Davita Greenmount Central Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 47759 Based on the overall findings of the survey, the facility’s governing body failed to meet the Conditions for Coverage (CfC: 494.30) for Infection Control as evidenced by: The facility’s governing body failed to ensure a safe and effective system for infection prevention and control and thereby failed to meet the minimum requirements for Conditions for Coverage (CfC: 494.30) for Infection Control. This failure placed all patients at increased risk for harm and death as evidenced by the following regulations that were violated: 1.) Infection Control - Clean/dirty;med prep area; no common carts (V0117) 2.) Infection Control - Disinfect surfaces/equipment/written protocols (V0122) 3.) Infection Control - Hbv: Test All, rev Results/Status B4 admit (V0124) 4.) Infection Control - Aseptic Techniques for IV Meds (V0143) 5.) Infection Control - Staff education - catheter/catheter care (V0147)”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 47759 Based on the overall findings of the survey, the facility ’ s Medical Director failed to meet the Conditions for Coverage (CfC: 494.150) Responsibilities of the Medical Director as evidenced by: Based on the overall findings of the survey, the facility’s Medical Director failed to ensure that all the facility ’ s staff members adhered to the facility’s policies and procedures; thereby, the facility failed to meet the minimum requirements for Conditions for Coverage (CfC: 494.150) Responsibilities of the Medical Director. This failure posed a potential risk of safety to the patients and denied patients their rights to a minimum standard of medical care as evidenced by the regulations that were violated: Medical Director Responsibilities-Ensure All Adhere to Policies and Procedures (V0715)”

“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: 47759 Based on review of the facility’s emergency documents, review of the facility’s policies and procedures and staff interviews, the facility’s governing body failed to evaluate the facility’s response to emergency events and revise the facility’s emergency plan as needed. This failure placed the patients at potential risk of harm in the event of an emergency evacuation. Findings Included: On 12/18/2023, at 09:45 a.m., during record review of the facility’s policy Facility Emergency Management Plan (EMP) (04-07-01) page 27 under EMP training exercises, it stated: “The facility will conduct and/or participate in one (1) exercise to test the facility’s EMP at least annually, conducted on opposite years (one year full-scale exercise, next year facility based/exercise of choice).” Page 28 Number 2 F stated: “If the facility experiences an actual emergency event or response of sufficient magnitude that requires activation of the relevant emergency plans ... Utilize Facility Emergency Plan Activation template and document: a. Event that occurred b. Plan and policies activated c. evaluation of the plan. d. plan revisions required e. Governing body review.” Number 3 letter b state: “fire safety drills are required on a quarterly basis.” Letter c stated: “One drill to be conducted for each shift of patients.” On 12/18/2023, at 09:47 a.m., review of the facility’s mock code and fire drills revealed that the facility failed to conduct the following: (1) conduct a mock drill for the year 2023-during record review of the facility’s mock code and fire drills, the surveyor observed that the facility’s last mock drill was performed on November 15, 2022. (2) conduct an evaluation of the two emergency events that occurred August 2023- during record review of the facility’s emergency documents, the facility could not present the surveyor the Emergency Plan Activation Template (3) conduct fire drills for every shift - the facility had two fire drills, however, each fire drill was conducted only for one shift. On 12/18/2023, at 11:20 a.m., Staff #14 corroborated that each fire drill must be conducted with each shift and not just one shift. On 12/18/2023, at 11:35 a.m., interviews with the interim Facility Administrator and the Group Facility Administrator (GFA) revealed that in August 2023, the facility’s emergency plan was activated two times. The GFA then corroborated that whenever the emergency plan has been activated, the staff must evaluate the emergency outcome using the Facility Emergency Plan Activation Template, reflect on the emergency plan, and make revisions to the facility’s emergency plan as needed.”

