abbreviations: L & C- Licensed and Certified Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nursing HHA-Home Health Agency EHR- Electronic Health Record Registered Nurse (RN) PT-Physical Therapy SOC-start of care POC- Plan of Care SN- Skilled Nursing IV-Intravenous

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview the HHA failed to integrate services that were provided directly and under arrangement for one (Patient # 2) of two patients receiving skilled nursing services whose clinical records were reviewed with an allegation of delayed service provision. The agency failed to coordinate care provided by all disciplines, in that: Patient #2’s blood draws were delayed 22 days. The failure could cause a delay in the patient receiving timely care and treatment. Findings Included: During the entrance conference of an on-site complaint investigation, on 04/20/2023 at 10:25 a.m. the surveyor requested the agency's complaint log, reports, and records. The surveyor reviewed the agency’s complaint records from January 2022 through April 2023. Review of the complaint records revealed the following: Client # 2: A complaint letter, dated 12/23/2022, from Client # 2’s insurance company (Identifier 100) with an allegation of delayed treatment [lab work (blood draws), intravenous (given in the veins) antibiotic treatment and PT]. The letter read in part: “…Member complaint background [Patient # 2] is stating that he was discharged from the hospital on 12/06/2022. [Patient # 2] is also stating that he receives IV antibiotic treatment. [Patient # 2] is alleging that weekly blood draws were ordered. He is stating that [the agency] has not sent a nurse to perform the weekly blood draw. [Patient # 2] is stating that the pharmacy that delivers his IV antibiotics, will not deliver the medication until his labs are drawn. [Patient # 2] is stating that his labs have not been drawn by [the agency]and is stating that he will be without his next dose of antibiotics…[Patient # 2] is also stating that he has an order for physical therapy. He alleges that [the agency] has not followed up on the order and he states that he has not received any physical therapy…” Client # 2: Review of Client # 2's EHR revealed two POC(s) with a SOC date of 06/21/2021. The POC with the treatment period of 08/15/2022 to 12/12/2022 was signed by the Adm/DON and dated 08/14/2022. The POC with the treatment period of 12/13/2022 to 12/12/2023 was signed by RN B and dated 12/12/2022. The POC(s) contained a diagnosis of Quadriplegia (paralysis of all arms and legs). The POC(s) also included orders for SN visits for Monday, Wednesday, Friday, and Saturday. Continued review of Client # 2’s record revealed a physician’s order dated 12/06/2022, with “Date Printed:” as 12/06/2022. The physician’s order included a diagnosis of Urinary Tract Infection. The physician’s order also included the following: Intravenous antibiotic treatments; dressing changes weekly and as needed to the intravenous access insertion site, weekly lab work on Mondays. The lab work (blood tests) ordered were CBC, ESR, CMP, CRP and CPK: complete blood count (CBC). It is used to look at overall health and find a wide range of conditions, including infections; erythrocyte sedimentation rate (ESR). It measures how quickly erythrocytes, or red blood cells, separate from a blood sample that has been treated so the blood will not clot; A comprehensive metabolic panel (CMP) is a test that measures 14 different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. C-reactive protein (CRP) is produced by the liver. The level of CRP rises when there is inflammation throughout the body. The creatine phosphokinase (CPK) isoenzymes test measures the different forms of CPK in the blood. CPK is an enzyme found mainly in the heart, brain, and skeletal muscle. Further review of the record revealed a patient lab report dated 12/29/2022 that showed the lab work was completed on 12/28/2022. Review of Patient # 2’s SN visits revealed that RN B conducted a recertification visit on 12/12/2022. Review of Patient # 2’s visit calendar revealed that LVN A conducted SN visits on 12/12/2022; 12/16/2022; 12/17/2022; 12/19/2022; 12/21/2022; 12/23/2022; 12/24/2022; and 12/26/2022. The record did not reveal that the lab work was completed during any of the SN visits. Patient # 2’s blood draws were delayed from the date of the order (12/06/2022) until 12/28/2022. During an interview with the Adm/DON and Alt Adm on 04/21/2023 at 4:26 p.m. the surveyor asked what the agency’s processes were for ensuring physician’s orders were completed as ordered. The Adm/DON replied, “We process the lab work with laboratory (Identifier 300). When we get an order, the secretary pulls it out and puts it in [the EHR system, Identifier 400] and notifies the person who will complete it.” The surveyor also asked why the orders for Patient # 2 were not completed as ordered. The Adm/DON replied, “They said they faxed it to us. We did not receive it. When we received the order, I went out and drew the blood.” Review of agency policy titled “Implementing Care and Treatment PC.40” last reviewed 08/01/20 read in part: “…Procedure I. The Agency is responsible for patient/Client care, and must conduct and provide, either directly or under arrangement, all services rendered to patients/clients…”

Purpose of Visit: Recertification survey with Follow-up dated 11/30/2018 Entrance Date: 11/08/2021 An entrance conference was conducted with the Adm at 12:35 p.m. The Adm/DON was informed that the purpose of the survey was for a 36-month recertification survey with follow-up for survey dated 11/30/2018. L&C Census: 0 Exit Date: 11/15/2021 An exit conference was conducted at 4:29 p.m. with the Adm/DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was provided, a COVID-19 screening document. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) ADON - Alternate Director of Nurses (Alternate Supervising Nurse) L & C- Licensed and Certified CFR-Code of Federal Regulations

Purpose of Visit: Recertification survey with Follow-up dated 11/30/2018 Entrance Date: 11/08/2021 An entrance conference was conducted with the Adm/DON at 12:35 p.m. The Adm/DON was informed that the purpose of the survey was for a 36-month recertification survey with follow-up for survey dated 11/30/2018. L&C Census: 0 Exit Date: 11/15/2021 An exit conference was conducted at 4:29 p.m. with the Adm/DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was provided, a COVID-19 screening document. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met conditions of participation. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) ADON - Alternate Director of Nurses (Alternate Supervising Nurse) QAPI-Quality Assessment Performance Improvement PIP- Performance Improvement Projects COVID-19- Novel Coronavirus Disease 2019

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, in one of one agency QAPI program, the agency failed to conduct PIP (s) for the calendar years 2018 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk of not improving and providing quality care and services to the agency's patients. FINDINGS INCLUDED: During the entrance conference on 11/08/2021 at approximately 12:35 p.m., the surveyor requested all agency QAPI/documents/reports/binders. Record review of the agency's QAPI records did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018 and 2020. On 11/08/2021 the surveyor also reviewed the agency's business profile binder. The binder also did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018 and 2020. During an interview on 11/15/2021 at 2:00 p.m., with the Adm/DON the surveyor discussed the above findings of why the agency had not ensured that the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018 and 2020. The Adm/DON stated that Consult A was normally at the agency every quarter, but “in 2020 and 2021 she was not here.” The Adm/DON also replied, “With COVID we had a lot to juggle.” Review of agency policy titled “Quality Assessment Performance Improvement Program QAPI.1’ revised 011318 read in part: “…PROCEDURE…D. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and measurable progress achieved on these projects…”