Fkc Freedom Center of Central Pa

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 32324 Based on reviews of policies/procedures, medical records (MR) and interviews with clinic staff the clinic failed to ensure oversight of patients and evaluation of dialysis prescription for nine (9) of nine (9) records reviewed. MR 1-9. Findings include: Cross reference: 494.80(a)(2) Pt. Assessment Tag 503- The Clinic failed to ensure evaluation of the dialysis prescription through incomplete treatment sheets for nine (9) of nine (9) records reviewed. An immediate jeopardy situation was identified on 7/23/25 at 12:45 pm. at that time, the clinic Manager was presented with the required IJ template. The first draft of the removal plan was received 7/23/25 at 4:05 pm and sent back for revision at 4:15 pm. Revised removal plan was received and approved 7/24/25 at 10:00am. Approved removal plan was verified as fully implemented 7/25/25 at 6:00 am and the IJ was lifted.”

“CFC-CARE AT HOME CFR(s): 494.100 This Condition is not met as evidenced by: 39671 Based on reviews of policies/procedures, water treatment logs, medical records (MR), personnel files (PF), observations and interviews with staff the clinic failed to ensure oversight of the newly aquired home program. Findings include: Cross references: 494.100 Tag 581- The clinic failed to ensure Confirmation of Consent for Home Hemodialysis Treatment and the Home Hemodialysis Responsibility Consent forms were signed prior to initiation of training, per facility policy for nine (9) of (9) home hemodialysis MRs reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) 494.100(a) Tag 582- The clinic failed to ensure skilled nursing facility end stage renal dialysis (ESRD) residents have at least one trained care partner per facility policy for nine (9) of nine (9) home hemodialysis MRs reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) 494.100(a)(2) Tag 584- The clinic failed to ensure a qualified registered nurse (RN) was responsible for providing home hemodialysis for two (2) of four (4) RN employees. (RN #3 and RN #5) 494.100(b)(2),(3) Tag 587-The clinic failed to ensure treatment records were accurate, complete and followed physician orders for nine (9) of nine (9) home hemodialysis treatment records reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) 494.100(c)(1)(v) Tag 593- The clinic failed to ensure employees accurately documented in the chlorine testing log for one (1) of one (1) Portable Water System Total Chlorine Logs reviewed. (Portable Water System Total Chlorine Log #1) 494.100(c)(1)(v) Tag-595- The clinic failed to notify the medical director of microbiological test results at or above action level promptly, per clinic policy for one (1) of six (6) Fresenius T dialysis machines (Fresenius T Dialysis Machine #3) and for one (1) of five (5) Portable Reverse Osmosis (RO) Machines. (Portable RO Machine #4) 494.100(c)(1(vi)) Tag 597- The clinic failed to ensure the dialysis treatment area included ancillary equipment including but not limited to: centrifuge, lab printer and printer for one (1) of two (2) treatment area observations. (Treatment Area Observation #2) 494.100(c)(2) Tag 599- The clinic failed to ensure all staff members have access to the electronic medical record and paper medical records one (1) of two (2) treatment area observations. (Treatment Area Observation #1) The cumulative effect of these systemic problems resulted in the ESRD’s inability to ensure the provision quality healthcare to patients in a safe environment.”

