Fmc Liverpool Dialysis Center, LLC

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 52920 Based on document review and interview, the facility did not provide documentation that they had reviewed their emergency preparedness plan at least every two years, as required per §494.62, Condition for Coverage for End-Stage Renal Disease (ESRD) Facilities. Findings include: -- Per review of the facility’s “Emergency Plan” there was no documentation that the plan had been evaluated and updated every two years. -- During interview of Staff A, Non-clinical Staff, on 7/29/2025 at 11:10 am, they acknowledged the above finding.”

“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: 46619 Based on document review, observation, and interview, (1) in 7 of 20 observations, facility staff and patients did not perform hand hygiene and/or use gloves as required, (2) in 2 of 2 observations, facility staff did not ensure that a patient’s arteriovenous fistula (AVF) site was cleansed with soap and water, either by the patient or by staff, prior to beginning the process to access the AVF for dialysis treatment. These lapses place patients and staff at risk for potential infection. Findings pertaining to (1) include: -- Review of the facility’s policy and procedure (P&P) titled “Hand Hygiene,” revised 11/2023, indicated that hand hygiene should be performed before and after direct contact with patients, immediately after removing gloves, and after contact with inanimate objects near the patient. Patients should perform hand hygiene, if able, prior to and after each dialysis treatment. -- Per observation on 7/28/2025 at 10:39 am, at Station #7, Staff B, Clinical Staff, used a cell phone for treatment calculations. Staff B donned gloves to enter the station. Staff B did not perform hand hygiene prior to donning new gloves. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 10:41 am, at Station #7, Staff B, Clinical Staff, left the dialysis station to retrieve a thermometer. Staff B did not remove their gloves and perform hand hygiene prior to leaving the station. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 10:51 am, at Station #7, Staff B, Clinical Staff, removed their gloves, after giving medication to a patient, and did not perform hand hygiene. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 10:54 am, at Station #7, Staff B, Clinical Staff, removed gloves after adjusting the dialysis machine. Staff B touched their face and adjusted their glasses. Staff B did not perform hand hygiene after removing their gloves. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 11:05 am, at Station #20, Staff C, Clinical Staff, removed dirty gloves and did not perform hand hygiene prior to donning clean gloves. Staff C acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 11:30 am, at Station #20, Staff D, Clinical Staff, did not change gloves or perform hand hygiene after emptying and cleaning the prime waste receptacle. Staff D proceeded to clean and disinfect the dialysis machine. Staff D acknowledged this finding at the time of observation. -- Per observation on 7/29/2025 at 9:50 am, at Station #7, a patient independently left the treatment area to weigh themselves. The patient was not encouraged by staff to perform hand hygiene prior to leaving the treatment area. Staff E, Clinical Staff, acknowledged this finding at the time of observation. Findings pertaining to (2) include: -- Per review of the facility’s P&P titled “Access Assessment and Cannulation,” dated 5/5/2025, staff should, prior to accessing an AVF for treatment, ask the patient to wash access area with soap and water, per hand hygeine procedure. If the patient is unable to wash their own access, the staff should wear gloves to wash the patients access with soap and water. If unable to wash with soap and water, staff may use hand sanitizer with 60-70% alcohol to clean access arm. -- Per observation on 7/28/2025 at 11:00 am, at Station #10, Staff F, Clinical Staff, did not ensure the patient’s AVF was washed prior to cannulation. Staff F acknowledged this finding at the time of observation. -- Per observation on 7/29/2025 at 9:49 am, at Station #17, Staff G, Clinical Staff, did not ensure that the patient’s AVF was washed prior to cannulation. Staff G acknowledged this finding at the time of observation.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 48296 Based on document review, observation, and interview, in 3 of 20 observations, facility staff did not ensure items taken into the hemodialysis station were cleaned/disinfected between each patient and/or station. Specifically, thermometers and stethoscopes were not cleaned/disinfected after use and/or between stations. This places patients and staff at risk for infection. Findings include: -- Review of the facility’s policy and procedure (P&P) titled “Cleaning and Disinfecting the Dialysis Station,” dated 9/5/2023, indicated supplies brought into the dialysis station must be disinfected after use. -- Per observation on 7/28/2025 at 10:41 am, at Station #7, Staff B, Clinical Staff, used a thermometer to take a patient’s temperature. Staff B returned the thermometer to the desk to be available for patient use. Staff B did not clean/disinfect the thermometer after using it in the dialysis station. Staff B acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 11:06 am, at Station #6, Staff F, Clinical Staff, used a thermometer to take the patients temperature. Staff F returned the thermometer to the desk to be available for patient use. Staff F did not clean/disinfect the thermometer after using it in the dialysis station. Staff F acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 11:15 am, at Station #6, Staff F, Clinical Staff, used a stethoscope to auscultate a patients arteriovenous fistula (AVF) prior to cannulating. Staff F placed the stethoscope around their neck and then cannulated the patient. Staff F left the dialysis station to provide care to another patient. Staff F did not clean/disinfect the stethoscope after use. Staff F acknowledged this finding at the time of observation.”

