Fkc Mount Airy

“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: 45377 Based on a review of medical records (MR), hemodialysis treatment records, hemodialysis patient schedule, facility policy, and an interview with the clinical manager (CM) and director of operations (DO), the medical director failed to ensure that the facility followed its policy related to Early Termination or Arriving Late to Treatment for one (1) of three (3) MR’s reviewed: MR#1 Findings include: The Facility’s Early Termination or Arriving Late for Treatment Policy, Reference Number 45623, reviewed on October 7, 2025 at approximately 11:15 AM reads in part, “Arriving Late: There may be times when a patient’s transportation is delayed and arrives late for their scheduled time. If the patient arrives after their scheduled time for dialysis treatment, start the patients’ treatment as soon as possible. Staff should do their best to accommodate the patient’s prescribed treatment time. If this is not possible due to facility hours of operation, the provider must be notified to review the time delay and determine the appropriate intervention. The facility staff should make every attempt to assist the patient with rescheduling any lost treatment time.” A review of patient schedules and hemodialysis treatment records from 06/30/2025 through 10/04/2025 were reviewed on October 7, 2025 starting at 10:30 AM. The admission date (AD) is indicated below. MR#1, AD 06/30/2025 was prescribed hemodialysis (HD) treatments for four (4) hours in duration from 6/30/24 to 9/1/25. On 9/3/25, the treatment duration was decreased to 3.5 hours. MR#1 received HD treatments via a central venous catheter (CVC). MR#1 was to have a 1:1 sitter (provided by the family) during HD treatments due to behavioral issues and concern for patient safety From 6/30/25 to 7/28/25, HD treatment sheets noted that treatments were completed as expected. Treatment times ranged from 3 hours (h) 49 minutes (m) to 4h, 8m. After 7/28/25 and through 9/1/25, treatment times were periodically less than the ordered duration of 4 hours due to various reasons noted below. 7/30/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. The patient arrived to the dialysis center late. HD treatment was initiated at 1:48 PM and ended at 3:45 PM. Total HD Treatment Time (HDTT): 1h, 57m. The treatment sheet contained a treatment status categorized as ‘Complete, Unexpected, Late arrival with inability to extend treatment.’ 8/4/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. MR#1 arrived to the dialysis center late, accompanied by family. Treatment was initiated at 12:12 PM and ended at 3:45 PM. Total HDTT: 3h, 33m: The treatment status noted, ‘Complete, Unexpected, Late arrival with inability to extend treatment.’ 8/11/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. MR#1 arrived to the dialysis center late, accompanied by family. Treatment was initiated at 12:17 PM and ended at 3:47 PM. Total HDTT: 3h, 30m: The treatment status noted, ‘Complete, Unexpected, Late arrival with inability to extend treatment, Physician notified.’ 8/20/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. Treatment was initiated at 11:50 PM and ended at 2:51 PM. Total HDTT: 3h, 1m. The treatment status noted, ‘Complete, Unexpected, Late arrival with inability to extend treatment.’ However, MR#1 did not arrive late. A nurses’ note stated that treatment ended early for patient safety because MR#1 was restless and confused. repeatedly attempting to get out of the chair, and there was no support person at chairside. 8/25/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. Treatment was initiated at 11:55 PM and ended at 3:08 PM. Total HDTT: 3h, 13m. The treatment status noted, ‘Complete, Unexpected, Other.’ The HD technician noted that MR#1 was bending the central venous catheter (CVC) causing high venous pressures. The nurses’ note stated that MR#1 was pulling on the CVC, unable to be reoriented, restless, attempting to get up, no caregiver at chairside, and therefore, treatment was terminated early. 8/27/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. Treatment was initiated at 12:06 PM and ended at 3:38 PM. Total HDTT: 3h, 32m. The treatment status noted, ‘Complete, Unexpected, Transportation.’ There was no further documentation as to the issue with transportation, i.e., whether MR#1 arrived late for treatment due to transportation, or left early due to transportation. A nurses’ note stated that the MR#1 was agitated throughout treatment, needed continuous redirection related to tugging at the CVC, was able to complete treatment in full (even though the treatment time was 30 minutes short), and that a family meeting was held with the clinical manager (CM) and charge nurse (CN) to discuss MR#1. 8/29/25: MR#1 was scheduled for HD treatment from 11:45 AM to 3:45 PM. Treatment was initiated at 12:15 PM and ended 3:51 PM. Total HDTT: 3h, 36m. The treatment status noted, ‘Completed, Unexpected, Transportation.’ Although there was no further note elaborating on the issue with transportation, it is assumed that MR#1 arrived late, given that treatment started late and ended at the scheduled time. A note by the CM indicated that the treatment days were going to change to Tuesday, Thursday, and Saturday (TTS), and after consulting with the physician, treatment duration would be decreased to 3.5 hours due to MR#1 achieving optimal and efficient removal of waste products during dialysis. 