Capitol Dialysis

“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: 27689 Based on observations and interview, it was determined that facility staff failed to comply with the 2012 edition of the Life Safety Code of the National Fire protection Association (NFPA) 101, as evidenced by a lack of documented fire drills during the year 2023 and 2024. The findings include: On June 14, 2024, a review of the fire drills logs for the year 2023, and 2024, showed that quarterly drills were partially conducted during the third and fourth quarter of the year 2023, and the second quarter of the year 2024, and were not completed during the first quarter of the year 2024. The 2012 Edition of NFPA 101section 21.7.1.6 states “...Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions”. The Facility Administrator acknowledged these findings during a face-to-face interview on June 17, 2024, at approximately 5:00 PM.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 27513 Based on the review of six (6) of 18 sample records and an interview with the Facility Administrator, the facility staff failed to ensure that six (6) patients achieved their prescribed dry weight. (Patients #5, #7, #8, #11, #14, and #18). Findings included ... Review of six (6) patients (Hemodialysis Treatment Flow sheet records showed that on the following dates mentioned the patient’s prescribed dry weight was not met: 1. A review of Resident# 5 treatment sheets dated from May 30, 2024, to June 6, 2024, showed the dates the dry weights were not met: May 30, 2024, Prescribed dry weight 91kg; Post dry weight 89.9kg, June 1, 2024, Prescribed dry weight 91kg; Post dry weight 89.2kg June 4, 2024, Prescribed dry weight 91kg; Post dry weight 90.5kg June 6, 2024, Prescribed dry weight 90.5k; Post dry weight 89.5kg June 8, 2024, Prescribed dry weight 90.5kg; Post dry weight 89.5kg June 11, 2024, Prescribed dry weight 90.5kg; Post dry weight 89.5kg 2. A review of Resident#7 treatment sheets dated from May 2, 2024, to May 30, 2024, showed the dates the dry weights were not met: May 2, 2024, Prescribed dry weight 57.5kg; Post dry weight 61.7kg, May 6, 2024, Prescribed dry weight 57.5kg; Post dry weight 62.7kg, May 10, 2024, Prescribed dry weight 57.5kg; Post dry weight 62kg, May 23, 2024, Prescribed dry weight 57.5kg; Post dry weight 58.8kg, May 27, 2024, Prescribed dry weight 57.5kg; Post dry weight 61.3kg May 30, 2024, Prescribed dry weight 57.5kg; Post dry weight 60.4kg 3. A review of Resident#8 treatment sheets dated from April 2, 2024, to June 11, 2024, showed the dates the dry weights were not met: April 2, 2024, Prescribed dry weight 49.5 kg; Post dry weight 55.8kg, April 9, 2024, Prescribed dry weight 49.5 kg; Post dry weight 54.8kg, April 29, 2024, Prescribed dry weight 49.5 kg; Post dry weight 54.8kg, May 2, 2024, Prescribed dry weight 49.5 kg; Post dry weight 52.3kg, June 8, 2024, Prescribed dry weight 49.5kg; Post dry weight 56.3kg June 11, 2024, Prescribed dry weight 49.5kg; Post dry weight 55.6kg 4. A review of Resident#11 treatment sheets dated from May 4, 2024, to May 18, 2024, showed the dates the dry weights were not met: May 4, 2024, Prescribed dry weight 96kg; Post dry weight 101.6kg, May 7, 2024, Prescribed dry weight 96kg; Post dry weight 100.1kg, May 10, 2024, Prescribed dry weight 96 kg; Post dry weight 102.5kg, May 11, 2024, Prescribed dry weight 96kg; Post dry weight 100.6kg, May 14, 2024, Prescribed dry weight 96kg; Post dry weight 102.5kg May 18, 2024, Prescribed dry weight 96kg; Post dry weight 102.5kg 5. A review of Resident#14 treatment sheets dated from May 31, 2024, to June 12, 2024, showed the dates the dry weights were not met: May 31, 2024, Prescribed dry weight 67kg; Post dry weight 68.3kg, June 3, 2024, Prescribed dry weight 67kg; Post dry weight 69.2kg, June 5, 2024, Prescribed dry weight 67 kg; Post dry weight 69kg, June 7, 2024, Prescribed dry weight 67kg; Post dry weight 69.2kg, June 10, 2024, Prescribed dry weight 67kg; Post dry weight 68.4kg June 12, 2024, Prescribed dry weight 67kg; Post dry weight 69.9kg 6. A review of Resident#18 treatment sheets dated from May 31, 2024, to June 12, 2024, showed the dates the dry weights were not met: May 31, 2024, Prescribed dry weight 45.5kg; Post dry weight 48.5kg, June 3, 2024, Prescribed dry weight 45.5kg; Post dry weight 48.1kg, June 5, 