“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: 47759 Based on observations, review of policies and procedures, and staff interview, the facility’s governing body failed to ensure that common medication carts/trays were not used to deliver medications to patients’ stations. This failure placed patients at risk of exposure to infectious diseases and blood borne pathogens to patients. Findings Included: On 12/18/2023 at 09:20 a.m., during record review of the facility’s policy Infection Control for Dialysis Facilities (1-05-01), page 3 number 10 stated: “Unused supplies (syringes, alcohol swabs, tape, etc.) or medications (including multiple dose vials containing diluents) taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients.” Page 2 number 9 stated, “If a common supply cart is used to store clean supplies in the patient treatment area, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. The cart will not be moved between stations to distribute supplies.” On 12/13/2023 at 09:00 a.m., during observations on the treatment floor, the surveyor observed Staff #11 give medication to different patients using a common supply cart that was moved from one station to another. On 12/14/2023 at 09:00 a.m., during observations on the treatment floor, the surveyor observed Staff #1 give medication to different patients using a common supply cart that was moved from one station to another. On 12/18/2023, at 02:00 p.m., the Group Facility Administrator corroborated that if the staff members placed medications on a cart, it should have been stationary and not brought from one station to another.”

“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: 47759 Based on staff interviews, review of policies and procedures, and review of the facility’s machine disinfect log, the facility’s governing body failed to ensure that all staff members followed the implemented machine disinfection procedure. This failure placed patients at potential risk for harm due to exposure to blood-borne pathogens and infectious diseases. Findings included: On 12/18/2023 at 10:20 a.m., during review of the facility ’ s policy, Fresenius Dialysis Delivery System Cleaning and Disinfection Policy (Policy 02-02-01), number 6 stated: “Facilities will develop a specific Dialysis Delivery System Cleaning and Disinfection Log in conjunction with the Biomedical Department and with approval by the Biomed Operations Manager (BOM). The specific log will be reviewed and approved by the governing body prior to implementation. Cleaning and disinfection of the dialysis delivery system will be documented on this log.” On 12/14/2023, at 02:37 p.m., during an interview with Staff #10, the surveyor asked what the facility’s policy was for disinfecting machines. According to Staff #10, every Monday, the machines were to go through integrated heat. Every Thursday, machines were to go through bleach. On 12/14/2023 at 02:40 p.m., review of the Fresenius Dialysis Delivery System Clean and Disinfect Log for November 1, 2023 through December 9, 2023 revealed that the facility staff failed to follow the implemented Dialysis Delivery System Cleaning and Disinfection policy as detailed below: 1. On 11/2/2023, a total of 21 dialysis machines were not disinfected with bleach. 2. On 11/06/2023, a total of 8 dialysis machines were not disinfected utilizing both citric acid and integrated heat disinfect. 3. On 11/09/2023, a total of 13 dialysis machines were not disinfected with bleach. 4. On 11/13/2023, a total of 14 dialysis machines were not disinfected utilizing both citric acid and integrated heat disinfect. 5. On 11/16/2023, a total of 17 dialysis machines were not disinfected with bleach. 6. On 11/20/2023, a total of 12 dialysis machines were not disinfected utilizing both citric acid and integrated heat disinfect. 7. On 11/23/2023, a total of 10 dialysis machines were not disinfected with bleach. 8. On 11/24/2023, a total of 8 dialysis machines were not disinfected utilizing both citric acid and integrated heat disinfect. 9. On 11/30/2023, a total of 14 dialysis machines were not disinfected with bleach. 10. On 12/04/2023, a total of 15 dialysis machines were not disinfected utilizing both citric acid and integrated heat disinfect. 