Davita Estrella Dialysis Center

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 49430 Based on document review and observation, it was determined that the facility failed to ensure staff aseptically maintain the site prior to cannulation with fistula needles. Failure to practice safe aseptic technique when cleansing and disinfecting a patient’s vascular access increases the risk for vascular access and blood stream infection. Findings include: Facility policy titled “AV FISTULA OR GRAFT CANNULATION WITH NIPRO OR MEDISYSTEMS SAFETY FISTULA NEEDLES (SFN) AND ADMINISTRATION OF HEPARIN LOADING DOSE” requires “8. Locate and palpate the needle cannulation site prior to skin preparation ....13. Do not palpate insertion site once area has been prepped ...” Observation on 05/13/2024 revealed Employee #19 accessing a Patient #20’s AVF. After scrub and dry time complete, and prior to needle cannulation, PCT palpated the site with gloved hand then cannulated the site with needles. Observation on 05/13/2024 revealed Employee #13 accessing a Patient #21’s AVF. After scrub and dry time complete, and prior to needle cannulation, PCT palpated the site with gloved hand then cannulated the site with needles. Employee #1 confirmed on 05/13/2024 that staff did not follow facility policy by palpating the site after disinfection.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49430 Based on review of facility policies and procedures, observations and staff interviews, the Department determined that the facility failed to: require staff dispose of expired supplies and medications, which has the potential risk of infection by using outdated items that may have lost their intended effectiveness for patients receiving hemodialysis treatments and; that oxygen cylinders were stored in a safe manor. Findings include: Facility policy, “Expiration Dates of Sterile Supplies” revealed: “...Sterile items will be checked before use to ensure that they have not expired...Appropriately dispose of sterile items that have reached the expiration date...” Observation on 05/13/2024 revealed the following expired supplies were found in the patient care area: Two (2) BD Vacutainer Safety-lock, 1 expired 02/29/2024, 1 expired 10/31/2020. One (1) InfusAID Intravascular Administration Set, expired 08/20217. One hundred thirty two (132) vials of Hectorol 4mcg/2ml, expired 04/2024. During an interview on 5/15/2024, Employee #1 confirmed the expiration dates of supplies and that the facility failed to ensure that medications, supplies and/or eqiupment had not expired.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 49430 Based on policy and procedure, observation, and interview, it was determined that the facility failed to ensure staff secured medications when not in use. Failure to secure medications when not in use may result in unauthorized access to prescription medication not prescribed to an individual and the potential for tampering or other compromise to the integrity of medications administered or dispensed. Findings include: A policy titled “Medication Preparation and Administration” revealed, “ ...The following steps must be taken for the securement ...All medications will be kept in a locked cabinet except when in use ....” Observation on 05/13/2024, revealed multi dose vials of heparin, unsecured, in all the care area pods, within drawers in the pods, sitting on top of the pods and in the boxes sitting on top of the pods that also contained the cannulation packs. Employee #1 confirmed during an interview on 05/13/2024, that the medication was not secured when not in use.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 49430 Based on document review, observation, and staff interview, the Department determined that the facility failed to ensure; 1. dialysis station chairs maintained their integrity which allowed sterilization and/or disinfection. Failure to maintain intact vinyl on dialysis chairs poses a risk of infection though cross contamination as exposed foam and fabric on the chair may harbor potentially infectious material that cannot be cleaned and/or disinfected. 2. biomedical technical staff performed annual preventive maintenance as required in the manufacturer’s directions for use which has the potential for patient injury or harm if dialysis machines are not maintained and normal operation is not verified. Findings include: 1. The facility policy titled “Physical Environment” requires: “...The space for treating each patient will be sufficient to provide needed care and services, prevent cross contamination....” 1. The facility policy titled “Infection Control for Dialysis Facilities” requires: “...Disinfection...Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials...Prior to routine disinfection, remove all visible blood...For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized...After all visible blood is cleaned...use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time...Use an appropriate disinfectant such as 1;100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces....” Observation on 05/13/2024 revealed the following. 1. Dialysis chairs at stations #1, 4, 5, 6, 7, 9, 10, 13, 14, 15, 16, 18, 19, 24 and the spare chair against the wall next to chair 5, had multiple tears and cracks in the vinyl covering the seat, arm and head areas of the chairs. Employees #1 confirmed on 05/14/2024, that the observed chairs were in disrepair with torn vinyl that prevented appropriate disinfection between patients. Findings include: 2. The facility policy titled “Preventive Maintenance Schedules for Equipment” requires “2. Dialysis delivery systems...devices will receive PM performed by trained Biomed teammates or outside vendor according to the manufacturer’s recommendations....”. 2. Braun’s Manufacture Instructions titled “Dialog+® Dialysis Machine Instructions for Use SW 9.1x” requires “ ...12.2.2 Technical safety inspection Technical safety inspection shall be performed and documented at least every 12 months ....”