2024, Prescribed dry weight 45.5kg; Post dry weight 48kg, June 7, 2024, Prescribed dry weight 45.5kg; Post dry weight 47.6kg, June 10, 2024, Prescribed dry weight 45.5kg; Post dry weight 47.5kg June 12, 2024, Prescribed dry weight 45.5kg; Post dry weight 47.3kg The evidence showed that facility staff failed to achieve Patient #5, #7, #8, #11, #14, and #18’s prescribed dry weight for the flow sheets date mentioned above. A face-to-face interview was conducted on June 18, 2024, at approximately 11:45 AM with the Facility Administrator. She acknowledged the findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 27513 Based on the review of 12 of 18 sample records and an interview with the Facility Administrator, facility staff failed to ensure that the patient’s adequacy goals are following current professionally accepted clinical practice to achieve and sustain the prescribed BFR [blood flow rate], and DFR [dialysis flow rate] during the patient’s dialysis treatment. (Patients #5, #6, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). Findings included ... “During the HD procedure, blood and dialysate flow through the dialyzer in a countercurrent manner, thus preventing concentration equilibration and maximizing solute transfer. This ensures that the blood is constantly exposed to fresh dialysate fluid, enabling passive diffusion of toxins from the blood to the dialysate through the semipermeable membrane of the dialyzer. Diffusion is a passive movement of solutes “down” their concentration gradients. Solutes move from a region of higher solute concentration to a region of lower solute concentration. In terms of HD, simple passive diffusion enables clearance of endogenous waste and other solutes such as toxins from blood into the dialysate. Diffusion and clearance of solutes depend on factors such as blood and dialysate flow rates, the dialyzer membrane composition, and solute characteristics. For instance, higher blood flow rate increases clearance by increasing the amount of blood being cleared per minute7. In addition, faster dialysate flow rate causes increased removal of solutes from the dialysate fluid resulting in a higher concentration gradient and a higher clearance rate8-10. Of note, the impact of blood flow is limited to small molecular weight (MW) molecules and is further complicated by patient specific access issues7,11. The blood flow rates may range from 250-500 mL/min while a typical dialysate flow rate is 500-800 mL/min.” https://advancedrenaleducation.com/wparep/article/hemodialysis/“ A review of 12 sampled resident Hemodialysis flow sheets showed the following: 1. Patient #5 Hemodialysis Treatment Flow Sheet showed that on the date 6/1/2024 from 1007 [10:07 am] through 1307 [1:07 am] the space allotted for documentation of the DFR was left blank indicating “not functioning. The Dialysis Order Report directs “DFR 600”. 2. Patient #6 Hemodialysis Treatment Flow Sheet showed that on the date 7/3/2023 from 1120 [11:20 am] through 1415 [2:15 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 3. Patient #9 Hemodialysis Treatment Flow Sheet showed that on the date 5/27/2024 from 1740 [5:40 pm] through 2100 [9:00 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 700”. 4. Patient #10 Hemodialysis Treatment Flow Sheet showed that on the date 6/10/2024 from 0638[6:38 am] through 1008[10:08 am] the space allotted for documentation of the BFR was set at 400 throughout dialysis treatment. The Dialysis Order Report directs “BFR 500”. 5a. Patient #11 Hemodialysis Treatment Flow Sheet showed that on the date 5/7/2024 from 1518 [3:18 pm] through 1415 [2:15 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 5b. Patient #11 Hemodialysis Treatment Flow Sheet dated 5/10/2024 showed that the BFR setting was 350 throughout dialysis treatment. The Dialysis Order Report directs “BFR 400”. 