11. On 12/7/2023, a total of 19 dialysis machines were not disinfected with bleach. On 12/18/2023, at 01:00 p.m., the Interim Facility Administrator and the Group Facility Administrator corroborated that machines should have been disinfected per policy and that these logs should have been properly filled by the staff members”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 47759 Based on staff interview, review of policies and procedures, and review of the facility’s serology report, the facility’s governing body failed to (1) ensure that all patient’s hepatitis B virology (HBV) status were known before admission to the facility and failed to (2) ensure routine testing was done for all patients. This failure placed patients and staff at risk of contracting infectious diseases. Patients: #8, #9, #10, #11, #12,#13, #14, #15, #16, #17, #18. Findings Included: On 12/15/2023 at 09:10 a.m., during record review of the facility’s policy, Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance (Policy 1-05-02), page 2 number 8 stated: “All permanent patients including Acute Kidney Injury (AKI) patients will have HBV serologic testing drawn immediately upon admission to the facility and results known within 7 days of admission (I.e., hepatitis B surface antigen [HBsAg], Hepatitis B Core Antibody [HBcAb], and Hepatitis B surface antibody [HBsAb]).” Page 4 stated if HBsAb was greater than 10 mIU/mL, to consider the patient immune and perform an annual antibody. If HBsAb was less than 10 mIU/mL, to consider the patient susceptible and perform a monthly surveillance testing. On 12/15/2023 at 10:00 a.m., during record review of the facility’s Hepatitis B Audit Report, the surveyor observed the following: 1. Patients #9, #10, #11, #12,#13, #14, #15, and #17 did not have documented HBV serologic admissions testing (HBsAg, HBcAb, and HBsAb) due within 7 days of admission. a. Staff #9 corroborated that all patients who are admitted must have serologic admissions testing performed. 2. Patient #8 did not have a documented HBsAb due April 2023. 3. Patient #16, a susceptible patient with a HBsAb <10 had missing HBsAg for the months of 03/2023 through 11/2023. 4. Patient #18 a susceptible patient with a HBsAb <10 had missing HBsAg for the months of 04/2023 through 11/2023.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 47759 Based on observations and review of policies and procedures, the facility’s governing body failed to ensure that the medications being administered to patients were handled aseptically. This failure placed the patients at potential risk of infection and cross contamination. Findings Included: On 12/18/2023 at 09:25 a.m., during record review of the facility’s policy “Preparation and Administration of Parenteral Medications (Non-Epo, Non Parsabiv) with all Dialyzer types,” page 2 number 7 stated: “If the medication is in a vial, remove the vial cap, and clean vial stopper with an alcohol pad. A new alcohol prep pad is used prior to each time a vial is entered.” On 12/13/2023, during observations on the treatment floor, the surveyor observed the following: 1. At 09:47 a.m., Staff #5 punctured an open multi-dose heparin without cleaning the septum. Staff #5 drew heparin up in a syringe 3 additional times and did not use an alcohol pad to disinfect the vial each time. 2. At 09:57 a.m., Staff #7 punctured an open multi-dose heparin without cleaning the septum. Staff #7 drew heparin up in a syringe 4 additional times and did not use an alcohol pad to disinfect the vial each time.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 47759 Based on observations and review of policies and procedures, the facility ’ s governing body failed to ensure that staff utilized aseptic technique when accessing central venous catheters. The failure to utilize aseptic technique when accessing central venous catheters increased the risk for serious infection(s) and related patient harm. Staff #3, #6, and #8. Patients #19, #20, #21, and #23. Findings included: On 12/18/2023, at 09:30 a.m. during record review of the facility’s policies and procedures Central Venous Catheter (CVC) with clearguard HD antimicrobial end caps (Procedure 1-04-02 B), page 2 stated, “Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. “ Page 5 number 16 stated, “Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of the hub thoroughly...” On 12/13/2023, during observations on the treatment floor, the surveyor observed the following: 1. At 10:05 a.m., during CVC treatment termination, Staff #3 scrubbed the arterial hub of Patient #19 for 4 seconds and scrubbed the venous hub for 7 seconds. 2. At 10:15 a.m., during CVC treatment termination, Staff #6 scrubbed the arterial hub of Patient #20 for 8 seconds and scrubbed the venous hub for 7 seconds. 3. At 10:20 a.m., during CVC treatment termination, Staff #8 scrubbed the arterial hub of Patient #21 for 9 seconds and scrubbed the venous hub for 5 seconds. On 12/14/2023, at 11:30 a.m., during CVC treatment initiation, the surveyor observed Staff #6 scrub the arterial hub of Patient #23 for 9 seconds and scrubbed the venous hub for 5 seconds.