Fresenius Medical Care of Southington

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 38422 Based on facility documentation and interviews the facility failed to provide Emergency Plan training to staff in accordance to facility policy. The findings included: On 05/28/25 at 11:00 AM, the surveyor was not provided with documentation from the Facility Administrator to indicate that the facility has developed, delivered to staff and reviewed at least annually, policies & procedures including evacuation, as required by the Emergency Preparedness Codes, §494.62(b)(2), Condition for Coverage for End-Stage Renal Disease (ESRD) Facilities; i.e. there is no documentation that staff has been trained on the Emergency Plan -either initially or at least annually.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 38422 Based on facility documentation and interviews the facility failed to ensure that drills for Emergency Preparedness were conducted. The findings included: On 05/28/25 at 11:00 AM, the surveyor was not provided with documentation from the Facility Administrator to indicate that any drills or exercises on the facility’s Emergency Plan have been conducted as required by the Emergency Preparedness Codes, §494.62(c)(4)-(6), Condition for Coverage for End-Stage Renal Disease (ESRD) Facilities; i.e.no exercises have been conducted of the Emergency Plan.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 32738 Based on observations and policy review, the facility failed to ensure that the hemodialysis machine was disinfected in accordance with facility policy. The findings include: a. Observation on 5/28/25 at 10:03 AM identified Staff Person #1 disinfecting station #3. Staff Person #1 failed to disinfect the TV arm. b. Observation on 5/28/25 at 10:30 AM identified that Staff Person #2 was disinfecting Station #2. Staff Person #2 failed to disinfect the side of the machine prior to placing the disinfected primer bucket back on the machine and failed to disinfect the TV, TV arm and back of the station. Review of the Cleaning and Disinfection of the Dialysis Station policy identified it is critical for the chair and dialysis equipment be thoroughly cleaned and disinfected between uses.”

“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: 38422 Based on facility documentation and interviews the facility failed to ensure that fire drills were conducted and staff were in-serviced on the fire plan. The findings included: On 05/28/25 at 11:00 AM the surveyor was not provided with documentation from the BioMed Technician or the Facility Administrator (FA) to indicate that the fire drills are being conducted at varying times and under various conditions, as required by section # 21.7.1.4 of the “Life Safety Code”; i.e. There was no documentation available at the time of survey to indicate any fire drills had been conducted in the past 12 months. On 05/28/25 at 11:00 AM the surveyor was not provided with documentation from the BioMed Technician or the Facility Administrator (FA) to indicate all staff have been periodically in-serviced on the facility fire plan and kept informed with respect to their duties under the plan, as required by section # 21.7.1.2 of the “Life Safety Code”;i.e. There was no documentation available at the time of survey to indicate any training had been completed by staff in the past 12 months.”

“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: 47491 Based on review of clinical records, interview, and review of facility documentation for two (2) of five (5) patients (Patient #4) reviewed for treatment prescription, the facility failed to administer the patient’s dialysis treatment in accordance with physician’s orders. The findings included: Patient #4 had diagnoses that included End Stage Renal Disease (ESRD). Physician’s orders directed hemodialysis three (3) times weekly for three (3) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a Blood Flow Rate (BFR) of 400, and Dialysate Flow Rate (DFR) of 800 while using a left forearm arteriovenous fistula. Review of Patient #4’s treatment records identified the following: a. On 5/5/25, Patient #4’s treatment was administered at a BFR of 300 from 6:40 AM to 8:34 AM without documentation identifying the reason the ordered DFR of 400 was not achieved. b. On 5/12/25, Patient #4’s treatment was administered at a BFR of 340 from 9:07 AM to 9:41 AM without documentation identifying the reason the ordered BFR of 400 was not achieved. Interview with the Facility Administrator 5/29/25 at 2:38 PM identified staff should be documenting reason the prescribed BFR could not be attained. Review of the Patient Assessment and Monitoring policy directed to check that the prescribed blood flow is being achieved or to document, in the medical record, if unable to meet the prescribed blood flow rate.”

