Davita Branford Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44675 Based on observation, interview and review of facility policy, the facility failed to ensure the hemodialysis chairs were maintained in a clean and sanitary manner. The findings included: Observation of the hemodialysis treatment floor during flash tour on 8/25/25 at 9:10 AM identified twelve (12) out of thirteen (13) dialysis chairs had rusted screws on both sides of the top of the treatment chairs. There were rusted stains down both sides of the treatment chairs (12 chairs). Interview with the Facility Administrator and Regional Operations Director on 8/27/25 at 2:00 PM identified they would be putting in a work order to have the screws replaced.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation, facility policy and interviews for one (1) of three (3) patients (Patient #7) observed during treatment discharge, the facility failed to ensure hand hygiene was performed following a bleeding event and prior to exiting the clinic, for one (1) out of four (4) patients, (Patient #10), reviewed for hand hygiene, the facility failed to ensure patients were offered hand hygiene after removing gloves, and for three (3) out of four (4) patients, (Patients #11, #12 and #13), review for treatment initiation, the facility failed to perform hand hygiene after access cleansing prior to cannulation per facility policy. The findings included: 1. Patient #7 had diagnoses that included End Stage Renal Disease (ESRD). Physician’s orders directed to hemodialysis treatments three times weekly for three (3) hours and thirty (30) minutes using a right upper arm arteriovenous fistula. Observation at 9:35 AM identified Patient #7’s dialysis treatment had ended. Staff Person #2 removed Patient #7’s arterial needle, applied gauze, tape and a clamp over the site to assist with clotting, however within minutes, Patient #7’s arterial site had started to bleed. Patient #7 applied additional pressure to the clamp with his/her ungloved left hand until receiving assistance from Staff Person #2, who then applied a new bandage and tape, and held the site for a few minutes before applying a clamp. Patient #7 was observed placing additional pressure on the clamp but was not offered a glove. After Staff Person #2 removed the clamp and inspected the dressing to ensure the bleeding had stopped, Patient #7 was discharged from the facility without performing hand hygiene. Patient #7 was observed using his/her left hand, which he/she used to apply additional pressure to the bleeding site, to open the door leading to the lobby. Interview with the Charge Nurse on 8/27/25 at 2:32 PM identified Patient #7 should have been offered a glove when holding his/her site whether a clamp was used, and hand hygiene should have been offered/given to the patient prior to exiting the clinic. 2. Patient #10 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times a week with a right forearm Arteriovenous Fistula (AVF). Observations conducted on 8/27/25 at 10:25 AM at Station #3 identified Patient #10 holding his/her right access after hemodialysis treatment. Patient #10 then removed his/her gloves, after his/her standing blood pressure was measured with Staff Person #1. Staff Person #1 did not offer hand hygiene to Patient #10. Patient #10 proceeded to the scale without performing hand hygiene. Review of the infection control for dialysis facilities policy directed that patients and caregivers will be encouraged to perform hand hygiene after treatment before leaving the treatment area. 3. Patient #11 had diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times a week with a right forearm arteriovenous fistula (AVF) with 16 gauge needles. Observations conducted on 8/27/25 at 10:29 AM at Station #2 identified Staff Person #6 performing treatment initiation for Patient #11. Staff Person #6 removed Patient #11’s analgesic cream, cleaned and disinfected Patient #11’s access and proceeded to canulate Patient #11’s access without the benefit of removing her gloves, performing hand hygiene and applying new gloves before cannulation. 4. Patient #12 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three (3) times a week with a left forearm AVF with 16 G needles. Observations conducted on 8/27/25 at 10:47 AM at Station #1 identified Staff Person #1 performing treatment initiation for Patient #12. Staff Person #1 cleaned and disinfected Patient #12’s access, applied analgesic spray and proceeded to cannulate Patient #12’s access without the benefit of removing her gloves, performing hand hygiene and applying new gloves before cannulation. At 11:00 AM, after cannulation of the venous site, Patient #12’s venous needle was removed due to Patient #12’s complaint of pain. At 11:10 AM Staff Person #6 cleaned and disinfected Patient #12’s venous site and proceeded to cannulation Patient #12’s access without the benefit of removing her gloves, performing hand hygiene and apply new gloves before cannulation. Review of the AV fistula or graft cannulation with safety fistula needles policy directed, in part, that while maintaining aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. Cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. If applicable, anesthetize needle insertion site. Remove gloves, perform hand hygiene and put on clean gloves prior to cannulation.