9/1/25: Treatment orders continued to be 4 hours in duration. Treatment time was 3h, 45m. 9/3/25: This treatment, scheduled for a Wednesday, was listed as absent, in order to initiate the switch to a TTS schedule. Treatment orders were decreased to 3.5 hours. A note entered on 9/3 stated, ‘changing treatment days to TTS.’ 9/4/25: This was the first treatment on the new TTS schedule as well as the new treatment duration of 3.5 hours. MR#1 was not listed on the 9/4 HD schedule so the scheduled start time was unknown. MR#1’s treatment was initiated at 1:30 PM and ended at 3:54 PM. Total HDTT: 2h, 24m. The treatment status noted, ‘Complete, Unexpected, Late Arrival with inability to extend treatment.’ 9/6/25: MR#1 was scheduled for HD treatment from 12:30 PM to 4:00 PM. Treatment was initiated at 12:53 PM and ended 3:55 PM. Total HDTT: 3h, 2m. The treatment status noted, ‘Completed, Unexpected, Late Arrival with inability to extend treatment.’ 9/9/25: MR#1 was scheduled for HD treatment from 11:55 AM to 3:25 PM. Treatment was initiated at 12:46 PM and ended 2:32 PM. Total HDTT: 1h, 46m. The treatment status noted, ‘Completed, Unexpected, Transportation.’ A nurses’ note stated, “when MR#1 arrived to clinic, after treatment was initiated, the family member mentioned leaving the clinic to go to the post office. Explained to daughter that if s/he leaves, the facility must terminate treatment. MR#1 was left patient alone for approximately 20 minutes. MR#1’s treatment was terminated early.” MR#1 was scheduled to receive 4 hours of HD treatments from 6/30/25 to 9/1/25, then 3.5 hours of treatment after 9/1/25. Between 7/30/25 and 9/9/25, there were eight (8) instances of MR#1 arriving late to the clinic, and three (3) instances involving MR#1’s behavior that led to shortened treatments. The facility’s “Early Termination or Arriving Late for Treatment” Policy states that staff should do their best to accommodate the patient’s prescribed treatment time, and if that is not possible due to facility hours of operation, the provider must be notified to review the time delay and determine the appropriate intervention. There was no evidence during the time frame of 7/30/25 to 8/28/25 of the physician/provider being notified of MR#1’s late arrivals that resulted in short treatment times, except for 1 instance of physician notification by the assigned nurse on 8/11/25. A clinical note by the CM on 8/29/25 indicated that physician discussion took place regarding reduction of the treatment time from 4 hours to 3.5 hours. All HD treatments after 9/9/25 through 10/4/25 met the expected treatment duration of 3.5 hours. An interview with the director of operations on October 7, 2025 starting at 2:40 PM confirmed the above findings.”

“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: 45377 Based on observations (OBS) in the in-center treatment area, self-care/self-dialysis treatment area, and home dialysis treatment area, a review of facility policy and an interview with the facility administrator, it was determined that the facility staff did not practice proper infection control for three (3) of fourteen (14) observations: MR#16, MR#17, and MR#18. Findings include: The Facility’s Policy Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer, Number 45640, reviewed June 23, 2025 at 3:00 PM reads in part, “ Termination: Disinfection of Catheter and Disconnecting the Patient: Discard gloves and perform hand hygiene. Don clean gloves. Verify that both arterial and venous bloodlines and arterial and venous catheter limbs are clamped. Carefully remove Fresenius HemaClip device from the bloodline and then from catheter limb and discard. Disconnect the arterial bloodline from the catheter limb. Using a sterile alcohol pad, scrub the sides and end of the hub ....allow to dry ...attach a prefilled sale syringe to the catheter limb ...repeat steps for the venous end of the catheter limb. “ The Facility’s Policy Post Treatment Fistula Needle Removal, Reference Number 47619, reviewed June 23, 2025 at 3:10 PM states in part, “ the person removing needles will perform hand hygiene and don clean gloves. “ The Facility’s Policy Hand Hygiene, Reference Number 47664 reviewed June 23, 2025 at 3:20 PM reads in part, “ Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water after contact with inanimate objects near the patient. “ Observation tour of self-care/self-dialysis treatment area, conducted June 24, 2025 starting at approximately 9:15 AM revealed: OBS #1, 06/24/2025, 9:25 AM: MR#16, PCT (patient care technician) #4, in preparation for discontinuation of dialysis from an arterio-venous (AV) fistula performed hand hygiene, donned gloves, touched the hemodialysis (HD) machine to silence the alarm, lowered the footrest, disconnected blood lines, touched the HD machine again, placed gauze over the access sites and removed the needles without changing gloves after touching inanimate objects prior to disconnecting the blood lines and removing the needles. OBS#2, 06/24/2025, 9:37 AM: MR#17, PCT#4, in preparation for discontinuation of dialysis from a central venous catheter (CVC) performed hand hygiene, donned gloves, touched the HD machine, then proceeded to disconnect the blood lines from the CVC without changing gloves after touching an inanimate object prior to disconnecting the blood lines. OBS#3, 06/24/2025, 10:10 AM: MR#18, PCT#4 in preparation for discontinuation of dialysis from an arterio-venous (AV) fistula performed hand hygiene, donned gloves, lowered the footrest, touched the hemodialysis (HD) machine and disconnected the blood lines without changing gloves after touching inanimate objects prior to disconnecting the blood lines and removing the needles. An interview conducted with the facility administrator and clinical manager on June 27, 2025 starting at 3:15 PM confirmed the above findings.