. 2. Review of facility documents titled “Technical Safety Inspection and Preventive Maintenance PM Dialog+” revealed 8 machine preventive maintenance (PM) logs to have inspections greater than 12 months; Serial Number 235168 PM preformed 04/13/2023. Machine was actively in use for patient treatment at station #6 at 10:00 on 05/15/2024. Serial Number 235169 PM preformed 04/21/2023. Machine was actively in use for patient treatment at station #11 at 10:00 on 05/15/2024. Employee #1 confirmed the dated recorded on the PM logs for the listed machines was greater than 12 months at the time of survey and that these machines were actively in use.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 49430 Based on facility observation and employee interview, it was determined that the facility failed to maintain the facility free from a condition or situation that may cause an individual to suffer physical injury. This deficient practice could result in a facility patient and/or employee to suffer injury or illness due to facility conditions. Findings include: 1. Observation on tour revealed twelve (12) fire safety ceiling sprinkler in facility, including staff areas and patient care areas, that have escutcheons not flush with drop-down ceiling tiles. The space around the escutcheons allows for the escape of heat and smoke which may intern render the sprinkler system to delay activation. 2. Observation on tour revealed three (3) active water leaks identified the water room: 2. The backflow connection is leaking onto the floor and puddles are accumulating causing slipping hazards as well as an open connection that may decrease pressure within the system and/or allow entrance of foreign particles (bacteria/fungus/mold/small particulates). 2. The line leading away from carbon tanks #1 is actively leaking onto the floor and puddles are accumulating causing possible slipping hazards, open connection that may decrease pressure within the system and/or allow entrance of foreign particles (bacteria/fungus/small particulates) and electrical shock 2. The reverse osmosis is actively leaking onto the floor and puddles are accumulating causing slipping hazards as well as an open connection that may decrease pressure within the system and/or allow entrance of foreign particles (bacteria/fungus/small particulates). Employee # 1 confirmed during an interview on 05/14/ 2024, that the escutcheons were not flush with the drop-down ceiling tiles and the water room had 3 active leaks during time of tour.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 49430 Based on a review of facility policy, medical records, and staff interviews, the Department determined that the administrator failed to require clinical staff to notify the registered nurse when the patient’s blood pressure (BP) and/or heart rate (HR) were out of range and/or vital signs were not preformed within a 30 minute interval per the facility policy and physician was not notified for patient’s post treatment weights (estimated dry weight- (EDW)) being equal to or greater than one (1) kilogram, which poses the potential risk of cardiovascular compromise, fluid overload and hospitalization. Findings include: Facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” requires “...Vital signs and treatment monitoring...completed at least every thirty (30) minutes...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Post-treatment: If patient is above or below 1 kg from the target weight...Pre-dialysis: Systolic greater the 180 mm Hg or less than 90 mm Hg...Diastolic greater than or equal to 100 mm Hg...Intradialytic: Difference of 20 mm Hg increase or decrease from patient’s last intradialytic treatment BP reading...Post Treatment: Standing systolic BP greater than 140 mm Hg or less than 90 mm Hg...Standing diastolic BP greater than 90 mm Hg or less than 50 mm HG...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute...”. Medical record review revealed patients had multiple occurrences of blood pressures and/or heart rates out of range, vital signs greater than 30-minute intervals, and weights 1 kg off from their prescribed target weight without documentation of the registered nurse being notified or the licensed nurse assessing the occurrence and/or notifying the physician of EDW. 1. Patient #4 medical records reveal leaving (4) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 2. Patient #5 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 3. Patient #8 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 1. Patient #4 medical records reveal leaving (6) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 2. Patient #5 medical records reveal leaving (6) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 3. Patient #6 medical records reveal leaving (5) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 4. Patient #7 medical records reveal leaving (5) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 5. Patient #8 medical records reveal leaving (6) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. Employee #1 confirmed during an interview on 05/14/2024 that the absense of documented registered nurse and/or nephrologist notifications did not follow facility policy.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 49430 Based on a review of facility policy, medical records, and staff interviews, the Department determined that the administrator failed to require clinical staff to notify the registered nurse when the patient’s blood pressure (BP) and/or heart rate (HR) were out of range and/or vital signs were not preformed within a 30 minute interval per the facility policy and physician was not notified for patient’s post treatment weights (estimated dry weight- (EDW)) being equal to or greater than one (1) kilogram, which poses the potential risk of cardiovascular compromise, fluid overload and hospitalization. Findings include: Facility policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” requires “...Vital signs and treatment monitoring...completed at least every thirty (30) minutes...