“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: 39671 Based on review of facility policy, home hemodialysis treatment records, and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure evaluation of the dialysis prescription through incomplete treatment sheets for nine (9) of nine (9) home hemodialysis treatment records reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) Findings include: A review was conducted of facility policy on July 24, 2025 at approximately 10:10 a.m. Policy ‘Patient Assessment and Monitoring’ states, “Data Collection: Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Pre-Treatment: Weight: Record pre-weight. Compare pre-weight to estimated dry weight. Blood Pressure: Record blood pressure. Verify: Systolic blood pressures greater than 180 mm/Hg and or diastolic blood pressures greater than 100 mm/Hg. Systolic blood pressures less than or equal to 100 mm/Hg systolic during treatment. Respirations: Record respiration rate. Document abnormalities such as: Rate, Shallow, Irregular, Shortness of breath....2. During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters as needed...3. 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 or per state regulations. Blood Pressure: Record blood pressure. Recheck blood pressures after a drop that requires interventions such as administering normal saline. Report to nurse: Systolic blood pressures greater than 180 mm/Hg; Diastolic blood pressure greater than 100 mm/Hg; Blood Pressure less than or equal to 100 mm/Hg systolic. Pulse: Record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats or minutes. Report to the nurse patients who heart rates have dropped below 60, risen above 100 or become irregular. 3. Machine Parameters and Extracorporeal Circuit: Check machine settings and measurements....4. Document any findings and interventions in the medical record. Post-Treatment: 1. The direct patient care staff may obtain the following: Weight: Obtain the patient’s post weight. Ensure the post weight is consistent with the goal set of the machine. Blood Pressure, Pulse, Respirations, Temperature and Observations: Ensure vital signs and overall condition are stable for discharge. Lung Sounds: The registered nurse will assess/re-assess post treatment as indicated. 2. Document findings in the patient’s record.” MR reviews conducted on July 23, 2025 between approximately 9:30 a.m.-3:30 p.m. revealed the following: MR# 1, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Machine #, Station #, BFR (Blood Flow Rate); DFR (Dialysate Flow Rate), pH, alarms verified, Machine Cond, Actual Cond, patient verified, Signature # 1 and Signature # 2. No documentation of post weight. No blood pressure recorded between 8:36 a.m. and 9:30 a.m. Pulse rates were documented as the following: Pulse Rate: 45 at 6:30 a.m., Pulse Rate: 44 at 7:00 a.m., Pulse Rate: 45 at 7:30 a.m., Pulse Rate: 48 at 7:56 a.m., Pulse Rate: 49 at 8:36 a.m., Pulse Rate: 46 at 9:30 a.m., Pulse Rate: 47 at 10:00 a.m., and Pulse Rate: 48 at 10:15 a.m. No documentation of pulse rates being manually verified, no documentation of registered nurse being notified of abnormal pulse rates and no documentation of registered nurse re-assessing patient. Physician order for Epogen was discontinued on 6/6/2025. Treatment record documented that Epogen 4400 units was administered to patient by registered nurse #5. ‘Post-Dialysis Evaluation’ section, questions “Patient’s post weight this treatment is: Below; At; Above; EDW” and “Are there any new complications for this access” were left blank. MR# 2, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. Estimated dry weight was documented: 76.5 kilogram (kg) and pre weight was documented 61 kg. No documentation of assessing the difference between estimated dry weight and re weight. No documentation of post weight MR# 3, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Machine #, pH, No documentation of post weight. Blood Pressure readings were documented as the following: Blood Pressure Reading: 92/64 at 5:44 a.m., 99/62 at 6:00 a.m., Blood Pressure Reading: 85/62 at 6:31 a.m., Blood Pressure Reading: 94/54 at 6:43 a.m., Blood Pressure Reading: 98/47 at 7:00 a.m., Blood Pressure Reading: 89/unable to read diastolic number at 7:30 a.m., Blood Pressure Reading: 95/58 at 8:00 a.m., Blood Pressure Reading: 96/67 at 8:39 a.m. and Blood Pressure Reading:89/60 at 8:45 a.m. No documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Pulse rates were documented as the following: Pulse Rate: 115 at 5:44 a.m., Pulse Rate: 114 at 6:00 a.m. and Pulse Rate: 48 at 8:45 a.m. No documentation of pulse rates being manually verified, no documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. ’ Post-Dialysis Evaluation ’ section on the treatment record was left blank. MR# 4, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Machine # and Machine Cond. No documentation of post weight. Blood Pressure readings were documented as the following: Blood Pressure Reading: 77/65 at 2:30 p.m. No documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Pulse rates were documented as the following: Pulse Rate: 56 at 10:57 a.m., Pulse Rate: 39 at 11:00 a.m., Pulse Rate: 49 at 11:30 a.m., Pulse Rate: 59 at 12:00 p.m., Pulse Rate: 52 at 12:30 p.m., Pulse Rate: 58 at 1:31 p.m., Pulse Rate:46 at 1:43 