“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: 46869 Based on observation and interview, facility staff did not ensure that uncleanable containers (cardboard boxes) from outside of the unit were stored separately from clean areas. Findings include: -- Per observation on 7/28/2025 at 9:35 am, of the facility’s main clean supply room, uncleanable containers were used to store clean supplies. -- Per observation, on 7/28/2025 at 9:45 am, of the facility’s medication room, uncleanable containers were used to store clean supplies. -- During interview of Staff H, Clinical Staff, on 7/28/2025 at 2:00 pm, they acknowledged the above findings.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 46619 Based on document review, observation, and interview, the facility did not ensure that regulated medical waste was disposed of in compliance with New York State Codes, Rules, and Regulations Title 10 (10NYCRR). Specifically, (1) they did not ensure that red-bagged medical waste was properly contained, (2) that used, blood-containing tubing was securely contained within a medical waste container, and (3) that sharps containers in patient care areas were replaced every 30 days. Findings pertaining to (1) include: -- Per facility’s policy and procedure (P&P), “General Cleanliness and Infection Control Guidelines,” last revised 5/5/2025, “Regulated medical waste shall be placed in a container that is in accordance with OSHA Bloodborne standard 1210.1030 and is closeable, leak proof and labeled and/or color coded.” -- Per observation on 7/28/2025 at 9:25 am, of the facility’s Pod 1, 3 large red-bagged medical waste containers did not have lids. -- Per observation on 7/28/2025 at 12:45 pm, of the facility’s Pod 2, 2 large red-bagged medical waste containers did not have lids. -- Per observation on 7/28/2025 at 12:50 pm, of the facility’s Pod 1, 1 large red-bagged medical waste containers did not have a lid. -- During interview of Staff H, Clinical Staff and Staff D, Clinical Staff, they acknowledged the above findings at the times of their observation. Findings pertaining to (2) include: -- Per facility’s P&P, titled “General Cleanliness and Infection Control Guidelines,” last revised 5/5/2025, “Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.” -- Per observation on 7/28/2025 at 9:30 am, of the facility’s Pod 1, dialysis tubing containing blood was not securely contained in a medical waste receptacle. -- During interview of Staff H, on 7/28/2025 at 2:00 pm, they acknowledged the above findings. Findings pertaining to (3): -- Review of facility’s P&P titled “Medical Waste Management Plan,” last reviewed 11/20/2023, revealed that there wasn’t a specified timeframe to remove sharps containers from patient care areas. Sharps containers must be removed from patient care areas after 30 days or upon generation of odors, whichever comes first, per 10NYCRR Part 70-2.2. -- Per observation on 7/28/2025 at 9:20 am, of the facility’s Pod 1, 4 sharps containers were not labeled with the date of when they were put into use within a patient care area. -- During interview of Staff H, on 7/28/2025 at 2:00 pm, they acknowledged the above findings.”

“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: 48296 Based on document review, observation, and interview, in 1 of 2 observations, facility staff did not clean and disinfect the dialysis machine post treatment per the dialysis unit’s policy and procedure (P&P). Specifically, the dialysis machine was cleaned and disinfected while a patient was in the treatment area. This places patients and staff at risk for potential exposure to infections. Findings include: -- Review of the dialysis unit’s P&P titled “Cleaning and Disinfecting the Dialysis Station,” dated 9/5/2023 indicated “the patient must completely vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry and set up for the next patient.” -- Per observation on 7/29/2025 at 9:43 am, at Station #12, Staff I, Clinical Staff, disinfected the station while a patient was holding pressure to their AVF site, following the end of treatment. Staff I then began to set up the dialysis machine for the next patient. This finding was acknowledged at the time of observation.”