“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: 47491 Based on review of clinical records, interviews, and review of facility documentation and policy for one (1) of four (4) patients (Patient #5) reviewed for fluid balance, the facility failed to follow physician’s orders related to ultrafiltration and low systolic blood pressures. The findings included: Patient #5 had diagnoses that included End Stage Renal Disease (ESRD). Physician’s orders directed to administer hemodialysis three (3) times weekly for three (3) hours and forty-five (45) minutes with a 2.0 potassium/2.5 calcium bath, a Blood Flow Rate (BFR) of 450, an autoflow dialysate flow rate (DFR) of 1.5, utilizing a left upper arm arteriovenous fistula. The physician’s orders further identified blood pressure parameters directing to pause ultrafiltration (removal of fluid) for systolic blood pressure of less than 90 millimeters of mercury (mm/hg). Review of Patient #5’s treatment sheets identified the following: a) On 5/5/25, blood pressures of 83/38 and 83/37 were identified at 11:13 AM and 11:32 AM without pausing ultrafiltration (UF) . Blood pressures of 85/38 and 84/38 were identified at 1:34 PM and 2:02 PM without pausing the UF. b) On 5/9/25, blood pressures of 75/24, 82/35, and 86/20 were identified between 11:31 AM and 12:39 PM without pausing the UF. c) On 5/12/25, blood pressures of 89/35, 80/39, 87/44, 77/41, 81/38, and 82/37 were identified from the initiation of treatment at 11:18 AM until 1:33 PM without pausing the UF. d) On 5/14/25, a blood pressure of 85/25 was identified at 11:31 AM without pausing ultrafiltration (UF). A blood pressure of 85/17 was identified at 2:32 PM without pausing the UF. e) On 5/19/25, blood pressures of 75/36, 70/22, 81/28, 86/22, 88/19, and 86/17 from 12:07 PM to 2:05 PM without pausing the UF. A blood pressure of 74/20 and 75/28 were identified at 2:34 PM and 3:02 PM without pausing the UF. f) On 5/21/25, blood pressures of 72/23 and 87/35 were identified at 11:33 AM and 12:01 PM without pausing the UF. Interview with the Director of Operations on 5/29/25 at 2:40 PM identified the standard of practice was to follow physician’s orders which indicated to pause ultrafiltration for systolic blood pressure below 90. Although requested, the facility was unable to provide a physician’s orders policy.”

“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 clinical record review, facility documentation, and interviews, for one (1) of five (5) patients reviewed for anemia (Patient #1), the facility failed to ensure that the decreased hemoglobin level was addressed timely. The findings included: Patient #1 had a diagnosis of End Stage Renal Disease and required hemodialysis three (3) times a week. Hemoglobin levels dated 5/12/25 identified a hemoglobin level of 8.6, a hemoglobin level dated 5/14/25 was 8.3 and on 5/21/25 the hemoglobin level is 8.7. A nurse’s note dated 5/23/25 identified that the patient had a new order for Micera 30 micrograms every two (2) weeks (a medication used to increase hemoglobin levels). Review of the clinical record failed to identify that the decreased level was addressed by the facility prior to 5/23/25 (11 days since the initial low hemoglobin level was drawn). Interview with the Facility Administrator on 5/28/25 at 1:30 PM that hemoglobin levels are reviewed weekly and discussed with the physician and then it is decided what the treatment regime will be, she further identified that she was unsure why there was a delay in initiating the Micera treatment.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 32738 Based on facility documentation and interviews the facility failed to ensure action plans were in place for indicators that were not met for Quality Assurance and Performance Improvement (QAPI). The findings included: Review and interview of QAPI with the Facility Administrator (FA) on 5/29/25 at 12:04 PM identified that the facility goal for Blood Stream Infections (BSI’s) was zero (0) percent. Review of QAPI identified that the facility percentages for January 2025 was 1.15 percent, February 2025 was 1.11 percent, March 2025 was 1.08 percent and for April 2025 was 1.01 percent (not met for a total of four (4) months). The FA identified that she did not have action plans in place to address the BSI’s. Review of the Quality Assessment and Performance Improvement Policy identified that the QAPI program is designed and implemented to objectively, systematically and comprehensively monitor, evaluate, and improve the quality and safety of patient care and services by identifying opportunities and resolving identified problems through the use of continuous quality improvement methodology achieve a measurable improvement in health outcomes and optimize the number of patients who achieve individual patient targets.”

