Fmc - Hopkinsville

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure 5 (Registered Nurse [RN] #1 and Patient Care Technician [PCT] #2, #3, #4, and #5) of 5 observed staff performed hand hygiene before they touched patient care supplies (access lines), before they touched patient care equipment (dialysis machine), and after they removed their gloves. Failure to perform hand hygiene provided a mode of cross contamination with the potential spread of pathogens, which could negatively impact the health and well-being of the 53 patients who received dialysis treatments and/or home therapy oversight at the facility. Findings included: A facility policy titled, “Hand Hygiene,” published 11/06/2023, indicated, “The table below identifies when hands shall be washed specifically with soap and water or when alcohol-based hand rubs can be used.” In part, the table indicated hands will be “Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water. Before and after direct contact with patients, Entering and leaving the treatment area” and “immediately after removing gloves.” Observation of the dialysis treatment area on 09/15/2025 with the Facility Administrator revealed the following: - At 10:02 AM, PCT #2 was observed in Station 4 while wearing a pair of gloves. PCT #2 touched her personal protective equipment (PPE) eyewear and then touched the access lines. - At 10:03 AM, PCT #2 was observed opening supply storage drawers near the nurses’ station with her bare left hand while holding a glove. PCT #2 then entered Station 4, applied the previously held glove, and touched the access lines. - At 10:25 AM, RN #1 was observed using a gloved hand to pull a waste container into Station 13 and then touched the dialysis machine with the same gloved hand. - At 10:27 AM, RN #1 was observed in Station 12 while wearing a pair of gloves. RN #1 exited the station and removed the pair of gloves. RN #1 obtained and applied a new pair of gloves, entered Station 13, and touched the dialysis machine. - At 11:04 AM, PCT #3 was observed in Station 15 while wearing a pair of gloves. PCT #3 exited the station and removed the pair of gloves. PCT #3 obtained and applied a new pair of gloves, re-entered Station 15, and touched the dialysis machine. Observation of the water test on 09/17/2025 at 11:04 AM in the water purification system area revealed RN #1 and PCT #5 each wore a pair of gloves. After performing the water test, RN #1 and PCT #5 each removed their pair of gloves and failed to perform hand hygiene. RN #1 and PCT #5 both stated they were expected to perform hand hygiene after removing gloves. Observation of the dialysis treatment area on 09/17/2025 with the Facility Administrator revealed the following: - At 2:02 PM, RN #1 was observed entering the treatment area from the office/staff lounge hallway. RN #1 applied a previously used PPE gown and eyewear and obtained and applied a pair of gloves. RN #1 entered Station 1 and touched the dialysis machine. - At 2:06 PM, PCT #4 was observed entering the treatment area from the office/staff lounge hallway. PCT #4 applied a previously used PPE gown and obtained and applied a pair of gloves. PCT #4 entered Station 10 and touched the dialysis machine. - At 2:50 PM, RN #1 was observed exiting Station 5 and removing a pair of gloves. RN #1 entered the nurses’ station and typed on the computer keyboard. During an interview on 09/15/2025 at 10:10 AM, PCT #2 acknowledged she did not perform hand hygiene before she touched the access lines. PCT #2 confirmed she was trained and expected to perform hand hygiene before she touched patient care supplies. During an interview on 09/15/2025 at 10:15 AM, the Facility Administrator stated staff were trained and expected to perform hand hygiene before they touched patient care supplies in the treatment stations. During an interview on 09/15/2025 at 10:26 AM, RN #1 acknowledged she touched the dialysis machine in Station 13 with the same gloved hand with which she had touched the waster container. RN #1 confirmed she was trained and expected to perform hand hygiene before touching patient care equipment. During an interview on 09/15/2025 at 10:28 AM, RN #1 confirmed she did not perform hand hygiene after she exited Station 12 and removed her gloves. RN #1 confirmed she was trained and expected to perform hand hygiene after removing gloves. During an interview on 09/15/2025 at 11:05 AM, PCT #3 confirmed she was trained and expected to perform hand hygiene after she removed her gloves. During an interview on 09/17/2025 at 2:04 PM, the Facility Administrator confirmed staff were expected to “wash their hands” upon entering the treatment area. During an interview on 09/17/2025 at 2:10 PM, RN #1 stated she did not perform hand hygiene upon entering the treatment area. During an interview on 09/17/2025 at 2:14 PM, PCT #4 stated he was trained and expected to perform hand hygiene upon entering the treatment area and before touching patient care equipment. During an interview on 09/19/2025 at 2:22 PM, the Medical Director confirmed staff should perform hand hygiene after they removed their gloves and before they touched patient care supplies and/or equipment.