“HOT H20 DISINF SYS-MONITORING CFR(s): 494.40(a) 6.3.4 Bacterial control devices 6.3.4.3 Hot water disinfection systems: monitoring Hot water disinfection systems should be monitored for temperature and time of exposure to hot water as specified by the manufacturer. Also, hot water disinfection should be performed at least as often as recommended by the manufacturer. The temperature of the water should be recorded at a point farthest from the water heater-that is, where the lowest water temperature is likely to occur ...and measured each time a disinfection cycle is performed. A record that verifies successful completion of the heat disinfection should be maintained. Successful completion is defined as meeting temperature and time requirements specified by the equipment manufacturer. This Standard is not met as evidenced by: 46869 Based on document review and interview, facility staff did not ensure that logs were completed for the daily hot water disinfection for the facility’s reverse osmosis (RO) system and RO water distribution system. Findings include: -- Review of the facility’s daily “CWP RO 9557” (RO water distribution system monitoring report), from 5/28/2025 to 7/28/2025, revealed the following: - There were 2 out of 4 days that the temperature for the daily RO system heat disinfection was not recorded, in 5/2025. - There were 15 out of 25 days that the temperature for the daily RO system heat disinfection was not recorded, in 6/2025. - There were 15 out of 24 days that the temperature for the daily RO system heat disinfection was not recorded, in 7/2025. -- Review of the technical update (developed by the company) titled “CWP/Dialysis Machine Integrated Heat Procedure,” dated 1/16/2017, specified that the recommended frequency of heat disinfection for the CWP (the facility’s RO system) is daily. -- Per interview of Staff J, Non-clinical Staff, on 7/28/2025 at 3:00 pm, they acknowledged the above findings.”

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 46869 Based on document review and interview, facility staff did not ensure that logs were completed for the weekly low-level chemical disinfection of the facility’s reverse osmosis (RO) system and RO water distribution system, as required by the manufacturer’s instructions for use (IFUs). Findings include: -- Review of the facility’s weekly “CWP Disinfect Start - 1106” and “CWP Disinfect End - 1107” logs, between 4/1/2025 and 7/31/2025, revealed the following: - 4/2025: There was 1 week that the data for the end of the weekly low-level chemical disinfection of the facility’s RO system and RO water distribution system was not recorded. This data included the test results for residual chemical in the system after disinfection was completed. - 5/2025: There was 1 week that the data for the end of the weekly low-level chemical disinfection of the facility’s RO system and RO water distribution system was not recorded. This data included the test results for residual chemical in the system after disinfection was completed. - 7/2025: There was 1 week that the data for the weekly low-level chemical disinfection of the facility’s RO system and RO water distribution system was not recorded, and 1 week that the data for the start of the low-level chemical disinfection was not recorded. This data included: - Start of test (YES/NO) - Disinfectant used - Disinfectant lot number - Expiration date for the disinfectant - Employee ID for employee who completed the system disinfection - Test results for residual chemical in the system after disinfection was completed. -- Review of the facility’s RO system IFUs, “CWP 100, Model H/S - Operator’s Guide,” dated 2012, revealed that the low-level chemical disinfection of the CWP (the facility’s RO system) must be completed at least once a week, at minimum. -- Per interview of Staff J, Non-clinical Staff, on 7/29/2025 at 11:30 am, they acknowledged the above findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49512 Based on document review, observation, and interview, in 2 of 2 observations, facility staff did not ensure that two drawers located in the medication administration area of Pod 2, which contained multiple medications, were secured. Having medications unsecured has the potential to affect patient safety. Findings include: -- Per review of the dialysis unit’s policy and procedure (P&P) titled “Medication Preparation and Administration,” revised 7/2025, indicated that all medications will be kept in a locked cabinet except when in use. -- Per observation on 7/28/2025 at 9:50 am, of Pod 2’s open medication administration area, a drawer containing multiple vials of Heparin (medication that prevents blood clots) was found to be unsecured. Staff K, Clinical Staff, acknowledged this finding at the time of observation. -- Per observation on 7/29/2025 at 12:20 pm, of the facility’s medication area in Pod 2, 2 drawers containing medications were not locked. Medications found in the drawers included, 1 box of Heparin, 3 boxes of Venofer, 5 bottles Cinacalcet Hydrochloride, and 1 tube and 2 boxes of Glutose 15. -- During interview of Staff H, Clinical Staff, on 7/29/2025 at 1:30 pm, they acknowledged the above findings.”