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 45377 Based on a review of the Fresenius Kidney Care (FKC) Log Readings Reports for Total Chlorine (TCL) and an interview with the facility administrator, the facility failed to assure that total chlorine checks were conducted at a minimum of every (4) hours during the months of April, May and June, 2025. Findings include: The Facility’s Policy Carbon Filtration Monitoring for Incenter Central Water Systems, Reference Number 46310, reviewed on June 24, 2025 at 3:45 PM reads in part, “Total Chlorine test will be performed prior to initial treatment and every four hours.” A review of the FKC Log Readings Report for TCL for April 1 through April 30, 2025 and May 1 through May 31, 2025 was conducted on June 24, 2025 at approximately 3:00 PM. The FKC Log Readings Report for TCL for June 1 through June 26 was conducted on June 27, 2025 at approximately 10:30 AM. The following information found that the readings did not occur every 4 hours on nine (9) occasions from April 1 to June 26, 2025: 04/07/2025: Test conducted 6:55 AM and 11:33 AM, 38 minutes late. 04/11/2025: Test conducted 4:35 AM and 8:38 AM, 3 minutes late. 04/30/2025: Test conducted 4:15 AM and 8:29 AM, 14 minutes late. 05/01/2025: Test conducted 2:40 PM and 6:45 PM, 5 minutes late. 05/09/2025: Test conducted 2:48 PM and 6:50 PM, 2 minutes late. 05/19/2025: Test conducted 2:00 PM and 6:28 PM, 28 minutes late. 05/28/2025: Test conducted 1:58 PM and 6:00 PM, 2 minutes late. 06/18/2025: Test conducted 4:25 AM and 8:40 AM, 15 minutes late. 06/18/2025: Test conducted 12:10 PM and 4;15 PM, 5 minutes late. A review of 05/29/2025 QAPI minutes conducted on June 26, 2025 at 11:00 AM found discussion related to an action plan for TCL checks. An interview conducted with the administrator and clinical manager on June 27, 2025 starting at 3:15 PM confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 45377 Based on review of facility policy, medical records (MR), and an interview with the facility administrator, the facility failed to ensure that blood flow rates (BFR) and/or the dialysate flow rates (DFR) were administered per physician orders, and/or failed to follow its policy for monitoring vital signs and machine safety checks. Seven (7) of fifteen (15) records reviewed did not meet the requirement: MR#1, MR#3, MR#4, MR#5, MR#6, MR#7, and MR#8. Findings include: Facility Policy Patient Assessment and Monitoring, Reference Number 45284, reviewed on June 25, 2025 at approximately 9:30 AM reads in part, “If the PCT (patient care technician)/LPN (licensed practical nurse) note any changes or abnormal findings in the patient’s condition...the registered nurse (RN) must assess the patient.” “Pre-Treatment: Record blood pressure. Verify: systolic blood pressure greater than 180mm/Hg and/or diastolic blood pressures greater than 100mm/Hg; Systolic blood pressures less than or equal to 100mmHg. During nursing rounds, the RN will review the data collected (from pre treatment) and assess the patient as needed. Document findings and interventions in the medical record. Contact the physician as needed for additional orders based on assessment findings and clinical judgment.” “During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes; Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes; Report to nurse: Systolic blood pressure greater than 180mm/Hg or less than 100mm/Hg or Diastolic blood pressure greater than 100mm/Hg. Recheck blood pressure after a drop that requires interventions such as administering normal saline.” “Machine Parameters and Extracorporeal Circuit: Check machine setting and measurements: 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.... Document any findings and interventions in the medical record.” “Post Treatment: Ensure vital signs and overall condition are stable for discharge. Document findings in the patient’s record.” Facility Policy Physician Order Documentation, Reference Number 46933 reviewed on June 25, 2025 at approximately 9:40 AM states in part, “It is the nurses’ responsibility to ensure that all treatment a patient received require an electronic order signed by the physician, nurse practitioner, or physician assistant. Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures, and other treatments, based on physician orders.” Facility Policy Medication Preparation and Administration, Reference Number 47488 reviewed on June 25, 2025 at 10:00 AM reads in part, “...Document reason for PRN (as needed) drug administration and effectiveness of medication post administration in the patient’s medical record. The licensed nurse should evaluate patient response when administered a PRN medication.” A review of medical records (MR) was conducted on June 24, 2025 starting at 2:00 PM and continued at various times on June 25, June 26, and June 27, 2025. The admission date (AD) is indicated below. MR#1 AD 03/15/2023 contained orders for a blood flow rate (BFR) 400mL/min and a dialysis flow rate (DFR) 800mL/min. The following findings were present on the HD treatment record: 06/11/2025: HD treatment was initiated at 12:15 PM. Blood pressure (BP) was noted to be 95/49. There was no documentation indicating that the RN was made aware of a systolic blood pressure (SBP) below 100mm/Hg at the start of treatment. BFR was decreased to 300 from 1:44 PM to 3:03 PM, then increased to 350 from 3:03 PM to the end of treatment at 4:32 PM. There was no documentation of the reason for the change in BFR. MR#3 AD 02/04/2024 contained orders for a BFR 475mL/min and DFR 800 mL/min. 06/11/2025: HD treatment was initiated at 6:15 AM. DFR was decreased to 360 at 9:30 AM then 320 at 10:00 AM, then increased to 800 at 10:43 PM at which time treatment was discontinued. 