6. Patient #12 Hemodialysis Treatment Flow Sheet dated 6/3/2024 showed that from 0659 [6:59 am] through 1020 [10:20 am] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 7. Patient #13 Hemodialysis Treatment Flow Sheet dated 7/3/2023 showed that from 0614 [6:14 am] through 0914 [9:14 am] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 8. Patient #14 Hemodialysis Treatment Flow Sheet dated 6/3/2024 showed that from 1120 [11:20 am] through 1415 [2:15 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 9. Patient #15 Hemodialysis Treatment Flow Sheet dated 6/3/2024 showed that from 1625 [4:25 pm] through 1855 [6:55 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 10. Patient #16 Hemodialysis Treatment Flow Sheet dated 6/3/2024 showed that from 1131 [11:31 am] through 1415 [2:15 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 11. Patient #17 Hemodialysis Treatment Flow Sheet dated 5/10/2024 showed that from 0650 [6:50 am] through 0952 [9:52 am] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 12a. Patient #18 Hemodialysis Treatment Flow Sheet dated 6/3/2024 showed that the DFR from 1629 [4:29 pm] through 1942 [7:42 pm] the space allotted for documentation of the DFR was left blank indicating “not functioning”. The Dialysis Order Report directs “DFR 600”. 12b. Patient #18 Hemodialysis Treatment Flow Sheet dated 6/5/2024 and 6/7/2024 showed the BFR setting was 400 throughout dialysis treatment. The Dialysis Order Report directs “BFR 450”. The evidence showed that facility staff failed to ensure that the adequacy plan for the prescribed BFR [blood flow rate], and DFR [dialysis flow rate] was achieved and sustained during the dialysis treatment of the patients (#5, #6, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) as mentioned above. A face-to-face interview was conducted on June 18, 2024, at approximately 11:45 AM with the Facility Administrator. She acknowledged the findings.”

“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: 27513 Based on the review of six (6) of 18 sample records and an interview with the Facility Administrator, facility staff failed to ensure that the patient ’ s albumin levels were achieved and sustained according to their established target goals. (Patients #4, #5, #8, #11, #12, and #14). Findings include .... Failed to ensure that albumin levels for six (6) Patients were achieved and sustained according to their established target goals as follow: 1.Review of the Dialysis Visit Note for Patient #4 showed that the Albumin level goals of greater than 4.0 were not met for the following dates: 3/2/23 albumin level was 3.9, 4/2/2024 Albumin level was 3.6, and 5/2/2024 Albumin level was 3.9. 2. Review of the Dialysis Visit Note for Patient #5 showed that the Albumin level goals of greater than 4.0 were not met for the following dates: 3/5/2024 Albumin level was 3.7, 4/2/2024 Albumin level was 3.6, and 5/2/2024 Albumin level was 3.8, 3. Review of the Dialysis Visit Note for Patient #8 showed that the Albumin level goals of greater than 4.0 were not met for the following dates 11/3/2023 albumin level was 3.4, and 12/5/2023 albumin level was 3.7, and 4/2/2024 Albumin level was 3.6. 4. Review of the Dialysis Visit Note for Patient #11 showed that the Albumin level goals of greater than 4.0 were not met for the following dates 2/7/23 Albumin level was 3.5, and 5/6/2024 albumin level was 3.6. 5. Review of the Dialysis Visit Note for Patient #12 showed that the Albumin level goals of greater than 4.0 were not met for the following dates 5/1/23 Albumin level was 3.6, and 5/1/2024 Albumin level was 3.7, and 6/3/2024 albumin level was 3.7 6. Review of the Dialysis Visit Note for Patient #14 showed that the Albumin level goals of greater than 4.0 were not met for the following dates 12/4/23 Albumin level was 3.9, 1/10/2024 Albumin level was 3.9, and 5/1/2024 albumin level was 3.6 The evidence showed that facility staff failed to ensure the patient ’ s albumin levels were achieved and sustained according to the established target goals of patients (#4, #5, #8, #11, #12, and #14) as mentioned above. A face-to-face interview was conducted on June 18, 2024, at approximately 11:45 AM with the Facility Administrator. She acknowledged the findings.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 27513 Based on the review of six (6) of 18 sample records and an interview with the Facility Administrator, facility staff failed to ensure that the patient ’ s Hemoglobin levels were achieved and sustained according to their established clinical target goals. (Patients #4, #8, #9, #11, #12, and #16). Findings include ... Facility staff failed to ensure that the Hemoglobin level goals for six (6) patients were achieved and sustained according to their established clinical target goals of greater than 10 and less than 11. 