p.m. and Pulse Rate: 52 at 2:01 p.m. No documentation of pulse rates being manually verified, no documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. ‘Post-Dialysis Evaluation’ section, questions “ Did new complaints or observations develop during treatment? “ , “Patient’s post weight this treatment is: Below; At; Above; EDW” and “Are there any new complications for this access” and “ Discharged to “ were left blank. MR# 5, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. No documentation of post weight. Pulse rates were documented as the following: Pulse Rate: 57 at 5:35 a.m., Pulse Rate: 49 at 6:03 a.m., Pulse Rate: 47 at 6:59 a.m., Pulse Rate: 53 at 7:30 a.m., Pulse Rate:52 at 7:56 a.m., Pulse Rate:52 at 8:37 a.m., Pulse Rate: 44 at 9:01 a.m. and Pulse Rate: 50 at 9:06 a.m. No documentation of pulse rates being manually verified, no documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Physician order for Heparin via Pump is a follows: 0.5 units per hour for a total of 3.5 hours. No documentation of the treatment record that the patient received Heparin via pump dose. ‘Post-Dialysis Evaluation’ section, questions “ Did new complaints or observations develop during treatment? “ , “Patient’s post weight this treatment is: Below; At; Above; EDW” and “Are there any new complications for this access” and “ Discharged to “ were left blank. MR# 6, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. No documentation of post weight. Blood Pressure readings were documented as the following: Blood Pressure Reading: 95/70 at 11:06 a.m., Blood Pressure Reading: 96/70 at 11:30 a.m., Blood Pressure Reading: 90/45 at 12:00 p.m., Blood Pressure Reading: 94/47 at 1:00 p.m. and Blood Pressure Reading: 89/44 at 1:06 p.m. No documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Physician order for Heparin Bolus is a follows: Heparin Bolus 3000 units every tx (treatment). In section ’ Heparin/Anticoagulation ’ showed that “ 3000 “ was handwritten. No additional documentation such as the name of medication, route, actual time administered and initials. ‘Post-Dialysis Evaluation’ section on the treatment record was left blank. MR# 7, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Patient verified. No documentation of post weight. Physician order for Epogen is as follows: Epogen 5700 units intravenous push (IVP) every treatment. ’ Medications ’ section on the treatment record Epogen was documented as being provided at 11:58 a.m. with a dose of 4400 units instead of the physician ordered dose of 5700 units. No documentation provided of dose change by the physician. Physician order for Venofer is as follows: Venofer 100 mg IVP every treatment. ’ Medications ’ section on the treatment record Venofer was documented as being provided at 12:00 p.m. with a dose of 50 mg units instead of the physician ordered dose of 100 mg. No documentation provided of dose change by the physician. ’ Post-Dialysis Evaluation ’ section on the treatment record was left blank. MR# 8, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: BFR and pH. No documentation of post weight. Heparin Bolus 4000 units every tx (treatment). In section ’ Heparin/Anticoagulation ’ showed that “ 4000 “ was handwritten. No additional documentation such as the name of medication, route, actual time administered and initials. MR# 9, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. No documentation of pre or post weight. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-IDT RESP FOR SERVICES=IN-CENTER PTS CFR(s): 494.100 A dialysis facility that is certified to provide services to home patients must ensure through its interdisciplinary team, that home dialysis services are at least equivalent to those provided to in-facility patients and meet all applicable conditions of this part. This Standard is not met as evidenced by: 39671 Based on review of facility policy, medical records (MRs), and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the facility failed to ensure Confirmation of Consent for Home Hemodialysis Treatment and the Home Hemodialysis Responsibility Consent forms were signed prior to initiation of training, per facility policy for nine (9) of (9) home hemodialysis MRs reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) Findings include: A review was conducted of facility policy on July 24, 2025 at approximately 11:00 a.m. Policy ‘HHD Confirmation of Consent and Patient Responsiblities Policy’ section, ‘Policy’, states, “The patient is required to sign the Confirmation of Consent for Home Hemodialysis Treatment and the Home Hemodialysis Responsibility Consent forms prior to initiation of training to ensure the patient’s understanding of the risks and benefits of home hemodialysis...” A review was conducted of facility ‘Confirmation of Consent for Home Hemodialysis Treatment” states, “...2. I have spoken with my physician(s) (or, if permitted in my state, with an advanced practice provider serving in my physician’s place) prior to the beginning dialysis, who has explained dialysis therapy, alternative, and associated risks, benefits and consequences...” MR reviews conducted on July 23, 2025 between approximately 9:30 a.m.