Davita St Luke’s Allentown Dialysis

“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: 36372 Based on review of facility policy/procedures, observations, and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, performing hand hygiene/donning clean gloves, for one (1) of two (2) ‘Access of AV Fistula or Graft for Initiation of Dialysis’ observations (Observation #2); one (1) of three (3) ‘Cleaning and Disinfection of the Dialysis Station’ observations (Observation #1); and two (2) of two (2) ‘Treatment Area’ observations (Observation #1, Observation #2). Findings include: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Procedure #1-04-01E ‘AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose’ ‘Procedure’ (1) states “Have patient wash access site with appropriate antibacterial soap, if able. If patient is unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent.” (2) Perform hand hygiene. Put on PPE.” ...... (11) “While maintaining aseptic technique, cleanse the site by applying skin antiseptic ....” Observations conducted in patient treatment area on August 7, 2025 and August 8, 2025 between approximately 8:35 a.m. - 12:30 p.m. revealed the following: Observation #2: During observation #2 of 2 ‘Access of AV Fistula or Graft for Initiation of Dialysis’ on 08/07/25 at approximately 11:05 a.m., of patient #9 at station #3; Employee #8 washed skin over access site and did not remove gloves/perform hand hygiene before applying antiseptic over cannulation site. Employee #8 applied antiseptic over cannulation site and then utilized a stethoscope to auscultate the cannulation site. Employee #8 did not repeat antiseptic to the site prior to inserting needles. Policy: 1-05-01 ‘Infection Control for Dialysis Facilities’ ‘Purpose’ “To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment.” ‘Disinfection’ (a)(ii) “Priming Containers are to be emptied prior to disinfection.” Observation #1: During observation #1 of 3 ’’Cleaning and Disinfection of the Dialysis Station’ on 08/07/25 at approximately 9:10 a.m., of patient #10 at station #11; Employee #5 emptied the prime waste receptacle and did not remove gloves/perform hand hygiene prior to disinfecting the machine. Policy: 1-05-01 ‘Infection Control for Dialysis Facilities’ ‘Purpose’ “To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment.” ‘Hand Hygiene’ (1) “All teammates, physicians, and non-physicians (NPP) will perform hand hygiene (a) Upon entering and exiting the patient treatment area.” Observation #1: During treatment area observations on 08/07/25 at approximately 11:00 a.m., employee #3 did not perform hand hygiene after taking off gown and face shield and exiting the treatment area to the staff hallway area. Observation #2: During treatment area observations on 08/07/25 at approximately 12:10 p.m., employee #3 did not perform hand hygiene after taking off gown and face shield to exit the treatment area to the patient waiting area to bring a patient (MR#7, in wheelchair) into the treatment area. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. confirmed the above findings.”

“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: 36372 Based on a review of facility policy/procedure, observations, patient medical record review, and an interview with the facility Administrator, it was determined the facility failed to ensure infection control measures were followed in non-treatment areas for three (3) of three (3) facility observations (Observation #1 - Observation #3). Findings include: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Policy:1-05-01 ‘Infection Control for Dialysis Facilities’ ‘PPE’ (i.e., gown, gloves, eye protection, face shield) section (5) (a) “Removed prior to leaving the treatment area. ...... (c) “PPE is not to be worn in non-treatment areas, .......” Observations conducted in patient treatment area on August 7, 2025 and August 8, 2025 between approximately 8:35 a.m. - 12:30 p.m. revealed the following: Observation #1: On 08/07/25 at approximately 9:30 a.m., employee #5 was observed exiting the patient treatment area into the staff hallway area. Employee #5 did not remove face shield. The face shield was slid back on top of employee #5’s head. Observation #2: On 08/07/25 at approximately 9:40 a.m., employee #8 was observed exiting the patient treatment area into the water treatment area. Employee #8 did not remove gown and face shield. Observation #3: On 08/07/25 at approximately 11:15 a.m., employee #3 was observed exiting the patient treatment area into the patient waiting room area to assist patient #8 (patient utilizing a wheelchair) into the treatment area. Employee #3 did not remove gown and face shield. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. confirmed the above findings.”

