Pnrs Eastern Oregon Dialysis Clinic

“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: 37237 Based on interview and review of documentation, it was determined the facility failed to complete a full-scale community/facility wide exercise every two years. Findings: Review of documentation revealed a fire disaster tabletop exercise was completed on 05/30/2023, and an earthquake disaster tabletop was completed on 10/24/2024. On 06/25/2025 at 1540, the CM confirmed a community/facility wide full-scale exercise was not completed during 2023 or 2024.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 37237 Based on observation and review of documentation, it was determined the facility failed to ensure staff did not eat in the treatment area. Findings: Observation of the nursing station in the treatment area on 06/26/2025 at 1235 revealed two pieces of candy remained visible on the desk and two bags of hard candies and a bag of cough drops were stored in the drawer at the nurses’ station. Review of the facility policy, “General Cleanliness and Infection Control Guidelines,” dated as “Published 05/05/2025” stipulated: “Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure ... Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.””

“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: 37237 Based on interview, review of patients’ immunization records and review of documentation, it was determined the facility failed to ensure that for 3 of 40 patients (Patients 6, 12 and 15): - The HBV serological status of all patients was known before admission; - That patients were routinely tested as required; and - That patients were offered the Hep B immunization series. Findings: Patient #6 Review of the facility’s “Hepatitis B Summary Report,” created “06/25/2025,” that included documentation of Hepatitis B vaccination status of 40 patients revealed Patient #6, with an admission date of 04/24/2025, lacked documentation for the “Most Recent Hep B core Ab Total (anti-HBc)” and “Most Recent Hep B Surface Ab Result (anti-HBs).” Patient #15 Review of the facility’s “Hepatitis B Summary Report,” created “06/25/2025,” that included documentation of Hepatitis B vaccination status of 40 patients revealed: - Patient #15’s “Most Recent Hepatitis Status” was listed as susceptible as of 05/20/2024. The “Suggested Actions” listed “Monthly ABsAg testing per policy. Offer Vaccine Annually.” * Review of the monthly Hep B Surface Ag (HBsAg) testing revealed tests were done 06/26/2024, 02/15/2025, 03/10/2025, 04/14/2025, 05/12/2025 and 06/02/2025. There were no monthly results documented for 7 months between July 2024 through January 2025. - In the section “Facility Non-Administer Reason” the facility documented “Vaccination Refused by Patient 08/24/2023.” The facility failed to provide documentation that the patient received further education or was offered the vaccine since 2023. Patient #12 Review of the facility’s “Hepatitis B Summary Report,” created “06/25/2025,” that included documentation of Hepatitis B vaccination status of 40 patients revealed Patient #12 was admitted to the facility on 04/23/2025. The patient tested as susceptible on 04/23/2025. As of 06/24/2025, the facility failed to provide documentation that the patient was offered the Hep B immunization series. * During interview with the CM on 06/26/2025 at approximately 0850, they stated the patient’s 1st vaccine dose in May was not given and was rescheduled to June. As of 06/24/2025, the patient had not started the immunization series. Review of the facility policy titled, “Patient Hepatitis B Testing Requirements,” dated as “Published 02/03/2025” stipulated: * “HBV status should be known prior to admission for all new patients.” * “If Hepatitis B Surface antibody (anti-HBs), and Hepatitis B core antibody ‘total’ (anti-HBc ‘total’) are not available prior to admission, obtain a physician order to immediately draw blood specimens and submit for testing. Anti-HBs and anti HBc ‘total’ results must be available within 7 days of admission.” Review of the facility policy titled, “Patient Vaccination for Hepatitis B,” dated as “Published 02/07/2022” stipulated: * “The Hepatitis B vaccine shall be offered to all susceptible patients including peritoneal and home hemodialysis patients.” * “Patients who are candidates for hepatitis B vaccine and decline, should be offered the Hepatitis B vaccine on an annual basis, at minimum. Provide patient education as needed ... A vaccine declination must be signed by the patient each year the vaccine is offered and refused ... Each offering of the vaccine should be documented in the patient’s medical record.” During an interview with the CM on 06/25/2025 at 1540, they confirmed the above findings.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 37237 Based on observation and the review of documentation it was determined that the facility failed to ensure that equipment and supplies used for isolation patients were labeled. Findings included, but not were not limited to: Observation of the isolation room on 06/24/2025 at 0850 revealed the following items found in the isolation room were not labeled for isolation only: - The dialysis machine - The dialysis treatment chair - A stethoscope - The centrifuge - A scale - A stool - A face shield - A biohazard bin - Clamps - A sharps container - A trash can - A gallon bleach container - A portable oxygen concentrator - A container of test strips - A small portable table - Multiple spray bottles Further observations revealed: - The rim of the drain of the dirty sink was surrounded by a black substance and the drain had a green substance inside. - A green substance surrounded the drain rim and was inside the drain of the clean sink. Review of the facility policy “Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+),” dated as Published: 06/04/2025” stipulated: * “If ... There are current HBsAg positive patients on census ... Then ... Equipment cannot be used for HBV negative patients on other shifts or days due to the risk of cross contamination. Equipment used for HBsAg positive patients should be reserved for the HBsAg positive patient unless repair or maintenance is needed.” * “All supplies used in the isolation room/area such as clamps, blood pressure cuffs, testing reagents, etc., should be labeled ‘isolation’ and not routinely removed.””