“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: 32738 Based on clinical record review, facility documentation, and interviews for three (3) of five (5) patients reviewed for assessments, (Patient #1), the facility failed to ensure that an abnormal finding present during the pre-dialysis assessment was re-assessed on the post dialysis assessment, and for Patient #4 and #5, the facility failed to ensure the pre-treatment assessments were entered into the electronic medical record in accordance with facility policy, for one (1) of six (6) residents reviewed for vaccinations, the facility failed to ensure a patient was tested for tuberculosis upon admission per facility policy, and for Patient #5 the facility failed to ensure that vital signs were obtained in accordance with facility policy. The findings included: 1. Patient #1 had a diagnosis of End Stage Renal Disease (ESRD) and required hemodialysis three (3) times a week. Review of a pre-treatment assessment dated 5/14/25 identified that the patient had Rhonci (rattling sounds) in the lungs and had 2 plus (+) and 3 + edema (swelling) in the legs. Review of the post treatment assessment failed to identify that the staff had re-assessed the patent for the abnormal lung sounds and edema at the end of treatment. Review of the patient and assessment monitoring policy identified that the registered nurse will re-assess any abnormal findings on the pre-assessment. 2a. Patient #4 had diagnoses that included end stage renal disease. Physician’s orders directed hendiadys three (3) times weekly for three (3) hours per treatment, using a 2.0 potassium/2.5 calcium bath, a Blood Flow Rate (BFR) of 400, and Dialysis Flow Rate (DFR) of 800 while using a left forearm arteriovenous fistula (AVF). Review of Resident #4’s treatment sheets identified the following: On 5/12/25, treatment was initiated at 6:46 AM and the pre-treatment assessment was documented in the electronic medical record at 3:27 PM (eight (8) hours and forty-one (41) minutes following treatment initiation). 2b. Patient #5 had diagnoses that included ESRD. Physician’s orders directed to hemodialysis three (3) times weekly for three (3) hours and forty-five (45) minutes with a 2.0 potassium/2.5 calcium bath, a blood flow rate (BFR) of 450, an outflow Dialysis flow rate of 1.5, using a left upper arm AVF. Review of Patient #5’s treatment sheets identified the following: i. On 5/16/25, treatment was initiated at 11:11 AM and the pre-treatment assessment was documented in the electronic medical record at 1:33 PM (two (2) hours and twenty-two (22) minutes following treatment initiation). ii. On 5/19/25, treatment was initiated at 11:26 AM and the facility failed to enter the pre-treatment assessment into the electronic medical record. Interview with the Clinical Operations Manager on 5/29/25 at 2:43 PM identified pre-treatment assessments should be entered into the electronic medical record preferably within one hour of treatment initiation. Review of the Nursing Supervision and Delegation policy identified the registered nurse must evaluate each patient preferably within an hour of treatment initiation or according to state requirements. 3. Patient #6 was admitted to the facility December 2024, had a diagnoses which included ESRD, and was administered hemodialysis treatments until transitioning to peritoneal dialysis on 4/4/25. Physician’s orders directed to conduct daily peritoneal dialysis treatments consisting of five (5) 3,000 milliliter exchanges and a last fill of 2,000 milliliters utilizing a peritoneal dialysis catheter in the abdomen. Review of facility documentation failed to identify Patient #6 had been administered a TST (Tuberculin Skin Test) upon admission to the facility in December 2024 and had not been administered a TST since. However, the facility identified a chest x-ray was performed 11/15/24 and used to clear Patient #6 of tuberculosis disease, however, the documentation failed to specify no evidence of tuberculosis. Interview with the Facility Administrator on 5/29/25 at 2:33 PM identified new admissions were to have a TST planted within thirty (30) days of admission or a chest x-ray within six (6) months of admission to check for tuberculosis disease. Review of the Patient Tuberculosis Testing policy directed patients without a documented tuberculosis test within the last year to be tested using the TST and that a recent chest x-ray within six (6) months could be used as evidence to rule out tuberculosis disease, however the chest x-ray must specify no evidence of tuberculosis. 4. Patient #5 had diagnoses that included End Stage Renal Disease (ESRD). Physician’s orders directed to administer hemodialysis three (3) times weekly for three (3) hours and forty-five (45) minutes with a 2.0 potassium/2.5 calcium bath, a Blood Flow Rate (BFR) of 450, an autoflow dialysate flow rate (DFR) of 1.5, utilizing a left upper arm AVF. The physician’s orders further identified blood pressure parameters directing to pause ultrafiltration (removal of fluid) for systolic blood pressure of less than 90 millimeters of mercury (mm/hg). Review of Patient #5’s treatment sheets identified the following: i. On 5/5/25, a blood pressure reading of 83/37 was identified at 11:32 AM. The next blood pressure reading of 92/44 was identified at 1:03 PM, one (1) hour and thirty-one (31) minutes following the previous reading. ii. On 5/16/25, a blood pressure reading of 105/31 was identified t 2:02 PM. The next blood pressure reading of 101/27 was identified at 2:59 PM, fifty-seven (57) minutes following the previous reading. Interview with the Facility Administrator on 5/29/25 at 2:44 PM identified vitals were to be taken every thirty (30) minutes while a patient was receiving treatment, and not to exceed forty-five (45) minutes. Review of the Patient Assessment and Monitoring policy directed blood pressure and pulse rate were to be obtained every thirty (30) minutes or more as needed, but not to exceed forty-five (45) minutes or per state regulation.”