“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: 36372 Based on review of facility policy/procedures, observations, and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, ensuring the dialysis station was disinfected before supplies were taken to the station to be used on another patient, for one (1) of three (3) ‘Cleaning and Disinfection of the Dialysis Station’ observations (Observation #3); Findings include: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Policy: 1-05-01 ‘Infection Control for Dialysis Facilities’ ‘Purpose’ “To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment.” ‘Disinfection’ (13) “At the end of each treatment, the dialysis station will be cleaned and disinfected. (a) Surfaces to disinfect include but not necessarily limited to: all surfaces in contact with the patient or their belongings .....” Observations conducted in patient treatment area on August 7, 2025 and August 8, 2025 between approximately 8:35 a.m. - 12:30 p.m. revealed the following: Observation #3: During observation #3 of 3 ’’Cleaning and Disinfection of the Dialysis Station’ on 08/07/25 at approximately 11:30 a.m. at station #11; Employee #8 set up the dialysis machine with the next patients supplies before the patient treatment chair, utilized by the prior patient, was disinfected. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. confirmed the above findings.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 36372 Based on review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters for one (1) of two (2) ‘Central Venous Catheter Exit Site Care’ and ‘Initiation of Dialysis with Central Venous Catheter’ observations (Observation #1). Findings: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Procedure: 1-04-02B’ ‘Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure’ (4) states “Remove old dressing and discard.” .... (5) states “Remove gloves and discard. Perform hand hygiene per procedure and re-glove.” ....(12) states “Place sterile 2x2 gauze over the catheter site ....” (14) states “Remove gloves and discard, perform hand hygiene per procedure and re-glove.” (15) states “Holding catheter with non-dominant hand, use other hand to place sterile 4x4 dressing under catheter limbs ...” (16) states “Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. .....” (17) “Attach sterile 10 ml syringes to the arterial and venous limbs.” Observations conducted in patient treatment area on August 7, 2025 and August 8, 2025 between approximately 8:35 a.m. - 12:30 p.m. revealed the following: Observation #1: During observation #1 of ‘Central Venous Catheter Exit Site Care’ on 08/07/22 at approximately 11:30 a.m. of patient #8, station #10, employee #5 removed the exit site dressing, discarded, and cleansed the site with antiseptic. Employee #5 left the exit site exposed and began the steps for ‘Initiation of Dialysis with Central Venous Catheter’, disinfecting the hubs and attaching sterile syringes. Prior to employee #5 applying the sterile dressing to the site, the patient leaned forward and the patients shirt came into contact with the CVC exit site. Employee #5 requested the patient to sit back and then applied the sterile dressing to the site, without first cleansing the site again with antiseptic. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. confirmed 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: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility acting Administrator, the facility failed to ensure the facility/water treatment area was secured against unauthorized individuals for one (1) of one (1) observations (Observation #1). Findings: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Policy 2-03-01 ‘Water Treatment Systems Minimum Component Requirement’ ‘General’ .....(3) “..... Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system, or for ordering or obtaining supplies.” Observations conducted in patient treatment area on August 7, 2025 and August 8, 2025 between approximately 8:35 a.m. - 12:30 p.m. revealed the following: Observation #1: On 08/08/25 at approximately 12:00 p.m., the door exiting the treatment area (with direct access to the water treatment area) was not latched completely. The door was closed but could still be pushed open without utilizing the door keypad with a code. Several attempts were made, to no avail, to see if the door would latch completely upon opening and closing. Direct access from unauthorized individuals to this area was possible. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. confirmed the above findings.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, observations, patient medical record review, and an interview with the facility Administrator, it was determined the facility failed to ensure a licensed nurse was made aware of patient tachycardia, during treatment, per policy, for one (1) of seven (7) in-center patient medical records (MR) reviewed (MR#5). Findings include: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Policy: 1-03-08 ‘Pre-Intra0Post Treatment Data Collection, Monitoring, and Nursing Assessment’ ‘Abnormal Findings’ “Unless other abnormal parameters are established by the facility Governing Body ....., the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patients medical record. ....” ‘Heart or Pulse Rate Pre/Intra/Post’ “Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat.” MR#5 Date of admission 07/19/25: Patient treatment flowsheet review was completed on 08/11/25 at approximately 1:00 p.m. revealed the following: 07/28/25: At 7:02 a.m. patient treatment was initiated. At 8:08 a.m. the patients heart rate was 132, at 8:31 a.m. heart rate was 141, at 9:24 a.m. heart rate was 151. No documentation of the licensed nurse being made aware of the abnormal heart rate. 07/30/25: At 6:50 a.m. patient treatment was initiated. At 7:31 a.m. the patients heart rate was 136, at 8:51 a.m. heart rate was 136, at 9:02 a.m. heart rate was 148. At 9:32 a.m. heart rate was 151. No documentation of the licensed nurse being made aware of the abnormal heart rate. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. 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: 36372 Based on a review of facility policy/procedure, review of medical records, and an interview with the facility Administrator; the facility failed to ensure the staff followed facility procedure for early termination of treatment for five (5) out of seven (7) in-center hemodialysis medical records (MR) reviewed (MR#1, MR#2, MR#3, MR#5, MR#6). Findings include: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Policy: 1-01-09 ‘Prescribed Treatment Time Not Met’ ‘Policy’ (A) ‘Completion of the Early Termination of treatment Against Medical Advice Form’ (1) The RN will verify that a patient signs the Early Termination of treatment Against Medical Advice form any time a patient requests to terminate their treatment earlier than the prescribed run time.” (3) The RN will obtain the patients signature on the Early Termination of treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. ...” (4) A RN must countersign all Early Termination of treatment Against Medical Advice forms A witness signature is required only if the patient refuses to sign the form.” (5) If a patient refuses to sign the Early Termination of treatment Against Medical Advice form, the RN will document the patients refusal ....” (B) ‘Prescribed Treatment Time Not Met’ (1) If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patients attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patients specific needs.” A review of patient medical records was completed on August 11, 2025 at approximately 1:00 p.m. MR#1 Date of admission 04/27/20: Physician ‘Active Treatment Orders’ for Hemodialysis included ‘Tx Time’ “210” minutes (total.) Patient treatment flow sheets were reviewed: On 07/23/25 patient treatment flow sheet stated Duration : “189 minutes.” On 07/28/25 patient treatment flow sheet stated Duration : “195 minutes.” No documentation of the early termination form being signed, and/or the physician being notified, and/or documentation by the registered nurse documenting patient refusal to sign. MR#2 Date of admission 10/29/20: Physician ‘Active Treatment Orders’ for Hemodialysis included ‘Tx Time’ “225” minutes (total.) Patient treatment flow sheets were reviewed: On 08/02/25 patient treatment flow sheet stated Duration : “209 minutes.” No documentation of the early termination form being signed, and/or the physician being notified, and/or documentation by the registered nurse documenting patient refusal to sign. MR#3 Date of admission 01/21/22: Physician ‘Active Treatment Orders’ for Hemodialysis included ‘Tx Time’ “240” minutes (total.) Patient treatment flow sheets were reviewed: On 08/04/25 patient treatment flow sheet stated Duration : “228 minutes.” On 08/06/25 patient treatment flow sheet stated Duration : “197 minutes.” No documentation of the early termination form being signed, and/or the physician being notified, and/or documentation by the registered nurse documenting patient refusal to sign. MR#5 Date of admission 07/19/25: Physician ‘Active Treatment Orders’ for Hemodialysis included ‘Tx Time’ “180” minutes (total.) Patient treatment flow sheets were reviewed: On 07/21/25 patient treatment flow sheet stated Duration : “161 minutes.” On 07/25/25 patient treatment flow sheet stated Duration : “135 minutes.” No documentation of the early termination form being signed, and/or the physician being notified, and/or documentation by the registered nurse documenting patient refusal to sign. MR#6 Date of admission 06/09/25: Physician ‘Active Treatment Orders’ for Hemodialysis included ‘Tx Time’ “240” minutes (total.) Patient treatment flow sheets were reviewed: On 07/25/25 patient treatment flow sheet stated Duration : “216 minutes.” No documentation of the early termination form being signed, and/or the physician being notified, and/or documentation by the registered nurse documenting patient refusal to sign. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. 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: 36372 Based on a review of facility policy/procedure, observations, patient medical record review, and an interview with the facility Administrator, it was determined the facility failed to ensure employees adhered to the facility mobile device policy for three (3) of three (3) facility observations (Observation #1); failed to ensure ectoparasitic infestation procedure was followed, per policy, for one (1) of seven (7) in-center patient medical records (MR) reviewed (MR#12); and failed to ensure dialysis machines were disinfected, per policy, for one (1) of one (1) machine disinfection logs reviewed (Log #1). Findings include: A review was conducted of facility policy/procedure on August 11, 2025 at approximately 1:15 p.m. Policy ‘PS-5.16’ Mobile Device Policy’ ‘Policy’ “To ensure that patient care is our primary focus, use of mobile devices is not permitted in the patient care areas. ......” Observation #1: On 08/07/25 at approximately 11:25 a.m., employee #5 was observed working with patients in the patient treatment area. Music was heard playing. Employee #5 was utilizing a personal mobile device to listen to music. The charge nurse (employee #3) was made aware and also heard the use of the personal mobile device being utilized for music listening. Policy:1-05-14 ‘Ectoparasitic Infestations (Fleas, Lice, Common Bed Bugs) Management’ ‘Policy’ (1) “Transmission based Precautions: (a) “Implement and discontinue additional precautions in consultation