Every finding on record at Springdale Home Care Services, LLC

On 04/20/2026 at 12:25 PM an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification survey for compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 04/23/2026 at 9:00 AM an exit conference was conducted with Agency Representatives. Preliminary findings were discussed.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Skilled Nurse (SN) failed to include all medications from the patient's medication list to ensure all medications were checked for potential adverse drug reactions and interactions in 1 (#1) of 13 (#1 - #13) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patient’s medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. The findings follow: Review of Clinical Record #1 revealed the following: A document titled Client Medication Report listing medication (Total Parenteral Nutrition) TPN 3:1AA, D:415G, IL75G, IN 2170 ml. This Medication Report, when viewed on a computer screen, shows the medication highlighted in blue indicating that the medication was not checked automatically by the Agency's Electronic Medical Record (EMR). There was no evidence this medication was manually reviewed by SN for adverse or significant drug interactions. On 04/22/2026 at 9:15 AM, Agency staff were presented with an opportunity to provide additional information and documentation. With no information provided, Agency Staff #1 affirmed the TPN medication was not reviewed.

. On 4/24/23 at 2:24 PM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 14/27/23 at 11:30 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on Clinical Record review, staff interview and patient interview, the Skilled Nurse (SN) failed to include all medications the patient was currently using during a review of the patients medication regimen in 2 (#3 and #10) of 17 (#1 - #17) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the SN and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Review of Clinical Record #3 revealed the following: A. Document titled “Medication Profile" showed three oral supplements, Ginger 559 mg by mouth daily, Omega3 D3 2000mg/1000 IU, Red Yeast Rice 600 mg twice daily by mouth, were not checked automatically by the EMR (electronic medical record) as evidenced by these medications, were highlighted in the color blue on the Medication Profile indicating they were not reviewed automatically with all other medications. There was no evidence these supplemental medications were manually reviewed by a SN for adverse effects, drug reactions, significant side effects or significant drug interactions. 2. Review of Clinical Record #10 revealed the following: A. Document titled "Home Health Certification and Plan of Care" dated 3/10/23 to 5/8/23 showed a diagnosis of "Malignant Neoplasm of Oropharynx", (cancer of a part of the inside of the mouth). This document contained orders that Patient #10 "started Chemo [therapy drugs used to treat cancer] today [3/10/23]." B. Review of a document titled "Client Medication Report" showed no evidence the Chemo drugs were listed and therefore were not reviewed by a SN for adverse effects, drug reactions, significant side effects or significant drug interactions. 3. On 04/27/2023 at 10:30 AM, Agency staff were presented with an opportunity to provide additional documentation and information. With no additional informatin provided, Agency staff #1 verified these medications were not reviewed for Patients #3 and #10.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview it was determined the Agency failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 3 (#4, #8, and #17) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect all current patients on census in that Physicians may be unaware of new assessment findings resulting in missed opportunities for revision of patient goals / interventions and prevention of hospitalizations. Review of Clinical Record #4 revealed the following: A. Document titled "Home Health Certification and Plan of Care dated 3/16/23 to 5/14/23 which contained a significant diagnosis of "Chronic Diastolic (congestive) Heart Failure" (A disorder where the heart does not pump properly to remove fluid from the patient's body causing weight gain as a sign and symption of a change in condition), and an order for “Skilled nurse to obtain weight every week and notify RN/MD of weight gain or loss of 5 lbs (pounds) within 7 days. Instruct patient/caregiver on importance of obtaining weight and keeping a weight log. B. On 3/20/23, Skilled Nurse (SN) visit documented the patients weight at "156.8 pounds (lbs)." The following SN visit occurred on 03/24/2023 and showed Patient #4 weighed "168 lbs.." This is an 11 lb. weight gain in 4 days. There was no evidence the physician was contacted regarding the 11 lb increase in weight. C. A SN visit note dated 04/10/2023 showed Patient #4' weighed 167 lbs. The next SN visit was two days later on 4/12/23 and showed the patient weighed 174 lbs. A seven lb. weight gain in two days. There was no evidence the physician was contacted regarding the 7 lbs. increase in weight 2. Review of Clinical Record #8 revealed the following: A. Physical Therapist (PT) visit dated 3/29/23 showed Patient #8 had a blood pressure reading of 93/44. The PT documented on the 3/29/23 visit note that Patient #8 "was unable to perform a full reassessment of objective measures ... due to low blood pressure, with the lowest systolic (upper reading) being in the 70s with patient seeing white specks." There was no evidence the Physician was notififed of the Patient's low blood pressure. 3. Review of Clinical Record #17 revealed the following: A. Review of SN visit note dated 2/7/23 showed Patient #17 had a blood pressure reading of 110/48. Further documentation by the SN on the 2/7/23 visits showed an attempt was made to contact the physician but "[SN] was "left on hold for 7 minutes will try back later". There was no evidence the Physician was contacted to report to low blood pressure. 3. During an interview with agency staff on 04/27/2023 at 10:30 AM, an opportunity to provide additional documentation. With no further documentation presented, Agency Staff member #1 verified the changes for Patients # 4, #8, and #17 were not reported to the Physicians.