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to prevent inaccurate venous pressure readings and possible blood cross contamination by not immediately removing the external transducer protector (TP, a filter which helped prevent the passage of bacteria, viruses, particulate matter, and fluid/blood to the dialysis machine by way of the arterial and venous pressure ports) when it became wetted with blood or other fluid during 1 of 1 observation. Failure to immediately remove a wetted external TP had the potential to cause inaccurate pressure readings and possible contamination of the dialysis machine’s transducer component and the potential to expose the 38 patients who received in-center dialysis treatments at the facility to bloodborne pathogens. The findings include: A facility policy titled, “5008X Wet Transducer Protector Policy,” published 06/26/2025, indicated, “Staff must replace the transducer protector (TP) when it becomes wet.” Observation of the hemodialysis treatment area on 09/15/2025 from 9:50 AM until 10:18 AM revealed a wetted external TP on the venous pressure port of the dialysis machine located in Station 7. During an interview on 09/15/2025 at 9:50 AM in the hemodialysis treatment area, the Facility Administrator observed and acknowledged the wetted TP in Station 7. The Facility Administrator stated the TP “should be changed immediately.” During an interview on 09/15/2025 at 10:18 AM in the hemodialysis treatment area, Patient Care Technician #4 confirmed he was trained and expected to change the external TP when it was observed to be wetted.”

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each dialysis treatment during 3 of 3 observations. Failure to thoroughly disinfect all environmental surfaces in the dialysis treatment stations had the potential to serve as a vehicle for transmission of infectious disease and negatively impact the safety and wellbeing of the 53 patients who received dialysis treatments and/or home therapy oversight at the facility. The findings include: A facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” published 09/02/2025, indicated, “The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses.” Further review indicated, “Definition Dialysis Station Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment, patient training, and/or patient clinic visits. Equipment in the dialysis station may include (but is not limited to) the following: *Dialysis machine/cycler and attachments such as IV [intravenous] pole, BP [blood pressure] cuff and hand sanitizer/holder, sharps container mounted to the machine, *Chair/bed, *Pureflow [sic] SL, *Individual television and remote.” Observation of the hemodialysis treatment area on 09/17/2025 revealed the following: - At 2:48 PM, Registered Nurse (RN) #1 was observed disinfecting Station 7. RN #1 failed to disinfect the IV pole and prongs, sanitizer bottle and bracket, and blood pressure (bp) storage basket attached to the side of the dialysis machine. RN #1 also failed to lower both chairside tables and disinfect the chair arms and table edges. - At 3:10 PM, Patient Care Technician (PCT) #5 was observed disinfecting Station 5. PCT #5 failed to disinfect the sanitizer bottle and bracket attached to the side of the dialysis machine and failed to lower both chairside tables and disinfect the chair arms and table edges. At 3:25 PM, PCT #2 was observed disinfecting Station 14. PCT #2 failed to disinfect the sanitizer bottle and bracket attached to the side of the dialysis machine and failed to lower both chairside tables and disinfect the chair arms and table edges. During an interview on 09/17/2025 at 2:51 PM, the Facility Administrator confirmed staff were expected to disinfect “everything” in the dialysis treatment stations after each dialysis treatment. During an interview on 09/17/2025 at 2:52 PM, RN #1 acknowledged she did not disinfect the IV pole and prongs, a sanitizer bottle and bracket, the bp storage basket, the chair arms, and the table edges. RN #1 confirmed she was trained to disinfect all surfaces after each dialysis treatment was terminated. During an interview on 09/17/2025 at 3:22 PM, PCT #5 acknowledged she did not disinfect the sanitizer bottle and bracket and failed to lower both chairside tables. PCT #5 stated, “I did not know I had to take it out [of the bracket]” when referring to the sanitizer bottle. PCT #5 confirmed she was trained and expected to disinfect all surfaces after each dialysis treatment. During an interview on 09/17/2025 at 3:26 PM, PCT #2 acknowledged she did not disinfect the sanitizer bottle and bracket and failed to lower both chairside tables. PCT #2 confirmed she was trained and expected to disinfect all surfaces after each dialysis treatment. During an interview on 09/19/2025 at 2:22 PM, the Medical Director confirmed staff were trained and expected to disinfect all surfaces after each dialysis treatment was terminated.