with physician.” (b) Additional precautions include: ......” MR #12 Date of admission 06/04/24: Documentation provided of the physician being notified on June 6, 2024 of bed bug infestation at patients home. Documentation provided of the facility policy/procedure being followed. An interview was conducted on 08/08/25 at approximately 2:30 p.m. with the facility social worker (employee #11). The social worker stated at the end of April 2025, she spoke with the exterminator company and they informed her treatments were completed at the patients home. She also spoke with the patients (acquaintance) and was informed certain (items) were replaced at the patients home. The social worker stated that there is no documentation to the above nor no documentation of the physician being notified (per policy) that additional precautions for this patient were no longer needed and could be discontinued. Policy: 1-15-01 ‘Fresenius Dialysis Delivery System Cleaning and Disinfection Policy’ ‘Purpose’ “To promote patient safety by cleaning and disinfection of Fresenius dialysis delivery systems.” ‘Examples of Cleaning/Disinfection Procedures and Intervals’ ‘Procedure’ ‘Heat Disinfection’ “Each Treatment Day (unless chemical disinfect day). .... ‘Bleach or Paracetic Acid Disinfection’ “Weekly.” .... (6) Facilities will develop a specific Dialysis Delivery System Cleaning and Disinfection Log .... Cleaning and Disinfection of dialysis delivery systems will be documented on this log. “ (8) “Completed logs will be filed ....” Dialysis Delivery System Cleaning and Disinfection Logs were reviewed on 08/08/25 at approximately 10:00 a.m. (Note: This facility utilizes bleach for machine disinfection on Tuesdays.) Log #1: The week of 11/17/24, no documentation provided of thirteen (13) of fifteen (15) dialysis machines being disinfected with bleach nor heat on Tuesday 11/19/24, nor utilizing bleach any other day that week. The week of 12/01/24, no documentation provided of fifteen (15) of fifteen (15) dialysis machines being disinfected with bleach nor heat on Tuesday 12/03/24, nor utilizing bleach any other day that week. The week of 06/29/25, no documentation provided of fifteen (15) of fifteen (15) dialysis machines being disinfected with bleach on Tuesday 07/01/25, nor utilizing bleach any other day that week. An interview with the facility Administrator on August 11, 2025 at approximately 1:30 p.m. confirmed 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: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility acting Administrator, the facility failed to ensure the facility/water treatment area was secured against unauthorized individuals for one (1) of one (1) observations (Observation #1). Findings: A review was conducted of facility policy on February 25, 2025 at approximately 1:30 p.m. Policy ‘Water Treatment Systems Minimum Component Requirement’ (2-03-01) ‘General’ .....(2) “..... Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system, and supply ordering. ....” Observations conducted in the patient treatment area/facility on February 25, 2025 at approximately 10:00 a.m. revealed the following: Observation #1: On 02/25/25 at approximately 10:15 a.m., the door exiting the treatment area (with direct access to the water treatment area and staff area) was observed to be propped open with a rubber floor door stop. Direct access from unauthorized individuals to these areas was possible. An interview with the facility acting Administrator on February 25, 2025 at approximately 2:00 p.m. 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: 36372 Based on a review of facility policy/procedure, a review of the patient medical record, and an interview with the facility acting Administrator, the facility failed to ensure patient post treatment blood pressure (BP) was obtained, per policy, for one (1) of one (1) medical records (MR) reviewed (MR #1) and failed to ensure the patient grievance procedure was followed, per policy, for one (1) of one (1) complaint/incident logs reviewed (Log#1). Findings: A review was conducted of facility policy on February 25, 2025 at approximately 1:30 p.m. Policy ‘Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment’ (1-03-08) ‘Abnormal Findings’ ‘Blood Pressure Post Treatment’ *”If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg. *Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. *If patient is unable to stand, document reason and sitting BP.” Patient medical record was reviewed on 02/25/25 at approximately 11:30 a.m. Patients date of admit is included below. MR#1, date of admit 10/16/24: Patient treatment flow sheets were reviewed from 02/10/25 - 02/21/25. On 02/10/25, the patients post treatment standing BP was not obtained. No documentation provided as to why the standing BP was not obtained. Policy ‘Patient Grievance’ ‘Internal Grievance Process’ ... (C) “.... If the patients grievance cannot be resolved by the FA, the ROD and Medical Director will be notified and a formal grievance conference will be coordinated. This grievance conference should occur within 10 days of receipt of the grievance.” Complaint/incident log reviewed on February 25, 2025 at approximately 1:00 p.m. Log #1: ‘Date of Complaint’ 1/21/25”. ‘Complaint Made By:’ “(MR#1)”. ‘Subject of Complaint’ “Multiple; BP cuff, chair time HHD”.’Date TM report of Grievance to CN or FA’ “1/21/25:”. ‘Date of discussion with Patient’ “1/21/25”. ‘Date Grievance Meeting Held’ “2/4/25”. ‘Grievance Report Completed’ “2/4/25”. Formal grievance conference was not held within ten (10) days, per facility policy. Conference was held on 2/4/25, fourteen (14) days after date of complaint received. An interview with the facility acting Administrator on February 25, 2025 at approximately 2:00 p.m. confirmed the above findings.”