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation and interviews, the facility failed to appropriately clean and disinfect the dialysis station and non-disposable equipment after hemodialysis treatment and after entering a patient station per facility policy. The findings included: a. Staff Person #1 was observed cleaning Station #4 at 10:08 AM and had failed to extend the patient’s chair during cleaning, disinfect the television, television arm, back counter, wall box, hoses on the front and side of the dialysis machine, the sides of the dialysis machine, the blood pressure cuff holder, and the IV pole. Furthermore, Staff Person #1 was observed to use a 1:100 bleach solution to clean the blood smear located on the right-side table and only cleaned the area one time. b. Staff Person #1 was observed cleaning Station #9 at 2:03 PM and had failed to disinfect the television, television arm, back counter, wall box, hoses on the front and side of the dialysis machine, the sides of the dialysis machine, the blood pressure cuff holder, and the IV pole. c. Observation conducted on 8/25/25 at 2:53 PM identified during disinfection of Station #1 after a patient treatment, Staff Person #5 failed to clean and disinfect the sides of the hemodialysis machine, the drain lines coming from the machine to the wallbox and the wallbox. He further failed to clean and disinfect the back counter of the hemodialysis station. d. Observation conducted on 8/27/25 at 9:59 AM identified during disinfection of Station #2 after a patient treatment, Staff Person #1 failed to thoroughly clean and disinfect the hemodialysis chair side table. After disinfection, tape from the previous treatment remained on the left chair side table. She further failed to clean and disinfect the outer side of the chair sides where there were rust stains identified. At 10:18 AM Staff Person #1 removed the tape from the chair side table but did not disinfect the area after removal. e. Observation conducted on 8/27/25 at 10:20 AM identified during disinfection of Station #1 after a patient treatment, Staff Person #6 failed to clean and disinfect the top of the IV pole attached to the hemodialysis machine. She further failed to clean and disinfect the outer side of the chair sides where there were rust stains identified and the back counter of the hemodialysis station. f. Observation conducted on 8/27/25 at 11:02 AM identified during disinfection of Station #3 after a patient treatment, Staff Person #6 failed to clean and disinfect the top of the IV pole attached to the hemodialysis machine. She further failed to clean and disinfect the back counter of the hemodialysis station. Review of the Infection Control for Dialysis Facilities policy directed the dialysis station to be disinfected at the end of treatment, which included, but not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs), frequently contacted by healthcare personnel (e.g. control panel, top, front, and sides of the dialysis machine, touchscreens; countertops), and that the wallbox, drain and water supply lines were considered part of the dialysis delivery station. The policy further directed for visible blood or gross blood spills to be cleaned with a 1:10 ration bleach solution and that after all visible blood was cleaned with the 1:10 bleach solution, teammates were to use a new disposable towel soaked with 1:10 bleach solution and clean the area a second time. g. Observations conducted on 8/27/25 at 11:00 AM identified Staff Person #1 at Station #2 for a Patient #11’s nursing assessment. Staff Person #1 osculated Patient #11’s lungs with the stethoscope, then proceeded to place the stethoscope on the nursing station counter (clean area), without the benefit of disinfecting the stethoscope after removal from the patient station. Review of the infection control for dialysis facilities policy directed that non-disposable items are to be disinfected after each patient use, prior to removal from the treatment area/station and if contaminated between uses. Stethoscopes will be disinfected with an alcohol prep pad and/or 1:100 bleach solution if they are visibility contaminated with blood or body fluids should be disinfected with a 1:10 bleach solution. 47491”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. 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 as 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 This Standard is not met as evidenced by: 32738 Based on review of clinical records, observation, interview, and review of facility documentation and policy for one (1) of three (3) patients observed during treatment initiation, the facility failed to ensure a staff member properly applied his/her mask during central venous catheter (CVC) care and treatment initiation. The findings included: Patient #9 had diagnoses that included end stage renal disease. Physician’s orders directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes utilizing a Central Venous Catheter (CVC). Observation on 8/27/25 at 10:39 AM identified Staff Person #4 was observed preparing Patient #9 for treatment initiation. Staff Person #4 was observed performing CVC exit site (which included removal of the old dressing, cleaning the exit site, and applying a new dressing), cleaning the CVC limbs with an antiseptic wipe, removing the endcaps of each CVC limb to extract the heparin dwell with a syringe, removing the used syringe and flushing each limb with normal saline, removing the normal saline syringe from the venous limb to instill heparin, then removing each syringe from each limb to initiate treatment. During the entire treatment preparation procedure, Staff Person #4 was observed with his/her mask only covering the tip of his/her nose, which left each nostril partially exposed. Interview with Staff Person #4 on 8/27/25 at 10:43 AM identified that his/her mask must have slid down while preparing Patient #9’s CVC for treatment. Staff Person #4 further indicated the mask should have been brought up to the bridge of his/her nose to completely cover each nostril area. Review of the Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure directed both teammate and patient were to wear masks covering the nose and mouth during this procedure to prevent exposure of the catheter and exit site to nasal droplets and infectious bacteria [such as methicillin-resistant Staphylococcus Aureus (MRSA).”