-3:30 p.m. revealed the following: MR# 1, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. No signed Confirmation of Consent for Home Hemodialysis Treatment were provided. Home Hemodialysis Responsibility Consent forms were signed on 7/9/2025, 9 days after initial treatment. MR# 2, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. MR# 3, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025. Confirmation of Consent for Home Hemodialysis Treatment and the Home Hemodialysis Responsibility Consent forms were both signed on 7/9/2025, 9 days after initial treatment. MR# 4, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. MR# 5, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. MR# 6, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. MR# 7, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. MR# 8, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. MR# 9, Date of Admission: 6/30/2025: Initial dialysis treatment was on 6/30/2025. Consent for Home Hemodialysis Treatment form was signed by the patient on 7/9/2025, 9 days after initial treatment. No signed Home Hemodialysis Responsibility Consent forms were provided. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-IDT OVERSEES HOME TRAINING CFR(s): 494.100(a) The interdisciplinary team must oversee training of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis (as defined in §494.10) and when the home dialysis caregiver or home dialysis modality changes. This Standard is not met as evidenced by: 39671 Based on review of clinic policy, home hemodialysis medical records (MRs), and an interview with the clinic Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure skilled nursing facility end stage renal dialysis (ESRD) residents have at least one trained care partner per facility policy for nine (9) of nine (9) home hemodialysis MRs reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) Findings include: A review was conducted of facility policy on July 24, 2025 at approximately 10:00 a.m. Policy ‘Administration of Home Therapy Services for Skilled Nursing Facility ESRD Resident’ section, ‘Care Partner Requirement’ states “...FKC Staff Member Care Partners (“FKC Care Partners”):...FKC will train the FKC Care Partners specific to the individual ESRD resident’s medical needs, as required for all care partner’s in-home dialysis programs.” MR reviews conducted on July 23, 2025 between approximately 9:30 a.m.-3:30 p.m. revealed the following: MR# 1, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 2, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 3, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 4, Date of Admission: 6/30/2025 :No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 5, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 6, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 7, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 8, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. MR# 9, Date of Admission: 6/30/2025: No documentation provided of trained FKC Care Partner specific to the individual ESRD resident’s medical needs. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-TRAINING CONDUCTED BY QUALIFIED RN CFR(s): 494.100(a)(2) The training must- (2) Be conducted by a registered nurse who meets the requirements of §494.140(b)(2); This Standard is not met as evidenced by: 39671 Based on review of Conditions of Participation for End Stage Renal Disease (ESRD) Facilities, employee resumes and an interview with the clinic Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure a qualified registered nurse (RN) was responsible for providing home hemodialysis for two (2) of four (4) RN employees. (RN #3 and RN #5) Findings include: Facility policy pertaining to qualifications for a registered nurse responsible for Home Hemodialysis was requested on July 24, 2025 at approximately 11”00 a.m. No facility policy was provided. Employee resume review conducted on July 24, 2025 between approximately 10:30 a.m. to 11:00 a.m. revealed the following: RN #3: No documentation of employee having three (3) months of experience working as a nurse in the specific modality: Home Hemodialysis. RN #5: No documentation of employee having three (3) months of experience working as a nurse in the specific modality: Home Hemodialysis. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 39671 Based on review of clinic policy, home hemodialysis treatment records, and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure treatment records were accurate, complete and followed physician orders for nine (9) of nine (9) home hemodialysis treatment records reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) Findings include: A review was conducted of facility policy on July 24, 2025 at approximately 10:10 a.m. Policy ‘Patient Assessment and Monitoring’ states, “Data Collection: Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Pre-Treatment: Weight: Record pre-weight. Compare pre-weight to estimated dry weight. Blood Pressure: Record blood pressure. Verify: Systolic blood pressures greater than 180 mm/Hg and or diastolic blood pressures greater than 100 mm/Hg. Systolic blood pressures less than or equal to 100 mm/Hg systolic during treatment. Respirations: Record respiration rate. Document abnormalities such as: Rate, Shallow, Irregular, Shortness of breath....2. During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters as needed...3. 