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 47759 Based on staff interviews, observations, and reviews of policies and procedures, the facility’s governing body failed to ensure that a label (with the correct date and preparer) had been affixed to the mixing tank and/or container prior to batch preparation of any solution. This failure placed the patients and staff at potential risk of harm. Findings Included: On 12/18/2023 at 09:35 a.m., during record review of the facility’s policy Bicarbonate Concentrate System Mixing (Policy 2-07-01), page 5 number 27 stated: “prior to batch mixing, a status label will be affixed to the bicarbonate mixer that identifies the batch formulation and date mixed until the bicarbonate in the tank is transferred or emptied.” Number 28 stated: “Bicarbonate concentrate is to be used the same day that it is mixed (with the exception of bicarbonate cartridges and facilities providing nocturnal dialysis). Any bicarbonate concentrate left over at the end of treatment day is to be discarded.” At 09:40 a.m., during record review of the facility ’ s policy Preparation of One to One Hundred (1:100) Bleach Solution (01-05-08B), page 3 number 12 stated: “With indelible marking pen and label, label container with expiration date, time, and initials. The solution is good for 24 hours only.” Number 13 stated: “When the solution is not being used, place a lid on the bleach solution container. On 12/13/2023, during clinical observations on the treatment floor, the surveyor observed the following: 1. At 08:19 a.m., during observations of the water room, the surveyor observed that the bicarbonate Tank did not have a label stating who prepared the solution or a date labeling when the solution was prepared. 2. During observations from 08:30 a.m. - 08:30 a.m., the surveyor observed a container filled with bleach solution near the dirty sink across station number 12, 9, and 5 with no label identifying who prepared the solution or a date labeling when the solution was prepared. On 12/13/2023, at 08:20 a.m., Staff #10 corroborated that a label should have been posted on the bicarbonate tank. On 12/13/2023, at 09:00 a.m., the Interim Facility Administrator corroborated that a label identifying who prepared the solution and the date it was prepared should have been attached to the bleach solutions prepared.”

“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: 47759 Based on staff interviews and record review, the facility’s governing body failed to ensure that all equipment (including the dialysis machines and equipment) were in functional working condition and were operated in accordance with the manufacturer’s recommendation. This failure placed the patients and staff at potential risk of harm Findings included: Definition: (1) Myron L Conductivity Meter: is an instrument that is used to measure water quality. (2) Calibration: A process of checking a measuring instrument to see if it is accurate and reliable. On 12/18/2023 at 09:05 a.m., during record review of the facility’s policy Calibration Check and Calibration of Portable Myron L Conductivity Meter (Procedure 02-08-01A), page 1 stated: “This procedure is to be performed prior to daily use or whenever inaccurate readings are suspected.” On 12/18/2023 at 09:50 a.m., during record review of the facility’s policy Medications requiring refrigeration (Policy 1-06-06), page 1 number 3 stated: “The refrigerator is checked ...Twice daily ...at the beginning and end of the day.” On 12/15/2023, at 09:45 a.m., during record review of the facility’s calibration log, the surveyor observed that there were several missing calibrations for the conductivity calibration log for the following equipment: 1. Meter ID #1: a. Missing logs for the months of July, August, September 2023. 2. Meter ID #2: a. Missing logs for the months of June, July, September, and November 2023. 3. Meter ID #3: a. Missing logs for the months of June through November 2023. On 12/14/2023, at 09:30 a.m., during staff interview, staff #10 corroborated that the staff members should have been performing calibrations on the Myron L conductivity meter daily. On 12/13/2023 at 08:30 a.m., during record review of the facility’s refrigerator log, the surveyor observed that there were missing logs for 10 out of the 12 months. Logs for January, February, March, April, May, June, July, September, October, and November were not documented. On 12/18/2023 at 02:00 p.m., Staff #1 was given the opportunity to provide further documentation; however, Staff #1 could not provide further documentation.”