1. Review of the Dialysis Visit Note for Patient #4 showed that the Hemoglobin level goals of greater than 10 and less than 11 were not met for the following dates: 2/16 /23 Hemoglobin level was 7.6, 3/2/23 Hemoglobin level was 7.0, 4/18/2024 Hemoglobin level was 8.6, and 5/2/2024 Hemoglobin level was 7.7, 5/30/2024 Hemoglobin level was 7.8 2. Review of the Dialysis Visit Note for Patient #8 showed that the Hemoglobin level goals of greater than 10 and less than 11 were not met for the following dates 11/16 /23 Hemoglobin level was 5.7, 12/5/23 Hemoglobin level was 6.4, and 4/2/2024 Hemoglobin level was 7.0 3. Review of the Dialysis Visit Note for Patient #9 showed that the Hemoglobin level goals of greater than 10 and less than 11 were not met for the following dates 12/8/23 Hemoglobin level was 9.5, 3/18 /24 Hemoglobin level was 9.4, and 5/18/2024 Hemoglobin level was 8.4. 4. Review of the Dialysis Visit Note for Patient #11 showed that the Hemoglobin level goals of greater than10 and less than 11 were not met for the following dates 2/7/23 Hemoglobin level was 7.7, 3/18 /24 Hemoglobin level was 9.4, and 5/6/2024 Hemoglobin level was 10.0. 5. Review of the Dialysis Visit Note for Patient #12 showed that the Hemoglobin level goals of greater than 10 and less than 11 were not met for the following dates 5/1/23 Hemoglobin level was 9.8, 5/8 /24 Hemoglobin level was 9.5, and 6/3/2024 Hemoglobin level was 9.3. 6. Review of the Dialysis Visit Note for Patient #16 showed that the Hemoglobin level goals of greater than 10 and less than 11 were not met for the following dates 11/15/23 Hemoglobin level was 10.0, 5/15/2024 Hemoglobin level was 9.7, and 5/29 /24 Hemoglobin level was 9.9. The evidence showed that facility staff failed to ensure the patient ’ s Hemoglobin levels were achieved and sustained according to the established target goals of patients (Patients #4, #8, #9, #11, #12, and #16) mentioned above. A face-to-face interview was conducted on June 18, 2024, at approximately 11:45 AM with the Facility Administrator. She acknowledged the findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 27513 Based on the review of six (6) of 18 sample records and an interview with the Facility Administrator, facility staff failed to ensure the dialysis patient ’ s plan of care was signed by the patients or their designees. (Patients #4, #5, #6, #11, #14 and #18). Findings include .... 1. A review of Patient #4’s in-center hemodialysis clinical record showed a transfer admission date of March 22, 2024, from [dialysis center name]. The Annual POC (plan of care) dated March 1, 2023, was found in the patient’s clinical record without the patient or patient designee ’ s signatures. 2. A review of Patient #5’s in-center hemodialysis clinical record showed an admission date of February 15, 2024. The Initial POC (plan of care) dated March 26, 2024, was found in the patient’s clinical record without the patient or patient designee ’ s signatures. 3. A review of Patient #6’s in-center hemodialysis clinical record showed an admission date of May 28, 2021. The Annual POC (plan of care) dated February 28, 2023, was found in the patient’s clinical record without the patient or patient designee ’ s signatures. 4. A review of Patient #11’s in-center hemodialysis clinical record showed an admission date of February 7, 2023. The Annual POC (plan of care) dated March 1, 2023, was found in the patient’s clinical record without the patient or designee signatures. 5. A review of Patient #14’s in-center hemodialysis clinical record showed an admission date of November 11, 2017. A monthly POC (plan of care) dated December 29, 2023, and the Annual POC dated January 31, 2024, were found in the patient’s clinical record without the patient or patient designee ’ s signatures. 6. A review of Patient #18’s in-center hemodialysis clinical record showed an admission date of June 13, 2017. The Annual POC (plan of care) dated June 30, 2023, was found in the patient’s clinical record without the patient or patient designee ’ s signatures. The evidence showed that facility staff failed to ensure the patient or patient designee ’ s signature were on the patients (#4, #5, #6, #11, #14, and #18) mentioned above POC. A face-to-face interview was conducted on June 18, 2024, at approximately 11:45 AM with the Facility Administrator. She acknowledged the findings.