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 or per state regulations. Blood Pressure: Record blood pressure. Recheck blood pressures after a drop that requires interventions such as administering normal saline. Report to nurse: Systolic blood pressures greater than 180 mm/Hg; Diastolic blood pressure greater than 100 mm/Hg; Blood Pressure less than or equal to 100 mm/Hg systolic. Pulse: Record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats or minutes. Report to the nurse patients who heart rates have dropped below 60, risen above 100 or become irregular. 3. Machine Parameters and Extracorporeal Circuit: Check machine settings and measurements....4. Document any findings and interventions in the medical record. Post-Treatment: 1. The direct patient care staff may obtain the following: Weight: Obtain the patient’s post weight. Ensure the post weight is consistent with the goal set of the machine. Blood Pressure, Pulse, Respirations, Temperature and Observations: Ensure vital signs and overall condition are stable for discharge. Lung Sounds: The registered nurse will assess/re-assess post treatment as indicated. 2. Document findings in the patient’s record.” MR reviews conducted on July 23, 2025 between approximately 9:30 a.m.-3:30 p.m. revealed the following: MR# 1, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Machine #, Station #, BFR (Blood Flow Rate); DFR (Dialysate Flow Rate), pH, alarms verified, Machine Cond, Actual Cond, patient verified, Signature # 1 and Signature # 2. No documentation of post weight. No blood pressure recorded between 8:36 a.m. and 9:30 a.m. Pulse rates were documented as the following: Pulse Rate: 45 at 6:30 a.m., Pulse Rate: 44 at 7:00 a.m., Pulse Rate: 45 at 7:30 a.m., Pulse Rate: 48 at 7:56 a.m., Pulse Rate: 49 at 8:36 a.m., Pulse Rate: 46 at 9:30 a.m., Pulse Rate: 47 at 10:00 a.m., and Pulse Rate: 48 at 10:15 a.m. No documentation of pulse rates being manually verified, no documentation of registered nurse being notified of abnormal pulse rates and no documentation of registered nurse re-assessing patient. Physician order for Epogen was discontinued on 6/6/2025. Treatment record documented that Epogen 4400 units was administered to patient by registered nurse #5. ‘Post-Dialysis Evaluation’ section, questions “Patient’s post weight this treatment is: Below; At; Above; EDW” and “Are there any new complications for this access” were left blank. MR# 2, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. Estimated dry weight was documented: 76.5 kilogram (kg) and pre weight was documented 61 kg. No documentation of assessing the difference between estimated dry weight and re weight. No documentation of post weight MR# 3, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Machine #, pH, No documentation of post weight. Blood Pressure readings were documented as the following: Blood Pressure Reading: 92/64 at 5:44 a.m., 99/62 at 6:00 a.m., Blood Pressure Reading: 85/62 at 6:31 a.m., Blood Pressure Reading: 94/54 at 6:43 a.m., Blood Pressure Reading: 98/47 at 7:00 a.m., Blood Pressure Reading: 89/unable to read diastolic number at 7:30 a.m., Blood Pressure Reading: 95/58 at 8:00 a.m., Blood Pressure Reading: 96/67 at 8:39 a.m. and Blood Pressure Reading:89/60 at 8:45 a.m. No documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Pulse rates were documented as the following: Pulse Rate: 115 at 5:44 a.m., Pulse Rate: 114 at 6:00 a.m. and Pulse Rate: 48 at 8:45 a.m. No documentation of pulse rates being manually verified, no documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. ’ Post-Dialysis Evaluation ’ section on the treatment record was left blank. MR# 4, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Machine # and Machine Cond. No documentation of post weight. Blood Pressure readings were documented as the following: Blood Pressure Reading: 77/65 at 2:30 p.m. No documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Pulse rates were documented as the following: Pulse Rate: 56 at 10:57 a.m., Pulse Rate: 39 at 11:00 a.m., Pulse Rate: 49 at 11:30 a.m., Pulse Rate: 59 at 12:00 p.m., Pulse Rate: 52 at 12:30 p.m., Pulse Rate: 58 at 1:31 p.m., Pulse Rate:46 at 1:43 p.m. and Pulse Rate: 52 at 2:01 p.m. No documentation of pulse rates being manually verified, no documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. ‘Post-Dialysis Evaluation’ section, questions “ Did new complaints or observations develop during treatment? “ , “Patient’s post weight this treatment is: Below; At; Above; EDW” and “Are there any new complications for this access” and “ Discharged to “ were left blank. MR# 5, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. No documentation of post weight. Pulse rates were documented as the following: Pulse Rate: 57 at 5:35 a.m., Pulse Rate: 49 at 6:03 a.m., Pulse Rate: 47 at 6:59 a.m., Pulse Rate: 53 at 7:30 a.m., Pulse Rate:52 at 7:56 a.m., Pulse Rate:52 at 8:37 a.m., Pulse Rate: 44 at 9:01 a.m. and Pulse Rate: 50 at 9:06 a.m. No documentation of pulse rates being manually verified, no documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Physician order for Heparin via Pump is a follows: 0.5 units per hour for a total of 3.5 hours. No documentation of the treatment record that the patient received Heparin via pump dose. ‘Post-Dialysis Evaluation’ section, questions “ Did new complaints or observations develop during