“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: 47759 Based on interviews and record reviews, the facility’s governing body failed to adhere to the prescribed orders for blood flow rate and dialysis flow rate and failed to document any reason why the prescribed orders were not followed. This failure to follow prescribed orders for blood flow rate and dialysis flow rate (1) increased the risk that individual procedures would be less effective and (2) increased the risk for patient harm. Patients: #1, #2, #3, #4, #5. Findings included: On 12/18/2023 at 09:00 a.m., during record review of the facility ’ s policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (Policy 1-03-08), page 4 number 10 stated: “If the dialysis prescription is not being met (including the inability to obtain prescribed blood flow rate or BFR) the reason will be documented, and the licensed nurse informed.” Number 11 stated: “Abnormal findings ...will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on the individual patient needs to determine if any clinical interventions are necessary.” Number 13 stated: “All findings, interventions, and patient response will be documented in the patient ’ s medical record.” Number 16 stated: “If an abnormal finding (s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge.” On 12/15/2023 at 09:30 a.m., review of medical records revealed that facility staff failed to follow prescribed orders as detailed below: 1. Patient #1 had a BFR prescription of 400 milliliter/minute (mL/min) for treatment date 12/11/2023 and a target weight of 53.5 kilogram (kg) for treatment date 12/06/2023. On treatment date 12/11/2023, the BFR documented for Patient #1 was set at 350 from 12:31 p.m. - 02:38 p.m., but no supporting documentation was found explaining why the BFR prescription was not followed. On treatment date 12/06/2023, Patient #1 ’ s post weight was 55.9 kg, which was 2.4 kg greater than the target weight, yet no supporting documentation was found explaining why the target weight was not achieved. 2. Patient #2 had a BFR prescription of 400 mL/min and a DFR prescription of 600mL/min. On treatment date 11/24/2023, the BFR documented for Patient #2 was set at 350 mL/min from 03:01 p.m. -04:30 p.m. and 450 mL/min from 04:31p.m. - 05:31 p.m., but no supporting documentation was found explaining why the BFR prescription was not followed. On the same treatment date, the DFR documented for Patient #2 was set at 800 mL/min from 03:01 p.m. - 06:02 p.m., but no supporting documentation was found explaining why the DFR prescription was not followed. 3. Patient #3 had a BFR prescription of 400 mL/min and a DFR prescription of 600mL/min. On treatment date 12/11/2023, the BFR documented for Patient #3 was set at 300 mL/min from 01:01 p.m. -02:31 p.m.; no supporting documentation was found explaining why the BFR prescription was not followed. On 12/08/2023, the DFR documented for Patient #3 was set at 800 mL/min from 01:01 p.m. -03:09 p.m., but no supporting documentation was found explaining why the DFR prescription was not followed. 4. Patient #4 had a BFR prescription of 450 mL/min and a DFR prescription of 600mL/min. On treatment date 12/05/2023, the BFR documented for Patient #4 was set at 350 mL/min from 02:32 p.m. -03:25 p.m.; no supporting documentation was found explaining why the BFR prescription was not followed. On 12/12/2023, the DFR documented for Patient #4 was set at 800 mL/min from 12:01 p.m. -02:31 p.m., but no supporting documentation was found explaining why the DFR prescription was not followed. 5. Patient #5 had a DFR prescription of 600 mL/min. On treatment date 12/09/2023, the DFR documented for Patient #5 was set at 800 from 06:44 a.m. - 10:28 a.m., but no supporting documentation was found explaining why the DFR prescription was not followed. On 12/18/2023 at 12:00 p.m., during interviews with the interim Facility Administrator (IFA), the IFA corroborated that if the dialysis prescription was not met, an explanation why the treatment order was not met should have been documented.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 47759 Based on staff interviews, review of policies and procedures, and review of selected patients’ plan of care, the facility’s governing body failed to ensure that an initial comprehensive assessment has been conducted on all new patients within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first outpatient dialysis session. This failure placed the affected patient at potential risk of harm and denied the patient’s rights. Findings included: On 12/18/2023 at 09:15 a.m., during record review of the facility ’ s Interdisciplinary team (IDT) Patient Assessment and Plan of Care (Policy 01-14-01), page 4 number 10 stated: “An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” On 12/15/2023 at 10:15 a.m., during record review of the sampled patients’ Plan of care (PoC), the surveyor observed the following: 1. Patient #1 was admitted to the facility on 08/2023. During record review, when the surveyor requested for the 30 day PoC for Patient #1 due 09/2023, the facility presented a PoC that was completed in 11/2023. 2. Patient #5 was admitted to the facility on 03/2023. During record review, when the surveyor requested for the 30 day PoC for Patient #5 due 04/2023, the facility presented a PoC that was completed in 06/2023. On 12/18/2023 at 02:00 p.m., the Facility Administrator (FA), Interim FA, and Staff #9 corroborated that Patient #1 and Patient #5’s PoC’s were late and should have been completed within 30 calendar days.”