06/16/2025: HD treatment was initiated at 6:18 AM. BFR was decreased to 450 was 9:38 AM to the end of treatment at 10:29 AM. 06/18/2025: HD treatment was initiated at 6:10 AM. DFR was decreased to 660 at 9:30 AM, then increased to 800 at 10:06 AM. 06/23/2025: HD treatment was initiated at 6:25 AM. BFR was 450 from 7:01 AM until the end of treatment at 10:39 AM. DFR ran at 700 from 8:10 AM to the end of treatment at 10:38 AM. There was no documentation as to the reasons for the altered BFR and/or DFR during the above treatments. MR#4 AD 08/30/2024 contained orders for a BFR 450mL/min and Dialysis Auto Flow Rate of 1.5 (675) rounded to 700. 06/18/2025: HD treatment was initiated at 6:03 PM. The DFR ran at 800 mL/min throughout the entire treatment. 06/20/2025: A pre-dialysis BP was obtained at 6:02 AM. HD treatment was initiated at 6:09 AM. The next set of vital signs was not obtained until 7:07 AM, approximately 1 hour later. BFR ran at 425 from 7:36 AM to the end of treatment at 9:31 AM. 06/23/2025: HD treatment was initiated at 6:16 AM. Documentation of SBP at 6:35 AM was 93/50 and at 7:01, SBP was 93/48. There was no documentation of notification to the nurse by the PCT. At 7:08, nurse intervention was recorded. There was no documentation as to the reasons for the altered BFR and/or DFR during the above treatments. MR#5 AD 12/29/2019 contained orders for a BFR 400 mL/min and a Dialysis Auto Flow Rate of 1.5 (600). 06/11/2025: HD treatment was initiated at 10:25 AM. BFR was decreased to 350 at 12:32 PM and remained at that rate until the end of treatment at 1:31 PM. At 12:04 PM and 12:32 PM, BP was recorded as 96/59 and 88/56. There was no documentation that the nurse was notified of the low blood pressures. 06/13/2025: Pre treatment weight was recorded at 48.9 kg. Post treatment weight was recorded at 66.5 (weight change of 17.60 kg). There was no recognition or documentation concerning the significant discrepancy in pre versus post weight. 06/16/2025: HD treatment was initiated at 10:29 AM. BFR was decreased to 350 at 11:00 AM until discontinuation of treatment at 1:33 PM. 06/20/2025: HD treatment was initiated at 10:30 AM. BFR was decreased to 300 at 12:52 PM until discontinuation of treatment at 1:34 PM. BP at 11:33 PM was 163/102, 12:00 PM 189/106, 12:52 PM 162/102, 1:07 PM 180/121, 1:34 PM 177/102, 1:35 PM 177/102. There was no documentation or notification to the nurse regarding the elevated blood pressures. The post nursing assessment at 3:46 noted “no unusual findings.” The patient was discharged from the facility around or shortly after 1:35 PM with a BP of 189/110 without any intervention or notations. BFR was decreased to 300 mL/min at 1:52 PM until discontinuation of treatment at 1:34 PM. There was no documentation as to the reason for the altered BFR. MR#6 AD 03/13/2025 contained orders for a BFR 400 mL/min and a DFR 800 mL/min 06/14/2025: HD treatment was initiated at 6:15 AM. BFR ran at 450 mL/min from 7:16 AM to 10:40 AM. 06/17/2025: HD treatment was initiated at 6:08 AM. Vital signs and machine parameters were obtained at 6:30 AM, and then not again until 8:05 AM (95 minutes later). There was no post treatment nursing assessment. 06/21/2025: There was no post HD treatment nursing evaluation. There was no documentation as to the reason for the altered BFR. MR#7 AD 05/09/2025 contained orders for a BFR 350 mL/min and a Dialysis Auto Flow Rate 1.5 (adjusted to 600). 06/18/2025: HD treatment initiated at 7:12 AM. BP 127/111 at 8:34 AM and rechecked at 9:02 AM 151/95. BP 187/97 at 10:30 AM, BP 189/100 at 11:02 AM and 189/104 at 11:10 AM. Post dialysis BP 191/120 at time of discharge at or shortly after 11:16 AM. There was no documentation that the nurse was notified of the elevated blood pressure during or after treatment and prior to discharge. The post HD treatment nursing evaluation noted “no unusual findings.” 06/20/2025: HD treatment was initiated at 7:12 AM. BFR and DFR was increased to 400/800 at 9:30 AM and decreased to prescribed levels at 10:32 AM. There was no documentation as to the reason for the altered BFR/DFR. MR#8 AD 05/13/2025 contained orders for a BFR 400 mL/min and DFR 600 mL/Min. 06/14/2025: HD treatment was initiated at 5:40 AM. At 6:10 AM, BP 175/101, 7:30 AM 168/102, 7:35 AM 177/103, 8:07 AM 173/100, 9:53 AM 169/106. Discharged with BP 169/106. There was no documentation that the nurse was notified of the elevated diastolic blood pressures during or after treatment and prior to discharge. The post HD treatment nursing evaluation noted “no unusual findings.” 06/19/2025: HD treatment was initiated at 5:45 AM. At 5:5 AM, BP 184/108, 6:03 AM 173/112, 6:03 AM (repeat) 213/118, 6:47 AM 187/111. Patient received Clonidine 0.1 mg by mouth. 7:07 AM 190/114, 7:07 (repeat) 187/124, 7:36 184/113, 8:08 169/114, 8:32 183/111, 8:43 164/101 (noted by RN), 9:00 AM 148/87. 9:43 AM 139/83. A repeat BP was not checked for 44 minutes after receiving a reading of 213/118. An interview conducted with the administrator and clinical manager on June 27, 2025 starting at 3:15 PM confirmed the above findings.”