“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: 52920 Based on document review, observation, and interview, facility staff did not ensure that all facility equipment was maintained and operated in accordance with the manufacturer’s recommendations. Additionally, facility staff did not ensure expired supplies were removed from the treatment area. Specifically, (1) the facility’s medication refrigerators’ temperature logs were not maintained, (2) expired and undated test strips were actively used by clinical staff, and (3) expired supplies were available for patient use. These lapses could put patients at risk for infection. Findings pertaining to (1) include: -- Review of the facility’s policy and procedure (P&P), “Medication Preparation and Administration,” last reviewed 7/7/2025, indicated a daily temperature log must be maintained to monitor the refrigerator’s temperature range. -- Review of the facility’s medication refrigeration temperature logs, for both medication refrigerators, for the months of 6/2025 and 7/2025, revealed that the facility did not record the temperatures of the refrigerators on multiple days: - 24 morning temperature readings were missing from the logs for refrigerator 2053609 in the month of 6/2025. - 24 morning temperature readings were missing from the logs for refrigerator 2053609 in the month of 7/2025. - 19 evening temperature readings were missing from the logs for refrigerator’s 2053609 in the month of 6/2025. - 19 evening temperature readings were missing from the logs for refrigerator’s 2053609 in the month of 7/2025. - 6 morning temperature readings were missing from the logs for refrigerator’s 2018697 in the month of 6/2025. - 4 morning temperature readings were missing from the logs for refrigerator’s 2018697 in the month of 7/2025. - 12 evening temperature readings were missing from the logs for refrigerator’s 2018697 in the month of 6/2025. - 7 evening temperature readings were missing from the logs for refrigerator’s 2018697 in the month of 7/2025. -- Per interview of Staff J, Non-clinical Staff, on 7/29/2025 at 9:00 am, they acknowledged the above findings. Findings pertaining to (2) include: -- Review of the facility’s P&P titled, “Test Strips & Solutions,” last reviewed 12/8/2015, revealed that Water Check Residual Chlorine test strips must be dated and initialed when first opened, and must be discarded when expired or 90 days after opening. -- Per observation on 7/28/2025 at 9:30 am, in Pod 1, Staff D, Clinical Staff, used a pH test strip, from a container of pH test strips that expired on 6/5/2025, to test a hemodialysis machine in Pod 1. Staff D acknowledged this finding. -- Per observation on 7/28/2025 at 9:33 am, in Pod 1, there was an opened container of Watercheck Residual Chlorine test strips, which was undated. -- Per observation on 7/28/2025 at 9:35 am, in the facility’s main clean supply room, there were the following expired supplies available for use: - One box of pH test strips, expired 1/30/2025 - One box of pH test strips, expired 6/5/2025 -- During interview of Staff D, Clinical Staff, they acknowledged the above findings at the times of their observation. Findings pertaining to (3) include: -- Review of the facility’s P&P titled, “Expiration Dates Sterile Supplies,” dated 7/4/2012, indicated that sterile items will be checked before use to ensure that they have not expired. Staff will appropriately dispose of sterile items that have reached the expiration date. -- Per observation on 7/28/2025 at 9:27 am, in Pod 1, there were 19 recirculation caps that expired on 3/31/2025, available for patient use. Staff H, Clinical Staff, acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 9:27 am, in Pod 1, there were 2 standard infusion sets that expired on 8/25/2024 and 3/21/2025, available for patient use. Staff H acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 9:41 am, in Pod 2, there were 10 recirculation caps that expired on 3/31/2025, available for patient use. Staff H acknowledged this finding at the time of observation. -- Per observation on 7/28/2025 at 9:45 am, in Pod 2, there were 11 Hemodialysis Fistula 16 G (gauge) needle sets that expired on 6/30/2025, available for patient use. Staff H acknowledged this finding at the time of observation.”