“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: 47640 Based on observations and interviews during a facility tour, the facility failed to ensure the treatmetn floor was maintained in a sanitary condition. The finding included. 1. On 08/26/25 at 09:50 AM, the surveyor, while accompanied by the Biomed Technician observed black stains on the treatment floor by stations #5 and #8, not providing a sanitary environment.”

“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: 47640 Based on observations and interviews, the facility failed to ensure that proper ventilation for the infectious waste room. The fidings included 1. On 08/26/25 at 10:10 AM, the surveyor, while accompanied by the Biomed Technician observed the Infectious Waste Room to the right lacked the proper ventilation as required by ANSI/ASHRAE/ASHE Standard 170-2017 table 7.1.”

“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: 47640 Based on clinical record review and interviews, the facility failed to ensure that the smoke detector was installed properly, a door latched properly and a leakage test on the sprinkler was performed. The finding included. 1. On 08/26/25 at 09:10 AM, the surveyor, while accompanied by the Biomed Technician observed the smoke detector in the back storage room was not flush to the ceiling, negating its ability to detect the presence of smoke. 2. On 08/26/25 at 10:20 AM, the surveyor, while accompanied by the Biomed Technician observed the EVS closet door by the staff breakroom does not latch, negating the doors’ ability to resist the passage of smoke and fire as required. 3. On 08/26/25 at 10:30 AM, during a documentation review, the surveyor was not provided with documentation from the facility to indicate the three (3) years air leakage test on the dry sprinkler system was completed by a licensed technician as required.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for one (1) of four (4) hemodialysis patients reviewed for hemodialysis prescriptions (Patient #1), the facility failed to ensure the patient’s blood sugars were completed and documented every treatment in accordance with the physician orders. The findings include the following: Patient #1’s diagnoses included End Stage Renal Disease (ESRD) and type 1 diabetes. Review of the physician’s orders directed hemodialysis three (3) times weekly for four (4) hours. A physician’s order dated 8/28/22 directed to check Patient 1’s blood glucose every dialysis treatment. Patient #1’s annual care plan dated 12/13/24 identified Patient #1 had diabetes, Patient #1 was not using his/her blood glucose sensor and preferred finger sticks. A sampled review of Patient #1’s treatment sheets identified on 8/1/25, 8/4/25, 8/6/25, 8/8/25, 8/11/25, 8/13/25, 8/15/25, 8/20/25, 8/22/25 and 8/25/25 Patient #1’s treatment sheet failed to identify a blood glucose was taken and documented. Review of Patient #1’s progress notes failed to identify a blood glucose was taken and documented for the identified sampled days. Interview and record review with the Clinical Coordinator on 8/27/25 at 2:00 PM identified Patient #1 had physician ordered blood sugar checks because he/she was a symptomatic diabetic. She identified Patient #1 has an implanted blood glucose monitoring device that he/she self-reports glucose results but is blind so the accuracy is questionable. Therefore, the facility staff should be measuring Patient #1’s blood glucose. She identified Patient #1’s physician order is for blood glucose every treatment and there was no documentation on the aforementioned dates that blood sugars were taken as ordered. Review of the hypoglycemia policy directed to monitor diabetic patient’s blood sugars per physician orders.”