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to secure and restrict access to the water purification and storage system only to authorized personnel who were responsible for the monitoring and maintenance of the system. The failure had the likelihood to allow unauthorized personnel access to the water purification and storage system and the potential to negatively impact the safety and well-being of the 38 patients who received dialysis treatments at the facility. The findings include: A facility policy titled, “Physical Security and Facility Access,” published 09/05/2023, indicated, “Restricted access must be maintained to prevent unwanted tampering with the water treatment equipment. The facility must be maintained to prevent unwanted entry by outside persons not involved in the daily operation of the clinic. This is accomplished by: - Locking all doors that allow access to the water treatment equipment. - No exterior building door will be left unlocked unless under the continual supervision of a facility staff member.” Upon entrance to the facility on 09/15/2025 at 8:05 AM, the Administrative Assistant (AA) was observed entering a numeric code on the keypad door lock on the door entering the office hallway from the lobby area. When the AA was asked the numeric code she entered on the keypad door lock, she recited a four-digit number. During the environmental tour conducted on 09/15/2025 beginning at 9:15 AM with the Facility Administrator, the Facility Administrator was observed to enter the same four-digit number the AA used on numeric keypad door lock from the lobby to enter the room that contained the water purification and storage system, the lobby door, and the room which contained the biohazard containers. During an interview on 09/15/2025 at 9:47 AM, the Facility Administrator stated the numeric code was “the same code” throughout the facility. During an interview on 09/19/2025 at 12:10 PM, the Facility Administrator stated, “Yes, all employees” used the corporate assigned four-digit code on all the numeric keypad door locks, including employees that were not trained to be responsible for the monitoring and maintenance of the water purification and storage system. During an interview on 09/19/2025 at 2:22 PM, the Medical Director confirmed the water purification and storage system should be restricted to only authorized personnel, those staff members who had been trained to be responsible for the water purification and storage system.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 35949 Based on observation, interview, manufacturer’s instructions for use (IFU) review, and facility procedure review, the facility failed to follow the bloodline manufacturer’s IFU by not maintaining the arterial drip chamber fluid levels at approximately 90% full and the venous drip chamber fluid levels at approximately 70% full during 3 of 3 observations. Failure to follow the manufacturer’s IFU had the potential to result in equipment malfunction and/or failure and negatively impact the safety and wellbeing of the 38 current patients who received dialysis treatments at the facility. The findings include: The manufacturer’s IFU titled, “CombiSet True Flow Series Hemodialysis Blood Tubing Set with Attached Priming Set and Transducer Protectors,” with a copyright date of 2024, indicated, “During Treatment a. Periodically check the extracorporeal circuit for any evidence of possible separation or leaks. b. Do not allow the access or bloodline connections to be covered with a blanket or clothing during treatment. c. Maintain fluid level in arterial chamber at approximately 90% full and venous chamber at approximately 70% full. Levels may rise or drop during the treatment due to changes in pressure or flow rate. Readjust levels as needed. Air leaks will also cause the chamber levels to fluctuate.” A facility procedure titled, “Priming an Optiflux Single Use E-beam Dialyzer,” published 05/05/2025, indicated, “8. Fill the Pre-pump arterial chamber: Vent the chamber by loosening the cap and opening the clamp on the level adjust line. Fill chamber 85% - 95% full and tighten cap. Close the clamp on the level adjust line.” Further review indicated, “12. Fill venous chamber: Vent the chamber by loosening the cap and opening the clamp on the level adjust line. Fill chamber 65% - 75% full. Tighten cap and close clamp on the level adjust line when chamber is filled.” Observation of the hemodialysis treatment area on 09/15/2025 at 9:50 AM revealed the arterial drip chamber fluid levels were approximately less than (<) 90% full in Stations 2, 3, 4, 7, 9, 10, 11, and 15, and approximately greater than (>) 70% full in Stations 3, 4, 7, 8, 9, 10, 11, 12, 15, and 16. Observation of the hemodialysis treatment area on 09/17/2025 at 2:00 PM revealed the arterial drip chamber fluid levels were approximately < 90% full in Stations 1, 3, 4, 7, 8, 9, 10, 11, 12, 14, and 16, and approximately > 70% full in Stations 3, 4, 7, 8, 9, 10, 11, 12, 14, and 16. Observation of the hemodialysis treatment area on 09/17/2025 at 2:15 PM with the Facility Administrator, revealed the arterial drip chamber fluid levels were approximately < 90% full in Stations 1, 3, 7, 8, 10, 11, 12, 14, and 16, and approximately > 70% full in Stations 3, 7, 8, 10, 11, 12, 14, and 16. During an interview on 09/17/2025 at 2:18 PM with the Facility Administrator after review of the manufacturer’s IFU, the Facility Administrator confirmed the drip chamber fluid levels were not maintained according to the manufacturer’s IFU. During an interview on 09/17/2025 at 2:21 PM, Patient Care Technician (PCT) #4 stated the drip chamber fluid levels should be “75 percent” full. PCT #4 confirmed the drip chamber fluid levels were not maintained according to the manufacturer’s IFU. During an interview on 09/19/2025 at 2:22 PM, the Medical Director confirmed the facility staff were expected to follow the manufacturer’s IFU for maintaining the drip chamber fluid levels during dialysis treatments.”