“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: 45377 Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the medical director did not ensure that the facility followed its policy and the CDC guidelines to ensure that employees are free from tuberculosis for nine (9) of nine (9) PF’s reviewed: PF#1, PF#2, PF#3, PF#5, PF#6, PF#7, PF#8, PF#9, and PF#10. Findings include: The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCW’s should receive TB screening annually. HCW’s with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf). *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). The Facility’s Policy Employee Tuberculosis Testing, reviewed on June 27, 2025 at 1:30 PM states in part, “TB testing using the two-step tuberculin skin test (TST) method is required upon hire.” A review of the personnel form, on June 26, 2025 at 2:30 PM, provided to and completed by the facility at the start of survey contained data which indicated that TB testing was not completed upon hire. A review of electronic PF’s was conducted with the clinical manager on June 27, 2025 starting at 11:00 AM. The date of hire (DOH) is indicated below: PF#1 DOH 10/14/2024 did not contain evidence that the individual was screened upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. PF#2 DOH 04/21/2024 contained a date of 03/12/2025 on the personnel form that was completed by the facility, indicating that TB testing had been completed. A review of the electronic PF found that a TB risk assessment was completed on 03/12/2025, but there was no evidence provided of completion of a TST or a single blood assay in the electronic PF or via any other documents. PF#3 DOH 07/22/2024 contained a date of 06/25/2025 on the personnel form that was completed by the facility indicating that TB testing had been completed. Discussion with the clinical manager found that TB testing for the individual was initiated on 06/25/2025, eleven (11) months after the DOH. There was no evidence of TB testing present in the electronic PF or via any other documents. PF#5 DOH 04/11/2024 did not contain evidence that the individual was screened upon hire using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. PF#6 DOH 04/02/2025 did not contain evidence that the individual was screened upon hire using a two-step tuberculin skin test (TST) or a single blood assay to test for infection with tuberculosis. Discussion with the clinical manager found that TB testing for the individual was being initiated on 06/27/2025, approximately three (3) months after the DOH. There was no evidence of TB testing present in the electronic PF or via any other documents. PF#7 DOH 05/27/2025 contained a date of 06/25/2025 on the personnel form that was completed by the facility, indicating that TB testing had been completed. Discussion with the clinical manager found that TB testing for the individual was initiated on 06/25/2025, eleven (11) months after the DOH. There was no evidence of TB testing present in the electronic PF or via any other documents.. PF#8 DOH 10/14/2024 contained a date of 03/28/2025 on the personnel form that was completed by the facility, indicating that TB testing had been completed. A review of the electronic PF found that a TB risk assessment was completed on 03/28/2025, but there was no evidence provided of completion of a TST or a single blood assay in the electronic PF or via any other documents. PF#9 DOH 01/13/2025 contained a date of 06/25/2025 on the personnel form that was completed by the facility indicating that TB testing had been completed. Discussion with the clinical manager found that TB testing for the individual was initiated on 06/25/2025, five (5) months after the DOH. There was no evidence of TB testing present in the electronic PF or via any other documents. PF#10 DOH 05/27/2025 contained a date of 06/25/2025 on the personnel form that was completed by the facility indicating that TB testing had been completed. Discussion with the clinical manager found that TB testing for the individual was initiated on 06/25/2025, one (1) month after the DOH. There was no evidence of TB testing present in the electronic PF or via any other documents. An interview conducted with the administrator and clinical manager on June 27, 2025 starting at 3:15 PM confirmed the above findings.”

“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: 45377 Based on a review of hemodialysis (HD) treatment records, patient and staff schedules, Kronos (timekeeping) reports), grievance log, and interviews with the clinical manager (CM) and facility administrator (FA), the facility failed to ensure that an adequate number of qualified personnel were present at the start of the shift to meet scheduling needs. Findings include: A review of HD treatment records, patient and staff schedules, and a Kronos report (from 5/5/2025 to 06/23/2025) took place from June 23, 2025 to June 27, 2025 on site at various times, and off site on July 3 and July 8, 2025 at various times. The admission date is indicated below. MR#3 Admission Date (AD): 02/04/2023. The HD treatment prescription contained an order for HD treatment length to be 4 hours (h) and 15 minutes (m). The scheduled time for the HD treatment was 6:10 AM to 10:25 AM. A review of HD treatment records, patient and staff schedules, and a Kronos report found the following: Wed May 7: PCT2, assigned to Pod 1, arrived at 4:24 AM (9m late). HD Treatment Initiated (HDTI) by patient care technician (PCT)12 at 6:20 AM (10m late). HD Treatment End (HDTE) 10:46 AM. HD Treatment Time (HDTT): 4h26m. A review of Kronos Clock In Time Report (CITR) for 05/07/2025 found that of the 7 Clock In Time (CIT) recorded, 2 of 7 employees clocked in late by 9m and 26m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon May 12: PCT15, assigned to Pod 1, arrived at 4:05 AM (10m early). HDTI by PCT16 at 6:38 AM (28m late). HDTE 11:02 AM. HDTT: 4h24m. A review of Kronos CITR for 5/12/2025 found that of the 7 CIT recorded, 3 of 6 employees clocked in late by 3m, 13m, and 16m. One clocking did not have the correct schedule start time and was therefore excluded from analysis. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Wed May 14: PCT17, assigned to Pod 1, arrived at 4:37 AM (7m late). HDTI by PCT13 at 6:23 AM (13 m late). HDTE10:32 AM. HDTT: 4h,9m. A review of Kronos CITR for 5/14/2025 found that of the 8 CIT recorded, 4 of 8 employees clocked in late by 1m, 6m, 7m, and 9m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri May 16: PCT15, assigned to Pod 1, arrived at 4:32 AM (17m late). HDTI by PCT18 at 6:15 AM (5 m late). HDTE 10:35 AM. HDTT 4h,20m. A review of Kronos CITR for 5/16/2025 found that of the 7 CIT recorded, 2 of 7 employees clocked in late by 8m and 17m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon May 19: PCT15, assigned to Pod 1, arrived at 5:16 AM (61 m late). HDTI by PCT13 at 6:15 AM (5m late). HDTE10:32 AM. HDTT: 4h,17m. A review of Kronos CITR for 5/19/2025 found that of the 7 CIT recorded, 3 of 7 employees clocked in late by 4m, 15m, and 61m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Wed May 21: PCT 2 was assigned to Pod 1. There was no clock in time on the Kronos report for PCT2. HDTI by PCT 16 at 6:31 AM (11 m late). HDTE 10:32 AM. HDTT: 4h,2m. A review of Kronos CITR for 5/21/2025 found that of the 7 CIT recorded, 4 of 7 clocked in late by 1m, 2m, 5m, and 13m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri May 23: PCT 14, assigned to Pod 1, arrived at 4:22 AM, 7m late. HDTI by PCT13 at 6:18 AM (8 min late). HDTE 10:33 AM. HDTT 4h15m. A review of Kronos CITR for 5/23/2025 found that of the 8 CIT recorded, 6 of 8 employees clocked in late by 5m, 7m, 7m, 9m, 11m, and 144m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Wed May 28: PCT14, assigned to Pod 1, arrived at 4:30 AM (15m late). HDTI by PCT2 at 6:15 AM (5m late). HDTE 10:25 AM. HDTT 4h10m. A review of Kronos CITR for 5/28/2025 found that of the 9 CIT recorded, 5 of 9 employees clocked in late by 4m, 11m, 12m, 15m, and 25m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri May 30: PCT12, assigned to Pod 1, arrived at 4:29 AM (14m late). HDTI by PCT13 at 6:16 AM (6m late). HDTE 10:28 AM. HDTT 4h12m. A review of Kronos CITR for 5/30/2025 found that of the 8 CIT recorded, 5 of 8 employees clocked in late by 2m, 4m, 6m, 7m, and 14m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon Jun 2: PCT15 was assigned to Pod 1. There was no clock in time for PCT15 on the Kronos report. HDTI by PCT13 at 6:29 AM (19m late). HDTE 10:23 AM. HDTT 3h54m. The “ treatment status “ noted at the top of the HD treatment record states: “ Completed, Unexpected, Late Arrival with Inability to Extend Treatment. “ Other than this notation, there is no note from the PCT or the RN addressing either the late treatment start time and whether it was facility-related or patient-related, nor the early treatment end time. A review of Kronos CITR for 6/2/2025 found that of the 9 CIT recorded, 4 of 9 employees clocked in late by 1m, 7m, 147m, and 392m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri, Jun 6: PCT2, assigned to Pod 1, arrived at 4:25 AM (10m late). HDTI by PCT2 at 6:20 AM (10m late). HDTE 10:42 AM. HDTT 4h22m. A review of Kronos CITR for 6/6/2025 round that of the 8 CIT recorded, 5 of 8 employees clocked in late by 4m, 6m, 8m, 10m, and 156m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon, Jun 9: PCT2, assigned to Pod 1, arrived at 4:24 AM (9m late). HDTI by PCT19 at 6:38 AM (28m late). HDTE 10:37 AM. HDTT 3h59m. The “ treatment status “ noted at the top of the HD treatment record states: “ Completed, Unexpected, Late Arrival with Inability to Extend Treatment. “ Other than this notation, there is no note from the PCT or the RN addressing either the late treatment start time and whether it was facility-related to patient-related, nor the early treatment end time. A review of Kronos CITR for 6/9/2025 found that of the 9 CIT recorded, 5 of 9 employees clocked in late by 2m, 4m, 9m, 10m, and 14m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Wed, Jun 11: PCT12, assigned to Pod 1, arrived at 4:32 AM (17m late). HDTI by PCT20 at 6:15 AM (5m late). HDTE: 10:41 AM. HDTT 4h26m. A review of Kronos CITR for 6/11/2025 found that of the 7 CIT recorded, 4 of 7 employees clocked in