“PA-ASSESS ANEMIA CFR(s): 494.80(a)(4) The patient’s comprehensive assessment must include, but is not limited to, the following: (4) Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). This Standard is not met as evidenced by: 32738 Based on review of clinical documentation, observations, interviews, and review of facility documentation and policy for one (1) of three (3) patients (Patient #2) reviewed for anemia, the facility failed to administer Micera (a medication used to stimulate production of red blood cells) in accordance with physician orders. The finding includes. Patient #2 had diagnoses that included end stage renal disease. Physician’s orders directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes using a left upper arm arteriovenous fistula. Review of laboratory results dated 6/18/25 identified Resident #2 had a hemoglobin level of 10.5 (within normal range), however lab results dated 7/9/25 identified Patient #2’s had a hemoglobin level of 8.9 (a 1.6 drop from the previous lab draw). Review of Patient #2’s 7/11/25 treatment sheet identified a physician order for 100 micrograms of Micera every two (2) weeks [an increase from the previous dose of 30 micrograms every four (4) weeks] to be administered, however the facility failed to administer the dose. Review of Patient #2’s clinical documentation identified he/she was hospitalized 7/14/25 to 7/26/25 and 8/4/25 to 8/8/25. Interview with the Charge Nurse on 8/26/25 at 1:36 PM identified the physician’s order of 100 micrograms of Micera should have been administered on 7/11/25 in accordance with physician’s orders, however, it was not administered, and the Charge Nurse failed to identify why it was missed. The Charge Nurse further identified that Patient #2 was administered 50 micrograms of Micera prior to his/her hospitalization on 7/14/25, and was unsure as to why the electronic medical record reverted back to the protocol order [50 micrograms of Micera every four (4) weeks] as physician’s orders took precedence over protocol orders. Interview with the Charge Nurse on 8/27/25 at 2:31 PM identified the facility’s standard of practice was to administer medications in accordance with physician’s orders”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 44675 Based on clinical records, facility policy and interviews for one (1) of four (4) patients (Patient #3), reviewed for care plans, the facility failed to implement the patient’s plan of care for abnormal trending albumins and failed to updated the care plan after the goal was not achieved per facility policy. Patient #3 was admitted to the facility with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis two (2) times weekly for four (4) hours with a left upper arteriovenous fistula (AVF). Review of the physician’s orders directed Oral Nutritional Supplementation (ONS) every treatment. Review of the annual care plan dated 12/17/24 identified Patient #3 had the current goal for albumin level trends to move toward and remain within recommended and appropriate clinical ranges with interventions that included to provide ongoing nutrition-related coaching, evaluate and implement ONS protocol per physician guidance and provide ongoing albumin related coaching. The time frame was for six (6) months. Review of Patient #3’s labs identified Patient #3’s albumin was 3.0 on 2/6/25. Review of the dietitian note dated 2/11/25 identified Patient #3’s albumin was 3.0. Patient #3 was encouraged to consume 4 oz of high protein with meals. Review of Patient #3’s labs identified Patient #3’s albumin was 3.2 on 3/6/25 and 2.7 on 4/10/25. Review of the dietitian note dated 4/14/25 identified Patient #3 was reviewed for hypo-responsiveness for albumin and to continue ONS. Review of Patient #3’s bloodwork identified Patient #3’s albumin was 2.8 on 5/15/25. Review of the dietician note dated 5/27/25 identified Patient #3 albumin was 2.8. A high protein diet was encouraged. Review of Patient #3’s labs identified Patient #3’s albumin was 2.7 on 6/5/25, 3/1 on 7/10/25 and 3.0 on 8/7/25. Review of the medical record failed to identify any dietary progress notes from 5/27/25 to current. The interdisciplinary team failed to updated the care plan with new goals and/or interventions after Patient #3 did not achieve his/her albumin goal within the designated time frame (6 months) identified in the plan of care. Interview with the Dietician on 8/27/25 at 2:00 PM identified the dietitian is required to document a progress note every ninety days. She identified if a patient is on nutrition support they should be documented monthly. Patient #3 received ONS during treatment and takes Nephro two times a day at home, and is seen monthly and she tries to chart on him/her when seen. Review of the progress notes policy directed documentation needs to include treatment given or planned, patient encounter and the condition of the patient. Review of the interdisciplinary team patient assessment and plan of care policy directed that the plan of care will include measurable and expected outcomes and estimated timetables to achieve the outcomes. 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. When a patient is unable to achieve the desired outcomes, the team will adjust the plan of care to reflect the patient’s current condition, document in the patient’s medical record the reasons why the patient was unable to achieve the goals, and implement plan of care changes to address the issues identified.