“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: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the appropriate procedures when assessing the patients’ vascular access prior to cannulation and practiced the correct infection control protocol. This failure placed the safety and wellbeing of the patients at potential risk of harm in maintaining their vascular access. Staff #3 and #7 Findings Included: On 12/18/2023 at 09:40 a.m., during review of the facility ’ s policy titled “Cannulation of Fistula or Graft”, Procedure 01-04-01E, page 2 number 5 stated: “perform inspection, auscultation, and palpation on the entire length of access. Determine presence of bruit and thrill. Rationale: The presence of a bruit and thrill indicates flow through the access.” Page 3 number 11 stated: “While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry.” Page 2 stated: “if using isopropyl alcohol 70%, use at least 4 prep pads per site with an effective contact time of 60 seconds.” Page 3 number 13 stated: “Do not palpate insertion site once area has been prepped. Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” On 12/13/2023, at 10:50 a.m., during treatment initiation of the clinical treatment floor, the surveyor observed Staff #3 disinfect Patient #22 ’ s access for 10 seconds total, then listened to Patient #22 ’ s access with a stethoscope, placed a tourniquet, and cannulated without disinfecting the site again. On 12/14/2023 at 11:15 a.m., during treatment initiation of the clinical treatment floor, the surveyor observed Staff #7 disinfect Patient #25 ’ s access for 15 seconds total, palpated Patient #25 ’ s access site and cannulated without disinfecting the site again.”

“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: 47759 Based on patient records reviewed and facility ’ s policies and procedure, the facility ’ s governing body failed to ensure that the interdisciplinary team (IDT) members, including the patient or the patient ’ s designee, met as a team in order to discuss the patients’ plans of care (PoC); or if the patient chooses not to sign the plan of care, choice must be documented on the plan of care, along with the reason the signature was not provided. This failure denied the affected patients their rights to a minimum standard of medical care. Findings Included: On 12/18/2023 at 09:15 a.m., during record review of the facility ’ s Interdisciplinary team (IDT) Patient Assessment and Plan of Care (Policy 01-14-01), page 1 number 1 stated: “The facility ’ s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient ’ s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP)... a social worker, and a dietician.” Number 2 stated: “The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient ’ s treatment plan and expectation for care.” On 12/15/2023 at 10:15 a.m., during record review of the sampled patient ’ s Plan of care (PoC), the surveyor observed the following 1. Patient #2 ’ s PoC completed on 05/25/2023 and 11/16/2023 did not have documentation stating that Patient #2 was informed of the PoC and/or documentation that Patient #2 was invited to attend the PoC meeting. 2. Patient #5 ’ s PoC completed on 11/9/2023 did not have documentation stating that Patient #5 was informed of the PoC and/or documentation that Patient #5 was invited to attend the PoC meeting. 3. Patient #6 ’ s PoC completed on 05/01/2023 did not have documentation stating that Patient #6 was informed of the PoC and/or documentation that Patient #5 was invited to attend the PoC meeting.”

