Davita Hartford Downtown 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 observations, facility documentation, facility policy and interviews, the facility failed to provide a clean and sanitary environment. The findings include: Flash tour observations conducted of the facility treatment floor on 2/5/24 at 9:15 AM identified the following: 1. Station #2, 3, 5 and 6’s wallbox (contains connections for the dialysis machine to receive acid and base concentrations, treated water and dispose of waste products) had a crusted white/yellow substance throughout the inside. 2. A Large stain of white crusted substance on the floor between Station #6 and Station #7 3. Station #8’s wallbox had a crusted white substance throughout the inside and orange/red heavy crusted substance throughout the pipe below the wallbox. 4. Station #10, 11, and 12’s wallbox had a crusted white substance throughout the inside. 5. The floor drain between station #15 and #16 had a buildup of a brown/black substance with splatter surrounding the drain on the floor. 6. Station #16’s wallbox had a crusted white substance throughout the inside and orange/red heavy crusted substance throughout the pipe below the wallbox. 7. Station #17, 18, and 19 and 22’s wallbox had a crusted yellow substance throughout the inside. 8. Station #23and #25 had an orange/red crusted substance throughout the pipe below the wallbox. 9. The floor drain between station #25 and #26 had a buildup of a brown/black substance with splatter surrounding the drain on the floor. 10. Station #27 and 28’s wallbox had a dark yellow crusted substance throughout the inside and orange/red heavy crusted substance throughout the pipe below the wallbox. 11. The clean sink on the back wall of the treatment floor had pieces of the wall peeling off. 12. The patient scale on the back wall of the treatment floor had sticker debris throughout the handlebar of the scale. 13. A total of six deodorant spray bottles, one spray bottle labeled “vinegar” and one spray bottle labeled “RO water” on the bleach wipe carts throughout the treatment floor. Observations conducted on 2/6/24 at 10:00 AM with the FA and Clinical Manager identified the observations conducted on 2/5/24 remained present throughout the treatment floor. Interview with the Clinical Manager on 2/6/24 at 10:00 AM identified the wall boxes and pipes below the wall boxes were not maintained in sanitary manner. Interview with the FA on 2/6/24 at 2:00 PM identified the spray bottles labeled “vinegar” and “RO Water” could be used for spraying the wallboxes to remove buildup debris. She further identified there should not be any spray bottles on the treatment floor due to the risk of potential spray back. Observations conducted on 2/7/24 (survey day three) at 10:08 AM identified the aforementioned concerns remained. Interview with the FA on 2/7/24 at 1:30 PM identified the yellow/red on the wallboxes could be staining. Observation of Station #8 identified there was crack in the wallbox which could be the potential cause for the buildup on the pipe below. She further identified she will communicate with the contracted cleaning company to ensure they are mopping the floor drains. She identified the team will be responsible for cleaning the pipes below the wallboxes (as the cleaning company will not touch the pipes). Review of the infection control for dialysis facilities policy directed that the policy’s purpose is to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. It further directed at the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include the wallbox, brain and water supply lines. Pressurized washers, spray bottles, or sprayers for cleaning purposes will not be used on wall boxes or the adjoining area. It further directed teammates will monitor and address wallbox residue/build up.”

“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 policy and interviews, the facility failed to ensure appropriate hand hygiene was performed. The findings included: Observations conducted on 2/7/24 at 11:00 AM identified RN #1 was at Station #3 with gloves on, changed the acid line connection in the wallbox and then continued to set up the machine without the benefit of performing hand hygiene/changing gloves after touching the wallbox connections. Observations conducted on 2/7/24 at 11:14 AM identified RN #1 was initiating treatment for the patient at Station #3. RN #1 had clean gloves on, pulled her eye goggles (PPE) down to cover her eyes and proceeded to connect the patient’s lines to the machine lines without the benefit of performing hand hygiene after touching a contaminated surface. Review of the infection control for dialysis facilities policy directed, in part, hand hygiene is to be performed after interacting with wall boxes (i.e. plugging/unplugging acid/bicarb lines from dialysis machine, change acid types), after contamination with blood or other infectious material and before touching clean areas.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 44675 Based on observations, facility policy and interviews, the facility failed to ensure clean surfaces remained clean and personal protective equipment (PPE) was stored appropriately. The findings included: Observations conducted on 2/7/24 at 11:43 AM identified Staff Person #2 removed her used gown and googles and placed them on the clean counter at the nursing station. Interview with the FA on 2/7/24 at 3:00 PM identified that PPE is considered dirty and that the counters are a clean surface where PPE should not be placed. Review of the infection control for dialysis facilities policy directed that clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.”