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...Post-treatment: If patient is above or below 1 kg from the target weight...Pre-dialysis: Systolic greater the 180 mm Hg or less than 90 mm Hg...Diastolic greater than or equal to 100 mm Hg...Intradialytic: Difference of 20 mm Hg increase or decrease from patient’s last intradialytic treatment BP reading...Post Treatment: Standing systolic BP greater than 140 mm Hg or less than 90 mm Hg...Standing diastolic BP greater than 90 mm Hg or less than 50 mm HG...Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute...”. Medical record review revealed patients had multiple occurrences of blood pressures and/or heart rates out of range, vital signs greater than 30-minute intervals, and weights 1 kg off from their prescribed target weight without documentation of the registered nurse being notified or the licensed nurse assessing the occurrence and/or notifying the physician of EDW. 1. Patient #4 medical records reveal leaving (4) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 2. Patient #5 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 3. Patient #8 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG from the estimated dry weight without any documentation of a physician being notified. 1. Patient #4 medical records reveal leaving (6) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 2. Patient #5 medical records reveal leaving (6) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 3. Patient #6 medical records reveal leaving (5) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 4. Patient #7 medical records reveal leaving (5) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. 5. Patient #8 medical records reveal leaving (6) of (6) treatments with of blood pressures, and/or heart rates out of range, and/or vital signs greater than 30-minute intervals, without any documentation of a registered nurse being notified. Employee #1 confirmed during an interview on 05/14/2024 that the absense of documented registered nurse and/or nephrologist notifications did not follow facility policy.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 49430 Based on review of policies and procedures, medical records and interview with staff, it was determined the administrator failed to ensure: 1. Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was updated to reflect changes in a patient’s health status from stable to unstable and; 2. Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) updated within the thirty day timeframe as required after designation as unstable. The failure to identify, assess and update the CIPA significantly increases the risk of hospital admissions, hospital readmissions and death to the dialysis patient population. Findings include: 1. Facility policy titled “Interdisciplinary Team (IDT) requires “ ...The facility’s interdisciplinary team will develop and implement a written ...comprehensive plan of care that specific the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition...” and “In addition, if the expected outcome is not achieved, the interdisciplinary team (or individual IDT member) will adjust the patient’s plan of care to achieve the specified goal ... Adjust the plan of care to reflect the patient’s current condition.” Facility policy titled “Development of Patient Care Plans” requires that “ ...Criteria for classifying patients as unstable ... Marked deterioration in the health status would be specifically identified and documented by the IDT. The following conditions have been suggested ... Change in ambulation severe enough to interfere with the patient’s ability to follow aspects of the treatment plan ... Significant changes in psychosocial needs: ... amputation ... The Plan of Care is completed within 30 days ...” Patient #5, hospitalized 12/29 to 2/6/2024 for bilateral below the knee amputation of both lower limbs per the document titled “MSW Monthly Progress Note” dated 2/29/2024. Further review of the of document stated, “ ...Patient reports it has been very hard for her ... Patient verbalized that her insurance does not always have vans for transport ...”. CIPA dated 07/01/2023 deemed patient as stable. No CIPA updates pre, intra or post hospitalization for bilateral below the knee amputation of both lower limbs to reflect the patient status change that required hospitalizations. Employee #1 confirmed in an interview on 5/14/2024 that CIPA updates were not provided and that the Plan of Care was not updated per facility policy. 2. Facility policy titled “Interdisciplinary Team (IDT) requires “ ...The facility’s interdisciplinary team will develop and implement a written ...comprehensive plan of care that specific the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition...” and “In addition, if the expected outcome is not achieved, the interdisciplinary team (or individual IDT member) will adjust the patient’s plan of care to achieve the specified goal ... Adjust the plan of care to reflect the patient’s current condition.” and “ Monthly (unstable): Monthly until the patient is determined by the interdisciplinary team to be stable ...” Chart review revealed patient #9 as having an unstable care plan dated 02/20/2024. The next care plan is dated 04/18/2024; greater than the required thirty (30) day reassessment. Employee #1 confirmed during an interview on 5/14/2024 that more than 30 days had passed between the Care Plans despite the required thirty (30) day reassessment per facility policy.