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44675 Based on review of clinical documentation, observations, interviews, and review of facility documentation and policy for one (1) of three (3) patients, (Patient #7) observed during treatment termination, the facility failed to ensure a patients access had clotted following a bleeding event and that new dressings were applied before exiting the clinic, for two (2) of seven (7) patients (Patient #9 and #11) observed during treatment initiation, the facility failed to allow the proper amount of time to elapse following the administration of heparin and the initiation of treatment, and for one (1) of three (3) patients (Patient #14) observed during cannulation, the facility failed to ensure the patient was cannulated in accordance with facility policy. The findings included: 1. Patient #7 had diagnoses that included End Stage Renal Disease (ESRD). Physician’s orders directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes using a right upper arm arteriovenous fistula. Observation on 8/25/25 at 9:35 AM identified Patient #7’s dialysis treatment had ended. Staff Person #2 removed Patient #7’s arterial needle, applied gauze, tape and a clamp over the site to assist with clotting, however within minutes, Patient #7’s arterial site had started to bleed. Patient #7 applied additional pressure to the clamp with his/her ungloved left hand until receiving assistance from Staff Person #2, who then applied a new bandage and tape, and held the site for a few minutes before applying a clamp. Patient #7 was observed placing additional pressure on the clamp. After Staff Person #2 removed the clamp and inspected the dressing to ensure the bleeding had stopped, however did not check under Patient #7’s dressing to ensure the bleeding had stopped, nor did he/she change the dressings that were stained with blood prior to discharging the patient. Interview with the Charge Nurse on 8/27/25 at 2:33 PM identified Patient #7’s access site should have been checked prior to discharge to ensure the bleeding had stopped and that Patient #7’s dressings should have been changed prior to being discharged from the unit. Review of the Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles policy directed once bleeding had stopped to discard the gauze or band-aid used to hold the site and inspect the site for any trauma and for hemostasis. The policy further directed to apply a new band-aid type or sterile dressing over the cannulation site(s). 2. Patient #9 had diagnoses that included end stage renal disease. Physician’s orders directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes utilizing a Central Venous Catheter (CVC). Observation on 8/27/25 at 10:39 AM identified Staff Person #4 instilling heparin into the venous limb of Patient #9’s CVC at 10:39 AM and treatment was initiated at 10:40 AM. Interview with Staff Person #4 at 10:43 AM identified he/she initiated treatment one (1) minute following the instillation of heparin and that he was not aware of what facility policy directed regarding this. 3. Patient #11 was admitted to the facility with diagnosis that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours with a right forearm arteriovenous fistula (AVF) and 1,600 units heparin loading lose. Observation conducted on 8/27/25 at 10:29 AM at Station #2 identified Staff Person #6 performing canulation and treatment initiation for hemodialysis treatment. At 10:41 AM Patient #11’s loading dose of heparin was administered. At 11:42 AM treatment was initiated without the benefit of waiting three (3) to five (5) minutes per facility policy. Review of the AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose policy directed to not initiate dialysis for a minimum of three (3) to five (5) minutes after administering the heparin loading dose. Review of the anticoagulation policy identified heparin is the primary anticoagulant used to prevent clothing. The policy directed to anticoagulated the patient, the initial loading dose of heparin is administered through the venous fistula needle at least three (3) to five (5) minutes prior to the initiation of hemodialysis treatment. 4. Patient #14 had diagnoses that included ESRD. Physician’s orders directed to hemodialysis treatments three (3) times weekly for three (3) hours and thirty (30) minutes utilizing a left upper arm arteriovenous fistula (AVF). Observation on 8/27/25 at 10:18 AM identified Staff Person #3 preparing Patient #14’s access for cannulation by first cleaning Patient #14’s access with an antiseptic pad in a vertical motion, over and around the access. Staff Person #3 then palpated the access to determine where he/she would insert the needles and proceeded to insert the needles without re-cleaning the areas he/she touched. Interview with the Charge Nurse on 8/27/25 at 2:38 PM identified each cannulation site should be cleaned utilizing an antiseptic pad for thirty (30) seconds in a circular, inner to outer motion. The Charge Nurse further identified the access should not be touched prior to cannulation, but if this did occur, each site that was touched should be recleaned using the same method as stated above in order to prevent cross contamination. Review of The AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles and Administration of Heparin Loading Dose policy directed staff to not palpate the insertion site once the area has been prepped as touching it would contaminate the site and possibly allow for the introduction of bacteria during cannulation.”