“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: 44675 Based on observations, facility documentation and interviews, the facility failed to appropriately clean and disinfect the dialysis station and non-disposable equipment after a hemodialysis treatment. The findings included: a) Observations conducted on 2/6/24 at 1:55 PM of Station #4 disinfection after hemodialysis treatment identified Staff Person #1 failed to clean and disinfect the lower portion of the wallbox. b) Observations conducted on 2/7/24 at 11:19 AM of RN #1 identified she performed an assessment on the patient on Station #3 during hemodialysis treatment. RN #1 removed her stethoscope from her neck to auscultate the patient’s lung and heart sounds. RN #1 then placed the stethoscope back around her neck without the benefit of disinfecting the stethoscope. At 11:24 AM, RN #1 performed an assessment on the patient on Station #1 during hemodialysis treatment. RN #1 removed her stethoscope from her neck to auscultate the patient’s lung and heart sounds without the benefit of disinfecting the stethoscope that was previously used for the patient at Station #3. c) Observations conducted on 2/7/24 at 11:40 PM of Station #5 disinfection after hemodialysis treatment identified Staff Person #2 failed to clean and disinfect the top of the IV pole and the entire wallbox. Interview with the FA on 2/6/24 at 2:00 PM identified the wallboxes need to be cleaned and disinfected after every treatment. Review of the infection control for dialysis facilities policy identified the dialysis delivery system including IV poles will be wiped clean with a bleach solution of the appropriate strength after each treatment. It further identified the wall box, drain, and water supply lines are considered part of the dialysis delivery system and should be clean with 1:100 bleach as part of the routine station disinfection between each patient treatment. It further identified non-disposable items are to be disinfected after each patient use. Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 32738 Based on clinical record review, facility documentation, and interviews for one (1) of twelve (12) patients reviewed for Hepatitis vaccination status ( Patient # 4), the facility failed to ensure a Hepatitis B susceptible patient was vaccinated. The findings include: Patient #4 had a diagnosis of End Stage Renal Disease and required hemodialyssi three (3) times weekly. Review of the Hepatitis B surface antibodies for Patient #4 identified that on 11/9/23 and on 1/19/24 the antibodies were 5 ( any result below 10 indicates that the patient is susceptible to the Hepatitis B virus). Review of the vaccination and surveillance report identified that the patient last received that Energix vaccine in 2021. Interview with the Facility Administrator on 2/6/24 at 12:47 PM identified that the resident was not offered a second vaccination series or a booster when the resident became susceptible to the hepatitis virus because of an oversight on behalf of the facility. The physician would be called and either a booster or a second series would be offered to the patient. Review of the Hepatitis B surveillance vaccination policy identified that if the patient is determined to have an antibody level below 10, the patient will be offered the vaccination.”

“IC-HBV-ISOLATION-STAFFING CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another. This Standard is not met as evidenced by: 44675 Based on observation, facility policy and interviews for one (1) of two (2) patients ,(Patient #3) ,reviewed for isolation, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for a patient with an active infection of Hepatitis B per facility policy. Patient #3 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly. Review of Patient #3’s hepatitis B antigen dated 11/2/22 identified it as positive (indicated hepatitis B virus is present). Review of the treatment flowsheet dated 2/5/24 identified Patient #3’s treatment was initiated at 11:17 AM and completed at 2:22 PM in Station #13 (isolation room). Observation of Staff Person #4 on 2/5/24 at 2:00 PM identified Staff Person #4 entered the isolation room directly to the treatment room (not utilizing the ante room) without the benefit of applying a fluid resistant/fluid impervious gown and dedicated mask/eye protection, checked Patient #3’s dialysis lines and exited the isolation with the same PPE on he entered with. Review of the hepatitis B surveillance, vaccination, infection control measures and isolation guidance policy directed when entering the isolation room/area or station for any reason, physicians, social workers, dietitians, and all other teammates will wear long-sleeved fluid resistant/fluid impervious gowns in addition to gloves, face shield, or mask and eye protection. It further directed PPE will be removed, gloves discarded, and hand hygiene performed immediately when leaving the room or area.”