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 48296 Based on document review, medical record (MR) review, and interview, in 1 of 8 MRs, a patient (Patient #1) terminated treatment prior to their prescribed time. There was not a form signed by the patient or staff acknowledging the patient ended treatment early. This could lead to patients not understanding the risks of ending treatment early. Findings include: -- Review of the facility’s policy and procedure (P&P) titled “Early Termination or Arriving Late for Treatment,” dated 6/18/2025, indicated if a patient requests to leave treatment early the registered nurse (RN) is responsible to notify the provider, and document on the AMA (Against Medical Advice) form. AMA forms must be signed by the patient and witnessed by the supervising nurse with each early termination event. Forms must be filed in the patient’s MR. -- Review of Patient #1’s “Treatment Sheet for Facility,” dated 7/14/2025, indicated Patient #1 was scheduled for 4 hours of dialysis treatment. Patient #1 started treatment at 10:39 am and ended at 1:56 pm. Patient #1’s treatment ended 1 hour and 16 minutes prior to prescribed treatment time. At 3:04 pm, an RN documented “Pt came off treatment early due to being incontinent of stool”. There was no AMA form filled out and signed by Patient #1 and/or staff for this date. -- Review of Patient #1’s “Treatment Sheet for Facility,” dated 7/16/2025, indicated Patient #1 was scheduled for 4 hours of dialysis treatment. Patient #1 started treatment at 11:21 am and ended at 2:33 pm. Patient #1’s treatment ended 1 hour and 12 minutes prior to prescribed treatment time. At 4:04 pm, an RN documented “Pt came off treatment early due to use the bathroom”. There was no AMA form filled out and signed by Patient #1 and/or staff for this date. -- Review of Patient #1’s “Treatment Sheet for Facility,” dated 7/18/2025, indicated Patient #1 was scheduled for 4 hours of dialysis treatment. Patient #1 started treatment at 10:57 am and ended at 2:15 pm. Patient #1’s treatment ended 47 minutes prior to prescribed treatment time. At 11:39 am, an RN documented “Pt states that ... has to come off the machine early today”. There was no AMA form filled out and signed by Patient #1 and/or staff for this date. -- Per interview of Staff H, Clinical Staff, on 7/29/2025 at 11:25 am, they acknowledged the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 48296 Based on document review, medical record (MR) review, and interview, facility staff did not assess and monitor patients in accordance with generally accepted standards of chronic dialysis care. Specifically, in 2 of 8 MRs reviewed (Patient #1 and Patient #2), dialysis treatment sheets indicated the patients had abnormal vital signs. There was no documentation in the MR regarding these abnormal findings. This lack of appropriate monitoring poses a potential risk for adverse patient outcomes. Findings include: -- Review of the facility’s policy and procedure (P&P) titled “Patient Assessment and Monitoring”, dated 5/1/2023, indicated during treatment clinical staff should report to the registered nurse a systolic blood pressure (BP) greater than 180 mm/Hg. -- Review of the facility’s P&P titled “Hypertension,” dated 9/7/2021, indicated staff will recognize, report, and immediately address systolic BP greater than 180 mg/Hg and/or diastolic BP greater than 100 mg/Hg. Staff should notify the nurse in charge if a patient has blood pressure elevated beyond these parameters. The registered nurse (RN) will assess the patient and determine if further nursing interventions are needed. Staff should document in the patient’s MR. -- Review of Patient #1’s “Treatment Sheet,” dated 7/21/2025, indicated at 1:00 pm, Patient #1 had a BP of 190/122 mm/Hg. A patient care technician (PCT) wrote a comment that stated “access visible; Green AMP light; denies complaints; patient alert”. There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #2’s “Treatment Sheet,” dated 7/23/2025, indicated at 5:34 am that the patient’s BP was 178/115. The PCT documented, “Treatment initiated without problem; denies complaints.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #2’s “Treatment Sheet,” dated 7/23/2025, indicated at 5:58 am that the patient’s BP was 197/119. The PCT documented, “Denies complaints.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #2’s “Treatment Sheet,” dated 7/23/2025, indicated at 6:28 am that the patient’s BP was 194/116. The PCT documented, “Resting comfortably; Denies complaints.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. -- Review of Patient #2’s “Treatment Sheet,” dated 7/23/2025, indicated at 6:59 am that the patient’s BP was 205/107 The PCT documented, “Resting comfortably; Denies complaints.” There was no documentation in the MR that a licensed nurse was notified of the abnormal finding. Patient #2’s blood pressure remained above parameters throughout the reminder of their treatment on 7/23/2025. -- Review of Patient #2’s “Treatment Sheet,” dated 7/23/2025, indicated, at 3:23 pm, the RN documented their nursing evaluation post-dialysis. The RN documented patient was alert, oriented, with no complaints. Symptoms were documented as “none”. Lungs clear with no edema. Pulse regular. There was no documentation within the MR that the RN was aware of or assessed the patient’s elevated blood pressure. -- Per interview of Staff H, Clinical Staff, on 7/29/2025 at 11:25 am, they acknowledged the above findings.”