“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: 35949 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis treatment as prescribed by the medical provider for 4 (Patients #1, #2, #3, and #4) of 4 sampled in-center patients. Failure to follow the medical providers’ dialysis treatment had the potential to negatively impact the effectiveness of the prescribed dialysis treatment for the 53 patients who received dialysis treatments and/or home therapy oversight at the facility. The findings include: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated, “3. Machine Parameters and Extracorporeal Circuit: Check machine settings and measurements: *Check prescribed blood flow [rate] is being achieved or reason is documented in medical record if unable to meet prescribed blood flow [rate].” 1. Patient #1’s treatment sheet dated 08/18/2025 revealed a prescribed blood flow rate (BFR) of 450 milliliters per minute (mL/min). Patient #1’s BFR was documented between 300 mL/min and 350 mL/min from 9:35 AM until the treatment was terminated at 10:51 AM. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 08/22/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 08/25/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented as 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 08/27/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented between 325 mL/min and 410 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/01/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented as 250 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/08/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented between 350 mL/min and 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/10/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented between 200 mL/min and 355 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/12/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented between 300 mL/min and 400 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #1’s treatment sheet dated 09/15/2025 revealed a prescribed BFR of 450 mL/min. Patient #1’s BFR was documented as 350 mL/min from 8:18 AM until the treatment was terminated at 10:55 AM. There was no rationale documented why the prescribed BFR was not achieved. 2. Patient #2’s treatment sheet dated 09/03/2025 revealed a blood flow rate (BFR) of 500 milliliters per min (mL/min). Patient #2’s BFR was documented as 450 mL/min from 10:38 AM until the treatment was terminated at 11:42 AM. There was no rationale documented why the prescribed BFR was not achieved. 3. Patient #3’s treatment sheet dated 08/18/2025 revealed a prescribed blood flow rate (BFR) of 500 milliliters per minute (mL/min). Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 08/20/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 08/22/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 08/25/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 08/27/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 09/01/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 09/05/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 09/08/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented as 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 09/10/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented between 200 mL/min and 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 09/12/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented between 200 mL/min and 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. Patient #3’s treatment sheet dated 09/15/2025 revealed a prescribed BFR of 500 mL/min. Patient #3’s BFR was documented between 300 mL/min and 450 mL/min during the entire treatment. There was no rationale documented why the prescribed BFR was not achieved. 4. Patient #4’s treatment sheet dated 09/09/2025 revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). Patient #4’s BFR was documented as 450 mL/min from 6:52 AM until 8:36 AM. There was no rationale documented why the prescribed BFR was not achieved. During an interview on 09/19/2025 at 9:53 AM, the Facility Administrator stated staff were trained and expected to “document why” when the prescribed blood flow rate was not followed. During an interview on 09/19/2025 at 2:22 PM, the Medical Director stated staff were trained and expected to document reasons for changes to the prescribed blood flow rate. During an interview on 09/19/2025 at 3:15 PM, Patient Care Technician #4 stated he was expected to “put a reason” why the prescribed blood flow rate was not achieved. During an interview on 09/19/2025 at 4:22 PM, Registered Nurse #1 stated she was trained and expected to “chart why” when the prescribed blood flow rate was not achieved.”