“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: 47759 Based on review of the facility’s policies and procedures, the medical director and the facility’s administration failed to ensure that the staff adhered to their own policies and procedures. This failure posed a potential risk of safety to the patients, and denied patients their rights to a minimum standard of medical care. Findings included: 1. Facility Emergency Management Plan (EMP) (4-07-01), page 27 number 2 letter E stated: “The facility will conduct and/or participate in one (1) exercise to test the facility’s EMP at least annually, conducted on opposite years (one year full-scale exercise, next year facility based/exercise of choice).” Page 28 Number 2 F stated: “If the facility experiences an actual emergency event or response of sufficient magnitude that requires activation of the relevant emergency plans ... Utilize Facility Emergency Plan Activation template and document: a. Event that occurred b. Plan and policies activated c. evaluation of the plan. d. plan revisions required e. Governing body review.” Number 3 letter b stated: “fire safety drills are required on a quarterly basis.” Letter c stated: “One drill to be conducted for each shift of patients.” (Cross reference tag E0039) 2. Infection Control for Dialysis Facilities (1-05-01) page 3 number 10 stated: “Unused supplies (syringes, alcohol swabs, tape, etc.) or medications (including multiple dose vials containing diluents) taken into the station should be used only for that patient and should not be returned to a common clean area or used on other patients.” Page 2 number 9 stated: “If a common supply cart is used to store clean supplies in the patient treatment area, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. The cart will not be moved between stations to distribute supplies.” (Cross reference tag V0117) 3. Fresenius Dialysis Delivery System Cleaning and Disinfection Policy (Policy 02-02-01), page 2 number 6 stated: “Facilities will develop a specific Dialysis Delivery System Cleaning and Disinfection Log in conjunction with the Biomedical Department and with approval by the Biomed Operations Manager (BOM). The specific log will be reviewed and approved by the Governing Body prior to implementation. Cleaning and disinfection of the dialysis delivery system will be documented on this log.” (Cross Reference Tag V0122) 4. Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance (1-05-02), page 2 number 8 stated: “All Permanent patients including Acute Kidney Injury (AKI) patients will have HBV serologic testing drawn immediately upon admission to the facility and results known within 7 days of admission (I.e., HBsAg, HBcAb, and HBsAb).” Page 3 stated that if HBsAb was greater than 10 mIU/mL, to consider the patient immune and to perform an annual antibody. If HBsAb was less than 10 mIU/mL, to consider the patient susceptible and to perform a monthly surveillance testing (Cross Reference Tag V0124) 5. Preparation and Administration of Parenteral Medications (Non-Epo, Non Parsabiv) with all Dialyzer types (Procedure 1-06-01A), page 2 number 7 stated: “If the medication is in a vial, remove the vial cap, and clean vial stopper with an alcohol pad. A new alcohol prep pad is used prior to each time a vial is entered.” (Cross Reference Tag V0143) 6. Central Venous Catheter (CVC) with clearguard HD antimicrobial end caps (Procedure 1-04-02 B), page 2 stated: “Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason.” Page 5 number 16 stated: “Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of the hub thoroughly...” (Cross Reference Tag V0147) 7. Bicarbonate Concentrate System Mixing (Policy 2-07-01), page 5 number 27 stated: “prior to batch mixing, a status label will be affixed to the bicarbonate mixer that identifies the batch formulation and date mixed until the bicarbonate in the tank is transferred or emptied.” Number 28 stated: “Bicarbonate concentrate is to be used the same day that it is mixed (with the exception of bicarbonate cartridges and facilities providing nocturnal dialysis). Any bicarbonate concentrate left over at the end of treatment day is to be discarded.” (Cross Reference Tag V0228) 8. Preparation of One to One Hundred (1:100) Bleach Solution (01-05-08B), page 3 number 12 stated: “With indelible marking pen and label, label container with expiration date, time, and initials. The solution is good for 24 hours only.” Number 13 stated: “When the solution is not being used, place a lid on the bleach solution container. (Cross Reference Tag V0228) 9. Calibration Check and Calibration of Portable Myron L Conductivity Meter (Procedure 02-08-01A), page 1 stated: “This procedure is to be performed prior to daily use or whenever inaccurate readings are suspected” (Cross Reference Tag V0403) 10. Medications requiring refrigeration (Policy 1-06-06), page 1 number 3 stated: “The refrigerator is checked ...Twice daily ...at the beginning and end of the day.” (Cross Reference Tag V0403) 11. Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (Policy 1-03-08), page 4 number 10 stated: “If the dialysis prescription is not being met (including the inability to obtain prescribed blood flow rate or BFR) the reason will be documented, and the licensed nurse informed.” Number 11 stated: “Abnormal findings ...will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on the individual patient needs to determine if any clinical interventions are necessary.” Number 13 stated: “All findings, interventions, and patient response will be documented in the patient ’ s medical record.” Number 16 stated: “If an abnormal finding (s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge.” (Cross Reference Tag V0503) 12. Interdisciplinary team (IDT) Patient Assessment and Plan of Care (Policy 01-14-01), page 4 number 10 stated: “An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” (Cross Reference Tag V0516) 13. Facility ’ s policy Procedure 01-04-01E, page 2 number 5 stated: “perform inspection, auscultation, and palpation on the entire length of access. Determine presence of bruit and thrill. Rationale: The presence of a bruit and thrill indicates flow through the access.” Page 3 number 11 stated: “While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry.” Page 2 stated, “If using isopropyl alcohol 70%, use at least 4 prep pads per site with an effective contact time of 60 seconds. Page 3 number 13 stated: “Do not palpate insertion site once area has been prepped. Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” (Cross Reference Tag V0551) 14. Facility ’ s policy (Policy 01-14-01), page 1 number 1 stated: “The facility ’ s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient ’ s personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP)... a social worker, and a dietician.” Number 2 stated: “The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient ’ s treatment plan and expectation for care.” (Cross Reference Tag V0556)”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 47759 Based on review of the facility staffing logs, review of the staffing exception reports, and interviews with randomly-selected staff members and patients, the facility’s governing body failed to ensure adequate staffing patterns. This practice placed the patients, and staff members’ well being and safety at risk. Findings include: The Code of Maryland Regulations 10.05.04.06C(1)(a)(b)(c)(i)(ii) for Freestanding Kidney Dialysis Centers states: “Dialysis Monitoring. Staffing Ratio. The monitoring individual-to-patient ratio at each center shall be a minimum of one staff member to three participants (patients) and staffing shall be sufficient to meet the needs of patients. The center shall establish provisions for back-up staff coverage during unexpected illnesses, vacations, and holidays. The charge nurse may not be included in the staffing ratio except when there are nine or fewer patients; or in the event of an emergency.” On 12/18/2023 at 10:00 a.m., during record review of the facility ’ s staffing schedule log and staffing exception reports, the surveyor observed the following: 1. On the week of 11/26/2023, the facility was short staffed 53% of the time. 8 out of the 15 shifts were short staffed resulting in a staffing ratio of 4:1 and/or the charge nurse assigned to patients. 2. On the week of 12/03/2023, the facility was short staffed 53% of the time. 8 out of the 15 shirts were short staffed resulting in a staffing ratio of 4:1 and/or the charge nurse assigned to patients. 3. On 12/11/2023-12/13/2023, the facility was short staffed 25% of the time. 2 out of the 8 shirts were short staffed resulting in the charge nurse assigned to a patient. On 12/14/2023 at 10:30 a.m., during an interview with Patient #24, the patient stated that the facility needed to have more staff members. On 12/14/2023 at 11:00 a.m., during an interview with a staff member, the staff member stated that the facility had been short staffed for months for both Patient Care Technician (PCT) and Registered Nurses (RN).”