late by 6m, 7m, 17m, and 73m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon, Jun 16: PCT 14, assigned to Pod 1, arrived at 4:24 AM (9m late). HDTI by PCT14 at 6:18 AM (8m late). HDTE: 10:31 AM. HDTT 4h13m. A review of Kronos CITR for 6/16/2025 found that of the 10 CIT recorded, 3 of 10 employees clocked in late by 2m, 7m, and 9m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon, Jun 23: PCT2, assigned to Pod 1, arrived at 4:37 AM (22m late). HDTI by PCT2 at 6:25 AM. (15m late). HDTE 10:38 AM. HDTT 4h13m. A review of Kronos CITR for 6/23/2025 found that of the 7 CIT recorded, 4 of 6 employees clocked in late by 4m, 5m, 9m, and 23m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. While the schedule, in all of the above instances, appeared to display adequate staffing, the tardiness of employees each day led to delays in treatment start times and in some cases, shortened or prolonged treatment duration. MR#5 Admission Date (AD): 08/30/2024. The HD treatment prescription contained an order for HD treatment length to be 4 hours (h) and 0minutes (m). The scheduled time for the HD treatment was 6:00 AM to 10:00 AM. A review of HD treatment records, patient and staff schedules, and a Kronos report found the following: Mon May 5: PCT13, assigned to Pod 5, arrived 5:05 AM (25m early). HDTI by PCT13 at 6:13 AM (13m late). HDTE: 10:26 AM. HDTT 4h13m. A review of Kronos CITR for 05/05/2025 found that of the eight (8) CIT recorded, 4 of 8 employees clocked in late by 2 m, 5m, 7m, and 33m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri May 9: PCT 13, assigned to Pod 5, arrived at 5:23 AM (7m early). HDTI by PCT 13 at 6:13 AM (13m late). HDTE 9:59 AM. HDTT 3h46m. A review of Kronos CITR for 05/09/2025 found that of the 8 CIT recorded, 5 of 8 employees clocked in late by 2m, 3m, 6m, 12m, and 16m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon May 12: PCT16, assigned to Pod 5, arrived at 5:33 AM (3m late). HDTI by PCT16 at 6:23 AM (23m late). HDTE 10:26 AM. HDTT 4h,3m. A review of Kronos CITR for 5/12/2025 found that of the 7 CIT recorded, 3 of 6 employees clocked in late by 3m, 13m, and 16m. One clocking did not have the correct schedule start time and was therefore excluded. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Wed May 21: PCT 16, assigned to Pod 5, arrived at 5:31 AM (1m late). HDTI by PCT16 at 6:15 AM (15m late). HDTE 10:01 AM. HDTT 3h46m. A review of Kronos CITR for 5/21/2025 found that of the 7 CIT recorded, 4 of 7 clocked in late by 1m, 2m, 5m, and 13m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri May 23: PCT13, assigned to Pod 5, arrived at 5:28 AM (2m early). HDTI by PCT13 at 6:08 AM (8m late). HDTE 9:57 AM. HDTT 3h49m. A review of Kronos CITR for 5/23/2025 found that of the 8 CIT recorded, 6 of 8 employees clocked in late by 5m, 7m, 7m, 9m, 11m, and 144m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon Jun 2: PCT13, assigned to Pod 5, arrived at 5:27 AM (3m early). HDTI by PCT13 at 6:14 AM (14m late). HDTE 10:06 AM. HDTT 3h52m. A review of Kronos CITR for 6/2/2025 found that of the 9 CIT recorded, 4 of 9 employees clocked in late by 1m, 7m, 147m, and 392m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri Jun 6: PCT13, assigned to Pod 5, arrived at 5:34 AM (4m late). HDTI by PCT13 at 6:11 AM (11m late). HDTE 9:45 AM. HDTT 3h34m. Approximately 9:44 AM, noted to have bleeding around arterial needle. MR4 did not want decannulation and recannulation, so treatment discontinued early. A review of Kronos CITR for 6/6/2025 round that of the 8 CIT recorded, 5 of 8 employees clocked in late by 4m, 6m, 8m, 10m, and 156m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon Jun 9: PCT5, assigned to Pod 5, arrived at 5:24 AM (6m early). HDTI by PCT5 at 6:15 AM (15m late). HDTE 10:19 AM. HDTT 4h4m. A review of Kronos CITR for 6/9/2025 found that of the 9 CIT recorded, 5 of 9 employees clocked in late by 2m, 4m, 9m, 10m, and 14m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Wed Jun 11: PCT18, assigned to Pod 5, arrived at 5:37 AM (7m late). HDTI by PCT18 at 6:10 AM (10m late). HDTE 10:15 AM. HDTT 4h5m. A review of Kronos CITR for 6/11/2025 found that of the 7 CIT recorded, 4 of 7 employees clocked in late by 6m, 7m, 17m, and 73m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon Jun 16: PCT5, assigned to Pod 5, arrived at 5:12 AM (18 min early). HDTI by PCT5 at 6:10 AM (10m late). HDTE 10:11 AM. HDTT 4h1m. A review of Kronos CITR for 6/16/2025 found that of the 10 CIT recorded, 3 of 10 employees clocked in late by 2m, 7m, and 9m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Fri Jun 20: PCT13 assigned to Pod 5, arrived at 5:18 AM (12m early). HDTI by PCT13 at 6:09 AM (9m late). HDTE 9:56 AM. HDTT 3h47m. A review of Kronos CITR for 6/20/2025 found that of the 8 CIT recorded, 6 of 8 employees clocked in late by 2m, 6m, 12m, 12m, 13m, and 19m The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. Mon Jun 23: PCT 13, assigned to Pod 5, arrived at 5:27 AM (3m early). HDTI by PCT13 at 6:16 AM (16m late). HDTE 10:03 AM. HDTT 3h47m. A review of Kronos CITR for 6/23/2025 found that of the 7 CIT recorded, 4 of 6 employees clocked in late by 4m, 5m, 9m, and 23m. The schedule provided by the facility found that: 6 PCT and 2 RN were to provide care for 26 patients on the schedule. 