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 during home visits, staff interviews, and review of the Agency's Policy and Procedure, the Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 2 (#1 and #3) of 7 (#1- #7) home visits conducted. This deficient practice had the potential to place all patients with wound care at risk for adverse outcomes, wound infection. and/or hospitalization. During a home visit on 4/25/23 at 9:50 AM with Patient #1, the surveyor observed the following: Wound care was being performed by the SN using saline, (for cleaning the wound), from a previously opened bottle that wasn’t labeled with date/time opened. The Surveyor asked Patient #1 when the bottle of saline had been opened and the Patient responded, “It’s been open a couple of days I think.” During this same home visit, Agency Staff #1 was asked about the Agency policy concerning multiuse containers, Agency staff #1 reported, “We have a policy, but the nurses aren’t really familiar with it because we don’t usually get these bigger containers, just the single use ones." 2 During a home visit on 04/25/2023 at 12:45 PM, with Patient #3, The Surveyor observed the following: A. The SN picked up a bottle of saline from a shelf with approximately half the fluid remaining in the bottle. The bottle was not dated with time/day of opening. When the Surveyor asked about when the bottle had been opened, both the SN and Patient #3 confirmed saline from the bottle had been used for, “Going on a week or so now.” Surveyor confirmed the bottle is stored on a shelf at room temperature. 3. Review of Baxter Healthcare Corporation. (a manufacturer and distributor of saline), the label directions show to “Discard unused portion.” 4.. Review of Information at Avacare Medical (a national supplier of saline), instructed “Once opened, saline ought to last 24 hours.”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on Clinical Record review, Agency Policy and Procedure review and staff interviews, it was determined the Physical Therapist (PT) failed to ensure written instructions for the aide services regarding the patients personal care activities were specific and individualized in 1(#12) of 3(#11, #12, and #13), which were 100% of all Clinical Records reviewed with aide services ordered. This deficient practice had the potential to affect all patients receiving aide services currently on census in that, the care provided may not be safe and effective and had the potential for negative patient outcomes. 1. Review of Clinical Record #12 revealed the following: A. Document titled "Home Health Certification and Plan of Care dated 3/17/23 to 5/15/23 contained orders that "Patient unable to shower at this time due to MD orders." B. Document titled "Visit Note Report" dated 3/17/23 contained documentation by the Physical Therapist (PT) that the Patient had a total hip replacement (THA) and in addition, showed Patient "unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in beside chair, or on commode, with the assistance or supervision of another person." C. Document titled "Aide Care Plan Report" complted by the PT showed the Aide was to assit the Patient every visit with "Bathing - Shower". 2. During an interview on 4/27/23 at 10:30 AM, Agency staff member #1 verified the Home Health Aide Care Plan was not specific to Patient #12 needs and did not follow the order for the Patient to not shower.