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 47148 Based review of documentation and interview, it was determined the facility failed to ensure staff followed the facility’s procedure regarding verifying the calibration of the approximate potential of hydrogen (pH) of the dialysate meter prior to initiating daily hemodialysis treatments. Findings: Observation of the facility records titled, “Myron L D-6 Meter Verification (Daily)” for the months of April, May and June 2025 revealed the documentation of the numeric value was to the tenth decimal point versus the hundredth decimal point which did not allow for verification whether or not the value was within the acceptable range. An example included, but not limited to: “4.0” when the acceptable levels were 3.96 to 4.04 and “7.0” when the acceptable levels were 6.96 to 7.04. - The April 2025 report revealed incomplete documentation for 12 out of 26 days the facility provided hemodialysis treatments. - The May 2025 report revealed incomplete documentation for 11 out of 21 days the facility provided hemodialysis treatments. - The June 2025 report revealed incomplete documentation for 5 out of 10 days the facility provided hemodialysis treatments. During an interview with the CM on 06/25/2025 at approximately 1520, the above findings were confirmed.”

“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: 37237 Based on observation and interview, it was determined that the facility failed to maintain a safe, functional, and comfortable environment for the patients, staff and public. Findings: Observations of the facility on 06/24/2025 beginning at 0840 revealed the following: - The countertop in the lab area had remnants of white paper stuck to the surface. - The fire extinguisher in the lab area lacked the monthly check in June. All other fire extinguishes in the facility were checked 06/19/2025, the one in the lab area was last signed off by staff on 05/09/2025. - The eyewash station in the lab area, attached to the dirty sink, lacked nozzle covers thereby leaving the nozzles exposed to dirt and debris. - The eyewash basin in the supply room was stained and many of the eyewash nozzle holes were covered by a black substance. - The eyewash station in the HHD training room lacked an identifying label. - The saline prime bucket on the dialysis machine at station 6 had a large brown stain inside. - There were white stains on the floor around treatment staton 1. On 06/26/2025 at 1700, the CM stated that the stain can be cleaned but comes back due to a leak. The following items were found to be expired and available for use: - A box of 36 “Crit-Line ... Blood Chambers” expired 11/30/2024. - A box of “ChloraPrep One-Step” single swab sticks expired 06/17/2025. - 6 boxes of “Tempa-DOTs,” temperature testing strips, expired between 11/16/2024 and 03/13/2025. - A box of 1000 “Povidone-Iodine” prep pads expired 03/30/2025. - A box of 24 “NxStage Express Fluid Warmer Disposable Sets” expired 12/24/2024. - 3 containers of “EZ Chek Blood Leak Test Strips” expired 04/30/2025. - 2 containers of “EZ Chek Ozone Test Strips” expired 05/31/2025. The CM and ATL confirmed the above findings on 06/26/2025 at 1700.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 47148 Based on observation, it was determined the facility failed to prominently display the current State agency mailing addresses and telephone complaint numbers where it can be easily seen and read by patients. Findings: During observation of the facility lobby/waiting area on 06/25/2025 at 0835, the facility failed to have correct information posted that provided the mailing address, contact information and phone number for complaints to the State survey agency. During an interview with the CM on 06/25/2025 at 1520, the above findings were confirmed.”