treatment? “ , “Patient’s post weight this treatment is: Below; At; Above; EDW” and “Are there any new complications for this access” and “ Discharged to “ were left blank. MR# 6, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. No documentation of post weight. Blood Pressure readings were documented as the following: Blood Pressure Reading: 95/70 at 11:06 a.m., Blood Pressure Reading: 96/70 at 11:30 a.m., Blood Pressure Reading: 90/45 at 12:00 p.m., Blood Pressure Reading: 94/47 at 1:00 p.m. and Blood Pressure Reading: 89/44 at 1:06 p.m. No documentation of a registered nurse being notified of abnormal blood pressure readings, interventions performed and no documentation of registered nurse re-assessing patient. Physician order for Heparin Bolus is a follows: Heparin Bolus 3000 units every tx (treatment). In section ’ Heparin/Anticoagulation ’ showed that “ 3000 “ was handwritten. No additional documentation such as the name of medication, route, actual time administered and initials. ‘Post-Dialysis Evaluation’ section on the treatment record was left blank. MR# 7, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: Patient verified. No documentation of post weight. Physician order for Epogen is as follows: Epogen 5700 units intravenous push (IVP) every treatment. ’ Medications ’ section on the treatment record Epogen was documented as being provided at 11:58 a.m. with a dose of 4400 units instead of the physician ordered dose of 5700 units. No documentation provided of dose change by the physician. Physician order for Venofer is as follows: Venofer 100 mg IVP every treatment. ’ Medications ’ section on the treatment record Venofer was documented as being provided at 12:00 p.m. with a dose of 50 mg units instead of the physician ordered dose of 100 mg. No documentation provided of dose change by the physician. ’ Post-Dialysis Evaluation ’ section on the treatment record was left blank. MR# 8, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. The following sections with the ‘Machine Set up” section on the treatment record were left blank: BFR and pH. No documentation of post weight. Heparin Bolus 4000 units every tx (treatment). In section ’ Heparin/Anticoagulation ’ showed that “ 4000 “ was handwritten. No additional documentation such as the name of medication, route, actual time administered and initials. MR# 9, Date of Admission: 6/30/2025: Review of Dialysis treatment record dated: 7/18/2025. No documentation of pre or post weight. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-MONITOR H20 /DIALYSATE INC ON SITE EVAL CFR(s): 494.100(c)(1)(v) Services include, but are not limited to, the following: (v) Monitoring of the quality of water and dialysate used by home hemodialysis patients including conducting an onsite evaluation This Standard is not met as evidenced by: 39671 Based on review of clinic policy, Portable Water System Total Chlorine Logs and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure employees accurately documented in the chlorine testing log for one (1) of one (1) Portable Water System Total Chlorine Logs reviewed. (Portable Water System Total Chlorine Log #1) Findings include: A review was conducted of facility policy on July 23, 2025 at approximately 10:00 a.m. Policy ‘Testing for Residual Bleach Using WaterCheck RC Residual Chlorine Reagent Test Strips’ section, ‘Purpose’ states “The purpose pf this policy and p[procedure is to direct staff and home therapies patient and/or care partner on using WaterCheck RC residual Chlorine reagent test strips....Documentation: Testing result for residual bleach must be documented in the approved electronic documentation system (TMS) or on the paper Hemodialysis machine log.” ‘Portable Water System Total Chlorine Log’ instructs the staff performing the test to check either box “Yes” or box “No” after the staff member documents the results of the chlorine levels. If box “No” is checked then the log states, “No = TAKE ACTION!” Portable Water System Total Chlorine Log review conducted on July 23, 2025 between approximately 11:30 a.m. to 1:00 p.m. revealed the following: Portable Water System Total Chlorine Log #1: On 7/2/2025- Portable Reverse Osmosis (RO) Machine #1, Test #1 at 4:57 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 8:10 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #3 at 11:03 a.m. no boxes were checked. Test #4 at 2:06 p.m. both boxes of “ Yes “ and “ No “ were checked. Test # 5 at 5:00 p.m. both boxes of “ Yes “ and “ No “ were checked. On 7/2/2025-Portable RO Machine #3, Test #1 at 5:15 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 8:15 a.m. Test #3 at 11:06 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #4 at 2:00 p.m. both boxes of “ Yes “ and “ No “ were checked. Test #5 at 5:00 p.m. both boxes of “ Yes “ and “ No “ were checked. On 7/4/2025-Portable RO Machine #4, Test #1 at 4:46 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 8:10 a.m. no boxes were checked. Test #3 at 11:20 a.m. both boxes of “ Yes “ and “ No “ were checked. On 7/4/2025- Portable RO Machine #3, Test #1 at 4:48 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 8:12 a.m. no boxes were checked. Test #3 at 11:20 a.m. both boxes of “ Yes “ and “ No “ were checked. On 7/4/2025- Portable RO Machine #1, Test #1 at 4:50 