“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: 44675 Based on observation, facility policy and interviews for one (1) of three (3) patients,(Patient #14), reviewed for catheter initiation, the facility failed to ensure the procedure was performed in a sanitary manner in accordance with facility policy. Patient #14 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly with a right chest central venous catheter (CVC; catheters inserted into a large vein that access the heart that serve as a direct pathway for blood flow during dialysis treatment). Observations conducted on 2/6/24 at 1:02 PM of Station #6, Machine #13, identified RN #2 was performing CVC care and treatment initiation for Patient #14 with her mask below her nose. Patient #14 failed to have a mask covering his/her nose and mouth. At 1:04 PM the charge nurse walked by Station #6 to converse with Patient #14 while Patient #14’s mask remained below his/her nose and mouth and the catheter limbs were open for connection to the dialysis lines. Review of the central venous catheter (CVC) policy directed to put on PPE and provide a mask to the patient. The teammate and patient will wear masks covering the nose and mouth during the procedure. It further identified those measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria such as MRSA.”

“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: 32738 Based on clinical record review, facility documentation, and interviews, for one (1) of twelve (12) patients reviewed for fluid balance, (Patient #6), the facility failed to address the patient’s increased post weights subsequent to dialysis treatment. The findings include: Patient #6 had a diagnosis of End Stage Renal Disease and required hemodialysis three (3) times weekly. Patient #6’s dialysis prescription directed a Estimated Dry Weight (EDW) of 77.5 kg. Review of Patient #6’s post dialysis weights from 1/25 through 2/3/24 identified that the post weights ranged from 80.6 to 85.5 kgs (3 to 8 kg’s above the EDW). Review of the clinical record failed to identify that the increased post weights were addressed by the facility. Interview with the Facility Administrator on 2/6/24 at 11:30 AM identified that the post weights on 1/25, 1/27, 1/30, 2/1, and 2/3 should have been addressed by the charge nurse by offering an extra treatment, and reported to the physician. The FA further identified that the patient’s dry weight may need to be adjusted. Review of the pre-intra-post dialysis monitoring policy identified that if the patient’s post weight is above 1 kg of the EDW the licensed nurse will be notified and an assessment will be done, the charge nurse will use clinical judgement based on individual patient needs to determine if any clinical interventions or notification of the physician are necessary prior to discharge from the facility.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 44675 Based on observations, facility documentation, and interviews for one (1) of three (3) patients, (Patient #13) reviewed for access, the facility failed to ensure an order for vascular clamps was in place per facility policy. The findings include: Patient #13 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly. Observation on 2/5/24 at 10:00 AM identified Patient #13 had two vascular clamps on his/her access until they were removed at 10:06 AM. Observation on 2/7/24 at 10:08 AM identified Patient #13 had two vascular clamps on his/her access until they were removed at 10:20 AM. Review of Patient #13’s annual care plan failed to identify Patient #13’s inability to hold his/her access and the need for more than one vascular clamp. Review of Patient #13’s physician orders failed to identify a physician’s order for vascular clamps and/or a physician’s order for the use of two vascular clamps at one time. Interview with the FA on 2/7/24 at 2:30 PM identified patients should only have one clamp on the access at a time and there should be a physician’s order in place for use of more than one clamp on a patient’s access at a time. She further identified that due to the new electronic medical record system, there is no order for vascular access clamps. Review of the Utilizing vascular access clamps policy identified a physician’s order is always required for utilization of vascular clamps. It further identified if a patient is unable to hold his/her own sites, it is recommended that only one clamp is used at a time.