“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: 35949 Based on interview, record review, and facility policy review, the facility failed to monitor patients’ vital signs and machine parameters according to the expectations in their policy for 4 (Patients #1, #2, #3, and #4) of 4 sampled in-center patients. Failure to monitor patients’ vital signs and/or machine parameters according to the facility’s policy during dialysis treatments provided an opportunity for changes to the patients’ vital signs, blood flow rate, dialysate flow rate, and/or arterial and venous pressures to be unrecognized and unaddressed and negatively impact the care provided to the 38 in-center patients who received dialysis treatments at the facility. The findings include: A facility policy titled, “Patient Assessment and Monitoring,” published 05/01/2023, indicated, “During Treatment * Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. * Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations.” 1. Patient #1’s treatment sheet dated 08/18/2025 revealed machine parameters were not documented for 63 minutes, from 9:35 AM until 10:38 AM. Patient #1’s treatment sheet dated 09/05/2025 revealed vital signs were not documented for 63 minutes, from 8:02 AM until 9:05 AM. Patient #1’s treatment sheet dated 09/10/2025 revealed machine parameters were not documented for 74 minutes, from 9:14 AM until 10:28 AM. 2. Patient #2’s treatment sheet dated 08/22/2025 revealed vital signs were not documented for 61 minutes, from 10:10 AM until 11:11 AM. Patient #2’s treatment sheet dated 08/29/2025 revealed vital signs were not documented for 57 minutes, from 10:05 AM until 11:02 AM. 3. Patient #3’s treatment sheet dated 08/18/2025 revealed vital signs and machine parameters were not documented for 49 minutes, from 8:32 AM until 9:21 AM. Patient #3’s treatment sheet dated 08/22/2025 revealed vital signs and machine parameters were not documented for 54 minutes, from 9:08 AM until 10:02 AM. 4. Patient #4’s treatment sheet dated 09/10/2025 revealed vital signs and machine parameters were not documented for 65 minutes, from 2:00 PM until 3:05 PM. Patient #4’s treatment sheet dated 09/15/2025 revealed machine parameters were not documented for 69 minutes, from 2:00 PM until 3:09 PM, vital signs were not documented for 92 minutes, from 2:30 PM until 4:02 PM, and machine parameters and vital signs were not documented for 62 minutes, from 4:02 PM until 5:04 PM. During an interview on 09/19/2025 at 9:53 AM, the Facility Administrator stated vital signs and machine parameters should be documented “every half hour.” During an interview on 09/19/2025 at 2:22 PM, the Medical Director confirmed staff were expected to document vital signs and machine parameters every 30 minutes and not to exceed 45 minutes, according to the facility policy. During an interview on 09/19/2025 at 3:15 PM, Patient Care Technician #4 confirmed he was trained and expected to document vital signs and machine parameters “every half an hour - 30 minutes.” During an interview on 09/19/2025 at 4:22 PM, Registered Nurse #1 confirmed she was trained and expected to document vital signs and machine parameters every “30 minutes.””