1 PCT had a 1:3 ratio, 5 PCT had a 1:4 ratio, and a 2 RN provided care for 3 patients. While the schedule, in all of the above instances, appeared to display adequate staffing, the tardiness of employees each day led to delays in treatment start times and in some cases, shortened or prolonged treatment duration. MR#15 AD: 08/19/2010. The HD treatment prescription contained an order for HD treatment length to be 3 hours (h) and 0 minutes (m). The scheduled time for the HD treatment was 5:15 AM to 8:1 AM. A review of HD treatment records, and patient and staff schedules found the following start of treatment times and treatment duration: 5/27: 5:57 AM (42m late). Treatment time (HDTT); 2h, 39m. The “treatment status” noted at the top of the HD treatment record noted: Completed, Unexpected, Facility Issue.” 5/29: 5:21 AM (6m late). HDTT 3h,2m. 5/31: 5:31 AM (16m late), HDTT 3h,2m. 6/3: 5:36 AM (21m late). HDTT 2h, 44m. “Treatment status” stated: Completed, Unexpected, Facility Issue.” 6/5: 5:30 AM (15m late). HDTT 3h,17m. 6/7: 5:55 AM (40m late). HDTT 3h, 5m. 6/10: 5:21 AM (6m late). HDTT 3h, 9m. 6/12: 5:26 AM (11m late). HDTT 2h, 50m. 6/14: 5:30 AM 15m late). HDTT 3h, 3m. 6/17: 5:22 AM (7m late). HDTT 3h, 35m. 6/19: 5:42 AM (27m late). HDTT 2h, 59m. 6/21: 5:56 AM (41m late). HDTT 3h, 4m. 6/24: 5:26 AM (11m late). HDTT 3h, 4m. While the schedule, in all of the above instances, appeared to display adequate staffing, the tardiness of employees each day led to delays in treatment start times and in some cases, shortened or prolonged treatment duration. A review of Kronos reports took place on June 26, 2025 starting at approximately 3:00 PM on site and off site starting at approximately 9:00 PM, and again on July 3 and July 8 off site at various times off site. The reports found that anywhere from two (2) to seven (7) employees, on any given day, are late for their scheduled shift start times leading to delays in treatment start times and/or shortened or prolonged treatment duration times. Kronos reports from May 1, 2025 to June 25, 2025 found the following: May 01: 2 out of 5 (2/5) employees (EE) late (compared to the scheduled start time) with a lateness range (LR) of 2 to 16m. May 02: 6/7 EE late with a LR 5 to 11m. May 03: 5/7 EE late with a LR 6 to 180 min. May 05: 4/8 EE late with a LR 2 to 33m. May 06: 4/7 EE late with a LR 3 to 12m. May 07: 2/7 EE late with a LR 9 to 26m. May 08: 4/8 EE late with a LR 5 to 20 m. May 09: 5/8 EE late with a LR 2 to 16 m. May 10: 6/7 EE late with a LR 2 to 15m. May 12: 3/7 EE late with a LR 3 to 16m. May 13: 3/7 EE late with a LR 6 to 27m. May 14: 4/8 EE late with a LR 1 to 9m. May 15: 6/8 EE late with a LR 1 to 75m. May 16: 2/7 EE late with a LR 8 to 17m. May 17: 3/5 EE late with a LR 5 to 9m and 1 unknown scheduled starttime. May 19: 3/7 EE late with a LR 4 to 61m. May 20: 2/6 EE late with a LR 2m. May 21: 4/7 EE late with a LR 2 to 13m. May 22: 3/7 EE late with a LR 1 to 16m. May 23: 6/8 EE late with a LR 5 to 144m. May 24: 7/8 EE late with a LR 14 to 97m. May 26: 5/7 EE late with a LR 4 to 15m and 1 unknown scheduled start time. May 27: 7/7 EE late with a LR 1 to 81m. May 28: 5/9 EE late with a LR 4 to 25m. May 29: 4/8 EE late with a LR 56 to 258m. May 30: 5/8 EE late with a LR 2 to 14m. May 31: 3/6 EE late with a LR 12 to 112m. Jun 02: 4/9 EE late with LR 1 to 392m. Jun 03: 6/9 EE late with LR 1 to 250m. Jun 04: 4/7 EE late with LR 1 to 8m. Jun 05: 2/6 EE late with LR 1 to 24m. Jun 06: 5/8 EE late with LR 4 to 156m. Jun 07: 6/6 EE late with LR 2 to 62m. Jun 09: 5/9 EE late with LR 4 to 14m. Jun 10: 5/8 EE late with LR 1 to 271m. Jun 11: 4/7 EE late with LR 6 to 73m. Jun 12: 4/8 EE late with LR 4 to 259m. Jun 13: 5/9 EE late with LR 1 to 12m. Jun 14: 4/6 EE late with LR 8 to 31m. Jun 16: 3/10 EE late with LR 2 to 9m. Jun 17: 5/8 EE late with LR 5 to 137m. Jun 18: 3/7 EE late with LR 8 to 396m. Jun 19: 5/8 EE late with LR 3 to 22m. Jun 20: 6/8 EE late with LR 2 to 19m. Jun 21: 6/8 EE late with LR 6 to 19m. Jun 23: 4/7 EE late with LR 9 to 22m. Jun 24: 4/5 EE late with LR 3 to 6m. Jun 25: 3/5 EE late with LR 3 to 10m and 1 unknown scheduled start time. A brief interview was held with the FA on June 27, 2025 at approximately 9:30 AM to review the Kronos reports/tardiness incidents. The FA stated that both s/he and the CM are aware of the lateness issues and are developing an action plan to address the tardiness. An interview was held with the CM on June 27, 2025 at approximately 10:00 AM to review the Kronos reports/tardiness events. The CM stated that both s/he and the FA are aware of the tardiness by employees and are working on holding employees accountable to scheduled start times through disciplinary reviews. The surveyor asked for a copy of any disciplinary reviews that had been conducted but none were provided. An interview conducted with the facility administrator and clinical manager on June 27 2025 at approximately 3:45 PM confirmed that staff tardiness is evident and widespread.”