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 49430 Based on record review and interview, it was determined that the facility failed to update the unstable car plan within the thirty (30) timeframe which poses the risk of uncoordinated care which may contribute to the unstable status, which that had been identified by the team previously, and further deterioration of the patient’s health status. Facility policy titled “Interdisciplinary Team (IDT) requires “ ...The facility’s interdisciplinary team will develop and implement a written ...comprehensive plan of care that specific the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition...” and “In addition, if the expected outcome is not achieved, the interdisciplinary team (or individual IDT member) will adjust the patient’s plan of care to achieve the specified goal ... Adjust the plan of care to reflect the patient’s current condition.” and “ Monthly (unstable): Monthly until the patient is determined by the interdisciplinary team to be stable ...” Chart review revealed patient #9 as having an unstable care plan dated 02/20/2024. The next care plan is dated 04/18/2024; greater than the required thirty (30) day reassessment. Employee #1 confirmed during an interview on 5/14/2024 that more than 30 days had passed between the Care Plans despite the required thirty (30) day reassessment per facility policy.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 49430 Based on review of facility policy, medical records and staff interview, the Department determined that the facility failed to ensure: 1. That there was documented monthly Registered Dietitian Progress Notes, which poses a potential risk of lack of coordination and continuity of care; and 2. That there was documented monthly Physician Progress Notes, which poses a potential risk of lack of coordination and continuity of care. Findings include: 1. Policy Titled “Medical Record Quality Assurance” requires “...are required to record patient progress notes at least monthly...document changes in patient’s nutritional status and needs ...”. On 05/13/2024, surveyor requested monthly Dietitian Progress Notes of selected 5 patients currently on the facility census. Review of medical records reveal absence, or note lacking sufficient information, of Dietitian Progress Notes for the months between the range of April to January 2024. Of the documentation that was produced by the facility, Dietitian notes for April, 2024, read “Covering RD. Reviewed Labs with pt. Continue current POC. RDN III the last week of March, more thorough note next month.” This note was repeated in 5 of 5 patients charts for April, 2024. Review of medical records revealed an absence of dietitian progress notes for the months of: January for 4 of 5 patients, February for 3 of 5 patients, March for 3 of 5 patients. Employee #1 confirmed, on 05/13/2024, absence of Dietician Progress Notes for the months of January to March, 2024. 2. Policy titled “Medical Record Quality Assurance” requires “...Attending physicians are required to record progress notes at least monthly. All progress notes are to be dated and signed at the time they are written or entered electronically....” On 05/13/2024, surveyor requested Physician Progress Notes for selected 5 patients currently on the facility census. Medical records reveal absence of Physician Progress Notes for the month of April, March and February, 2024. Review of medical records revealed that patient #6 did not have Physician Progress Notes for the month of April, 2024. Review of medical records revealed that patient #7 did not Physician Progress Notes for the month of February and March, 2024. Employee #1 confirmed during an interview on 05/14/2024 that the absense of documented registered nurse and/or nephrologist notifications did not follow facility policy.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 50568 Based on record review and staff interview, the Department deternined that the facility failed to ensure to staff an adequate number of dieticians to meet the clinical needs of each patient. Lack of adequate dietary status, assessments, and interventions put the patient population at increased risk for noncompliance to treatments, late or inaccurate interdisciplinary plans of care increasing the risks of hospitalizations, decreased function and death. Finding includes: During interview on 5/13/2024 Employee #1 confirmed that for in center hemodialysis there is currently one dietician that is providing coverage from a near by facility that is under the same ownership since approximately October, 2023. Employee #1 confirmed that there are currently 118 patients on census at this facility. During an interview on 5/15/2024 with Employee # 1 and Employee #2, data review for the facility was being conducted. Data presented during review of QAPI for the past year revealed that patients had an higher recent average phosphorous blood levels for patients as compared to previous months. During review of Governing Body minutes, action plans for needing additional staff, including an RN, two PCTS, and an RD (“ ...Need One RN and two PCT’s and 1 RD ...”) were noted in the Meeting minutes dated October 12, 2023. On 05/13/2024, surveyor requested monthly Dietitian Progress Notes of selected 5 patients currently on the facility census. Review of medical records reveal absence, or note lacking sufficient information, of Dietitian Progress Notes for the months between the range of April to January 2024. Of the documentation that was produced by the facility, Dietitian notes for April, 2024, read “Covering RD. Reviewed Labs with pt. Continue current POC. RDN III the last week of March, more thorough note next month.” This note was repeated in 5 of 5 patients charts for April, 2024. Review of medical records revealed an absence of dietitian progress notes for the months of: January for 4 of 5 patients, February for 3 of 5 patients, March for 3 of 5 patients. Employee #1 confirmed, on 05/13/2024, absence of Dietician Progress Notes for the months of January to March, 2024.”