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 27513 Based on the review of 11 of 18 sampled clinical records, and interviews with the Facility Administrator, the facility staff failed to ensure that the documentation in the patient’s treatment records was consistently completed with pertinent information for coordinating patient care within the dialysis center. (Patient #5, #6, #7, #9, #10, #12, #13, #15, #16, #17, and #18). The findings include: Review of the Dialysis Flow Sheet Report from June 30, 2023, to June 17, 2024, showed that the normal saline fluid administered to initiate dialysis treatment [the Prime] and the normal saline administered at the end of the dialysis treatment [the rinse back] was not documented on the dialysis flow sheet for the Patients mention below: 1. Patient #5 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis treatment and the ending of dialysis treatment [rinse back] on June 8, 2024, was documented as 0.0 indicating “not given”. 2. Patient #6 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis on July 7, 2023, and the ending of dialysis on July 7, 2023, and July 17, 2023, was documented as 0.0 indicating “not given”. . 3. Patient #7 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis on May 30, 2024, was documented as 0.0 indicating “not given”. 4. Patient #9 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis, and at the ending of dialysis on May 24, 2024, May 27, 2024, May 29, 2024, May 31, 2024, June 5, 2024, and June 7, 2024, was documented as 0.0 indicating “not given”. 5. Patient #10 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis on June 3, 2024, June 5, 2024, and June 7, 2024, and the ending of dialysis on June 3, 2024, was documented as 0.0 indicating “not given”. 6. Patient #12 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis on June 12, 2024, was documented as 0.0 indicating “not given”. 7. Patient #13 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis on May 27, 2024, May 29, 2024, and May 31, 2023, and the ending of dialysis on May 27, 2024, and May 29, 2024, was documented as 0.0 indicating “not given”. 8. Patient #15 dialysis flow sheet treatment record showed that the normal saline administered, at the initiation of dialysis treatments on June 3, 2024, June 5, 2024, and June 7, 2024, was documented as 0.0 indicating “not given”. 9. Patient #16 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis treatments on June 12, 2024, and the ending of dialysis on June 5, 2024, and June 12, 2024, was documented as 0.0 indicating not given. 10. Patient #17 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis treatments on May 8, 2024, May 10, 2024, May 13, 2024, May 15, 2024, and May 17, 2024, and the ending of dialysis on May 8, 2024, May 10, 2024, May 15, 2024, and May 17, 2024, was documented as 0.0 indicating “not given”. 11. Patient #18 dialysis flow sheet treatment record showed that the normal saline administered at the initiation of dialysis treatments on June 7, 2024, and June 10, 2024, and the ending of dialysis treatment on June 10, 2024, was documented as 0.0 indicating “not given”. A face-to-face interview was conducted on June 17, 2024, at 11:00 AM with the Facility Administrator concerning the missing information that was not found documented on the resident flow sheet for the dates mentioned. She responded that the dialysis Technicians are responsible for the administration and documenting on the treatment flow sheet the time and the amount of prime or rinse back solution administered via IV (Intravenous) fluids to patients. The patient receives 250 ml before and after dialysis and 250 ml post dialysis equaling 500 ml (millimeters) of Normal saline unless otherwise (cramping or blood pressure drop, patient unresponsive). Further stated, she will educate dialysis technicians on the importance of documenting fluids given during dialysis. The clinical record lacked documented evidence that the dialysis technicians consistently completed Patient #5, #6, #7, #9, #10, #12, #13, #15, #16, #17, and #18’s treatment records documentation with the pertinent information for the coordinating of their care within the dialysis center. The facility Administrator acknowledged and confirmed the findings on June 17, 2024, at approximately 11:45 AM.”