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 32738 Based on clinical record review, facility documentation, interviews for one patient reviewed for peritoneal dialysis, (Patient#2), the facility failed to ensure that home records reflected the dialysis prescription, and missing documentation on the home records was addressed by the facility. The findings include: Patient #2 had a diagnosis of End Stage Renal Disease and required Peritoneal Dialysis (PD) seven (7) times weekly in the home setting, which was a Skilled Nursing Facility. The patients PD prescription directed to administer PD seven (7) days with a 2300 milliliter fill and five (5) exchanges over a time period of nine (9) hours. Review of facility documentation identified that the patient was new to PD and had started PD in the home setting on 1/11/24. a) Review of the home records from 1/12/24 through 1/31/24 identified that on 1/16, 1/20, 1/25, 1/28 and 1/29 the dialysate concentration was documented as “skipped”. Interview with the PD nurse on 2/7/24 at 1:34 PM identified that “skipped” entry meant that the staff at the SNF failed to enter the information regarding the concentration of the dialysate. The PD nurse identified that although she had reviewed the sheets and noted the “skipped” entries, she had not educated the SNF on ensuring that this information must be completed on the treatment records. b) Review of a fluid balance sheet dated 1/12/24 identified that Patient #2 had an estimated dry weight of 104 kilograms (kg). The fluid balance sheet identified that if the target weight was below by 1 kg to use (2) 1.5 % dextrose bags, if the patient is at the target weight to use (1) 1.5 % dextrose bag and (1) 2.5 Dextrose bag, if the target weight was 1-2 kg above target weight to use (2) 2.5 % dextrose bags, and if the weight was 3 kg or more above the target weight to use (1) 2.5% dextrose and (1) 4.25 % dextrose bag. Review of home treatment records from 1/13/24 to 1/16/24 identified that the weights ranged from 98.9 kg to 102.1 (all under EDW), the fluid balance sheet directed that when the resident was below the EDW, to administer (2) 1.5% dextrose bags, however, (2) 2.5 % dextrose bags were used on all three days. Interview with the PD nurse on 2/7/24 at 1:45 PM identified that she had instructed the SNF staff to use only (2) 2.5 % dextrose bags in an effort to remove more fluid and try to get the patient closer to h/her dry weight, however, there was no documentation in the clinical record or on the flow sheets to identify that the (2) 2.5% dextrose should be used instead of the (2) 1.5 % dextrose as the fluid balance sheet directed. c)Review of a fluid balance sheet dated 1/17/24 identified that the patient’s dry weight was changed to 99 kg. Review of the home records dated 1/18/24 through 1/30/24 identified that the weights ranged from 95.5 to 99.9 kg. The fluid balance sheet identified that if the target weight was below by 1 kg to use (2) 1.5 % dextrose bags, if the patient was at the target weight to use (1) 1.5 % dextrose bag and (1) 2.5 Dextrose bag, if the target weight was 1-2 kg above target weight to use (2) 2.5 % dextrose bags, and if the weight was 3 kg or more above the target weight to use (1) 2.5% dextrose and (1) 4.25 % dextrose bag. On 1/23/24 the weight was recorded as 99.9 kg and the fluid balance sheet identified that the patient received (2) 2.5 % dextrose bags, and the fluid balance sheet called for (1) 1.5 % and (1) 2.5 % dextrose bags. On 1/19, 1/20, 1/21, 1/22, 1/24, 1/25, 1/27, 1/28, 1/29, and 1/30/24 the patient’s weights ranged from 95.2 to 98.3 (below the EDW) and the patient received (2) 2.5 % dextrose bags instead of (2) 1.5% dextrose bags as the fluid balance flow sheet directed. Interview with the PD nurse on 2/7/24 at 2:00 PM identified that she had instructed the facility to administer (2) 2.5 % dextrose bags ongoing, however, when the resident’s weight dropped below the target weight (approximately 1/20/24) she should have notified the facility to start using the fluid balance chart, however she did not. Review of the Peritoneal Dialysis policy identified that all treatment data outlined on the daily treatment record must be collected and the PD nurse will review, if abnormalities are noted are noted they will be documented in the clinical record, and the physician notified of applicable.”