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 8:15 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #3 at 11:20 a.m. no boxes were checked. On 7/7/2025- Portable RO Machine #4, Test #1 at 5:10 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 9:09 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #4 at 5:00 p.m. both boxes of “ Yes “ and “ No “ were checked. On 7/7/2025- Portable RO Machine #3, Test #1 at 5:10 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 9:00 a.m. both boxes of “ Yes “ and “ No “ were checked. On 7/7/2025- Portable RO Machine #1, Test #1 at 5:10 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 9:05 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #3 at 1:00 p.m. both boxes of “ Yes “ and “ No “ were checked. On 7/9/2025- Portable RO Machine #4, Test #1 at 4:54 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #2 at 7:45 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #4 at 3:10 p.m. no boxes were checked. On 7/9/2025- Portable RO Machine #3, Test #1 at 4:49 a.m. both boxes of “ Yes “ and “ No “ were checked. Test #4 at 3:12 p.m. no boxes were checked. On 7/9/2025- Portable RO Machine #1, Test #1 at 4:46 a.m. both boxes of “ Yes “ and “ No “ were checked. On 7/14/2025- Portable RO Machine #1, Test #2 at 8:30 a.m. no boxes were checked. Test #3 at 11:15 a.m. no boxes were checked. On 7/21/2025- Portable RO Machine #3, Test #2 at 12:35 p.m. no boxes were checked. On 7/21/2025- Portable RO Machine #1, Test #3 at 12:40 p.m. no boxes were checked. On 7/21/2025- Portable RO Machine #1, Test #3 at 12:40 p.m. no boxes were checked. On 7/23/2025- Portable RO Machine #3, Test #2 at 8:42 a.m. no boxes were checked. On 7/23/2025- Portable RO Machine #1, Test #2 at 8:45 a.m. no boxes were checked. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-MEET RD52:2004 CFR(s): 494.100(c)(1)(v) The facility must meet testing and other requirements of ANSI/AAMI RD52:2004. In addition, bacteriological and endotoxin testing must be performed on a quarterly, or more frequent basis as needed, to ensure that the water and dialysate are within the AAMI limits. This Standard is not met as evidenced by: 39671 Based on review of clinic policies, Microbiological Monitoring documentation, and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to notify the medical director of microbiological test results at or above action level promptly, per facility policy for one (1) of six (6) Fresenius T dialysis machines (Fresenius T Dialysis Machine #3) and for one (1) of five (5) Portable Reverse Osmosis (RO) Machines. (Portable RO Machine #4) Findings include: A review was conducted of facility policies on July 22, 2025 at approximately 12:00 p.m. Policy ‘Microbiological Monitoring of Dialysate’ section, ‘Interpretation of Results’ states, “FMS Dialysate Standards Table: Test: Colony County; Action Level: 20 CFU/ml; Allowable Limit: 100 CFU/ml; Test: Endotoxin; Action Level: 0.06 EU/ml; Allowable Limit: 0.25 EU/ml; and AAMI Dialysate Standards Table: Test: Colony County; Action Level: 50 CFU/ml; Allowable Limit: 200 CFU/ml; Test: Endotoxin; Action Level: 1 EU/ml; Allowable Limit: 2 EU/ml” Policy ‘Microbiological Monitoring of Portable Reverse Osmosis’ section, ‘Interpretation of Results’ states, “FKC Water Standards Table: Test: Colony County; Action Level: 20 CFU/ml; Allowable Limit: 100 CFU/ml; Test: Endotoxin; Action Level: 0.125 EU/ml; Allowable Limit: 0.25 EU/ml; and AAMI Water Standards Table: Test: Colony County; Action Level: 50 CFU/ml; Allowable Limit: 200 CFU/ml; Test: Endotoxin; Action Level: 1 EU/ml; Allowable Limit: 2 EU/ml” Policy ‘Microbiological Monitoring of Dialysate’ section, ‘Documentation’ states “...Results at or above action level and any action taken will be documented and reported to Medical Director and Technical Management promptly and in accordance with “Dialysate Microbiological Results Decision Tree” and in the QAI records.” Microbiological Monitoring documentation reviews conducted on July 23, 2025 between approximately 9:30 a.m.-3:30 p.m. revealed the following: Fresenius T Dialysis Machine #3: Microbiological test collected on 6/26/2025, showed a dialysate colony count result of “>200”. No documentation provided of reporting the above action level result to the Medical Director promptly as per facility policy. Portable RO Machine #4: Microbiological test collected on 7/1/2025, showed a dialysate colony count result of “28”. No documentation provided of reporting the above action level result to the Medical Director promptly as per facility policy. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-PROVIDE ORDERED SUPPLIES/EQUIPMENT CFR(s): 494.100(c)(1)(vi) Services include, but are not limited to, the following: (vi) Purchasing, leasing, renting, delivering, installing, repairing and maintaining medically necessary home dialysis supplies and equipment (including supportive equipment) prescribed by the attending physician. This Standard is not met as evidenced by: 39671 Based on review of Condition of Participation for End Stage Renal Disease (ESRD) Facilities, treatment area observations and an interview with theclinic Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure the dialysis treatment area included ancillary equipment including but not limited to: centrifuge, lab printer and printer for one (1) of two (2) treatment area observations. (Treatment Area Observation #2) Findings include: Facility policies pertaining to ensuring the dialysis treatment area included ancillary equipment including but not limited to: centrifuge, lab printer and printer was requested on July 24, 2025 at approximately 11:45 a.m. No facility policy was provided. Treatment area observations conducted on July 23, 2025 between approximately 9:15 a.m. to 10:00 a.m. revealed the following: Treatment area observation #1: During observation, surveyor noted that there was no working lab printer and computer printer available for the employees to use during providing dialysis treatments to patients. Interview with employees revealed that a centrifuge did not get delivered to the dialysis den until July 9, 2025, 9 days after initial patient treatments have started. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”

“H-RECORDKEEPING SYSTEM CFR(s): 494.100(c)(2) (2) The dialysis facility must maintain a recordkeeping system that ensures continuity of care and patient privacy. This includes items and services furnished by durable medical equipment (DME) suppliers referred to in §414.330(a)(2) of this chapter. This Standard is not met as evidenced by: 39671 Based on treatment area observations and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure all staff members have access to the electronic medical record and paper medical records one (1) of two (2) treatment area observations. (Treatment Area Observation #1) Findings include: Facility policies pertaining to ensuring all staff members have access to the electronic medical record (EMR) and paper medical records was requested on July 24, 2025 at approximately 11:45 a.m. No facility policy was provided. Treatment area observations conducted on July 23, 2025 between approximately 9:15 a.m. to 10:00 a.m. revealed the following: Treatment area observation #1: During observation, surveyor noted that no internet connection was available in the dialysis den. Employees could not independently access the EMR to review labs, review physician orders, document notes, and document additional information regarding the care of the patient. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 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: 39671 Based on review of facility policy, medical records (MRs), and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the clinic failed to ensure an initial registered nurse assessment was completed prior to the first treatment for nine (9) of (9) home hemodialysis MRs reviewed. (MR# 1, MR# 2, MR# 3, MR# 4, MR# 5, MR# 6, MR# 7, MR# 8 and MR# 9) Findings include: A review was conducted of facility policy on July 24, 2025 at approximately 10:45 a.m. Policy ‘Comprehensive Interdisciplinary Assessment and Plan of Care’ section, ‘Prior to Initiation of the Patients First Treatment for Patients New to Dialysis’ states, “A registered nurse must perform an assessment on patients new to dialysis before initiation of their first treatment to determine immediate needs. The RN must document the assessment.” MR reviews conducted on July 23, 2025 between approximately 9:30 a.m.-3:30 p.m. revealed the following: MR# 1, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 2, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 3, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 4, Date of Admission: 6/30/2025 :No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 5, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 6, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 7, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 8, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. MR# 9, Date of Admission: 6/30/2025: No documentation provided of completed initial registered nurse assessment prior to first treatment. An interview with the facility Director of Operations of Central PA and Clinical Manager of Home Therapy Programs, on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings. Based on review of facility policy, Centers for Medicare & Medicaid Services (CMS) forms (FRM), and an interview with the facility Director of Operations of Central PA (EMP# 1) and Clinical Manager of Home Therapy Programs (EMP# 2), the facility failed to ensure the CMS Form 3427 was submitted prior to providing services to the first (End Stage Renal Dialysis (ESRD) resident at the new long term care (LTC) facility for one (1) of one (1) CMS Form reviewed. (CMS Form 3427 #1) Findings include: A review was conducted of facility policy on July 24, 2025 at approximately 2:15 p.m. Policy ‘Administration of Home Therapy Services for Skilled Nursing Facility ESRD Resident’ section, ’ Regulatory Requirements’ states, “The Home Therapy program must file CMS form 3427 to indicate that it will be providing home dialysis services at a LTC Facility. The Home Therapy program should submit its updated 3427 prior to providing services to the first ESRD resident at each new LTC Facility.” Review of required CMS forms conducted on July 24, 2025 between approximately 2:00 p.m. revealed the following: FRM #1: Form was signed by the Director of Operations on 7/8/2025. Facility started providing services to ESRD residents on 6/30/2025. Interviews with EMP #1 and EMP #2 on July 24, 2025 at approximately 3:00 p.m. confirmed the above findings.”