“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: 47148 Based on interview, review of medical records, and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed and that VS monitoring was completed according to facility policy for 3 of 5 in-center hemodialysis patients reviewed (Patient #s 1, 2 and 3.) Findings: Patient #2 Review of Patient #2’s Treatment Details Reports dated 05/21/2025 through 06/25/2025 (14 treatments) revealed the following: - Physician orders for hemodialysis treatment included a prescription for “DFR 600.” * On 05/21/2025 at 1606, the RN increased the DFR from 600 ml/min to 800 ml/min without any documentation as to why the increase was initiated. *Similar findings were identified on treatment sheets dated: 05/26/2025 and 06/25/2025. - Similar findings were identified for Patient #1. - On 06/13/2025, VS and patient assessment checks were documented at 1601. The next access check and face visualization were documented 59 minutes later at 1700. - Similar findings were identified for Patient #1. - Physician orders for hemodialysis treatment included a prescription for “Scheduled Hours: 03:00.” On 06/16/2025, treatment was initiated at 1511 and completed 2 hours and 22 minutes later at 1733. The treatment was shortened by 38 minutes. At 1722, the RN documented “Treatment ended early per pt request ...” There was no AMA documentation provided for the shortened treatment time. * Similar findings were identified for treatment sheets dated: 06/04/2025, 06/09/2024 and 06/13/2025. Patient #3 Review of Patient #3’s Treatment Details Reports dated 05/23/2025 through 06/25/2025 (15 treatments) revealed the following: - Physician orders for hemodialysis treatment included a prescription for “BFR 450” - On 05/26/2025, at 0546, a PCT set the BFR at 400 ml/min and initiated treatment. At 0557, an RN documented they verified the machine settings matched the prescription. The BFR remained at 400ml/min throughout the duration of the treatment. * Similar findings on treatment sheets dated: 05/30/2025 and 06/20/2025. - On 06/25/2025, at 0538, a PCT initiated treatment and performed an AFT. At 0738, an RN documented the BFR at 400 ml/min where it remained throughout the duration of the treatment. * Similar findings on treatment sheets dated: 06/04/2025. Review of facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, stipulated: * “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 [min] or more often as needed but not to exceed 45 minutes or per state regulations.” * “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.” * “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.””

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined the facility failed to implement facility policy that ensured pneumococcal vaccines were offered to qualifying patients for 10 of 39 patients reviewed (Patient #s 5 - 14). Findings: 1. Review of the Pneumonia Vaccination Report dated 06/24/2025 revealed the following: - Patient #5 had an order for a pneumococcal vaccine, but the vaccine was not administered in a timely manner. The last pneumococcal vaccination given was PCV13 on 12/13/2019 with an order to “Admin PCV20 as ordered on or after last dose 12/13/2024.” The vaccine had not been administered as of the 06/24/2025 report. *Similar findings were identified for Patient #s 8, 9 and 10. - Patient #6 was listed as “Vaccination Candidate” with the “Suggested Action(s)” listed as “Admin PCV20 as ordered on or after 06/25/2025.” The vaccine had not been administered as of the 06/25/2025 . * Similar findings were identified for Patient #s 7, 11, 12, 13 and 14. Review of the facility policy titled, “Pneumococcal Vaccine for Adult Patients,” dated as “Published: 02/25/2024,” stipulated: * “Adults who have previously been vaccinated with Prevnar 13 (PCV 13) and/or Pneumovax 23 (PPSV23) should follow the CMAB algorithm for recommended vaccine schedule.” During an interview with the CM and ATL on 06/26/2025 at 0850, the above findings were confirmed.”