“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 observation, facility policy and interviews for one (1) of three(3) patients, (Patient #1 and #14), reviewed for medical record review and catheter initiation, the facility failed to ensure the machine was set up appropriately prior to treatment initiation, potassium levels were drawn and the physician was notified of against medical advices (AMA) per facility policy. a. Patient #1 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly for 3 hours and 45 minutes with a left upper arm fistula. The annual care plan dated 12/14/23 identified Patient #1 was not completing the prescribed treatment time of 3 hours and 45 minutes, however, the care plan failed to identify interventions to address this issue. A sample review of Patient #1’s treatment flowsheets identified the following: 1. On 1/5/24 Patient #1 received 3 hours and 1 minute of treatment (44 minutes less than the prescribed treatment time). Patient #1 AMA form dated 1/5/24 identified his/her treatment was shortened by 45 minutes due to transportation issues and came late. 2. On 1/8/24 Patient #1 received 3 hours and 14 minutes of treatment (31 minutes less than the prescribed treatment time). Patient #1 AMA form dated 1/8/24 identified his/her treatment was shortened by 30 minutes due to transportation issues and came late. 3. On 1/15/24 Patient #1 received 3 hours and 15 minutes of treatment (30 minutes less than the prescribed treatment time). Patient #1’s AMA form dated 1/15/24 identified his/her treatment was shortened by 25 minutes because Patient #1 came late. 4. On 1/17/24 Patient #1 received 2 hours and 58 minutes of treatment (48 minutes less than the prescribed treatment time). Patient #1 AMA form dated 1/17/24 identified his/her treatment was shortened by 30 minutes due to transportation issues and came late. Review of Patient #1’s nursing notes for January 2024 failed to identify if the physician was notified and what orders were put into place (if any required). Review of the prescribed treatment time not met policy directed that id shortened/early termination of treatment exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any) and include what additional medical orders may be necessary to address the patient’s specific needs. Additionally, if the patient’s dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient electronic record at the time the treatment was terminated. b. Patient # 8 had a diagnosis of End Stage Renal Disease and required hemodialysis three (3) times weekly. Review of Patient #2’s hemodialysis prescription identified that the dialysate to be administered during hemodialysis treatment was a 1 K (potassium) and 2.5 Ca ( calcium) bath. Review of treatment sheets dated 11/13 through 12/27/23 identified that the patient was dialyzed with a 1K 2.5 Ca bath. Review of Patient #8’s weekly Potassium levels from 11/13/23 through 12/27/23 identified that levels were not drawn on 11/20 and 12/27/23. Interview with the facility administrator on 2/7/24 at 10:30 AM identified that any patient that is dialyzing on a 1 K bath requires weekly potassium levels. On 11/23/23 that the system had canceled the lab order, and it may have been because used an old label and when it got to the lab they would not process the blood because it was too old. On 12/27/23 the sample may have been taken, however, it is unclear if it was sent to the laboratory. Review of the use of low potassium dialysate policy identified that patients with less than a 2 K bath will have potassium levels weekly. c. Patient #14 had a diagnosis of end stage renal disease and required hemodialysis treatment three times weekly with a right chest central venous catheter. Observations conducted on 2/6/24 at 1:08 PM of Station #6 Machine #13 identified RN #2 connected Patient #14’s catheter limbs to the dialysis lines and attempted to start Patient #14’s treatment. RN #2 called for help because the pump was not flowing. Observation of Machine #13 identified the Hansens (connects the dialysis lines to the dialyzer) were not connected to the dialyzer. Review of Patient #14’s treatment flow sheet dated 2/6/24 identified at 12:52 the dialysis prescription set up was documented as verified by RN #2 (identified alarm test passed, machine conductivity was 14, pressure holding test passed, manual pH was 7.2, temperature test passed). Interview with Staff Person #3 on 2/6/24 at 1:10 PM identified Machine #13 only completed the priming process and did not perform testing and did not recirculate. She further identified she did not check the machine conductivity or test the pH of the machine. Review of Machine #13 with Staff Person #3 identified the machine last tested at 5:30 AM. Interview with RN #2 on 2/6/24 at 2:00 PM identified Machine #13 never tested or recirculated. Although Patient #14’s treatment flowsheet identified she verified the machine, she identified she did not check the machine’s pH or conductivity. She further identified the machine’s pH and conductivity needs to be tested prior to putting a patient on the machine. She identified the pH is checked when the machine is in recirculation. Interview with the FA on 2/7/24 at 2:30 PM identified the machine is tested, conductivity and pH are performed prior to treatment initiation. She identified the staff member verifies the machine is set up appropriately and signed off on the flowsheet prior to treatment initiation. Review of the machine start up and priming a single utilizing Fresenius 2008seriees dialysis delivery systems identified in step 31 the machine is primed, in step 35 the pressure holding and alarm tests are preformed (verifies that the dialysis system is operating correctly and safely prior to initiation of each treatment). If the dialysis delivery system fails any of the tests and the cause cannot be corrected or if it fails subsequent tests the dialysis delivery system should not be used for treatment. In step 39 the theoretical conductivity is compared to the displayed machine conductivity and in step 43 the independent pH is checked and documented in the patient’s flowsheet. In step 45 the dialysate lines are connected to the dialyzer ensuring the red Hansen is connected to the arterial end of the dialyzer and the blue Hansen is connected to the venous end of the dialyzer. In step 48 the machine is recirculated for 3 minutes.”