Fkc Newberry Commons

“INVENTORY CONTROL CFR(s): 494.50(b)(1) 9.2 Inventory control Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded. This Standard is not met as evidenced by: 39848 Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure proper inventory control for nine (9) of twelve (12) observations (Observation #1-#9). Findings: Review of Fresenius Kidney Care storage of supplies policy on 12/12/25 at approximately 3:30 PM revealed: Purpose: “ The purpose of this policy is to provide guidelines for storage and handling of supplies in the dialysis facility. “ ; Responsibility: “ Staff who stock and/or handle supplies in the dialysis facility. “ ; Background: “ Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged. “ ; General supplies and storage requirements: “ supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date. “ ; Discarding supplies requirements: “ Supplies will be discard when: Product expires; Supplies that are not routinely used (such as items stored in emergency carts, evacuation boxes, etc.) must be routinely inspected to ensure they remain in good condition. Supplies that are expired ....must be replaced. Review of facility ’ s medication and laboratory area on 12/11/25 between 9:50 AM-10:20 AM revealed: Observation (Obs) # 1: twenty (20) skin prep protective wipes with expiration date of 11/1/25. Obs # 2: Three (3) BD red top vacutainers with expiration date 5/31/25. Obs # 3: One (1) BBL culture swab plus collection and transport system with expiration date 10/23/25. Obs # 4: Thirty-six (36) Immunostics Inc. hema screen slide test for fecal occult blood with expiration date 2/28/25. Obs # 5: Nine (9) BD vacutainers culture and sensitivity (C&S) boric acid four (4) milliliters (ml) with expiration date 6/30/25. Obs # 6: Twenty-five (25) embrace pro blood glucose test strips with expiration date 3/31/24. Obs # 7: Twenty-three (23) EZ check blood leak test strips with expiration date 8/31/24. Review of crash cart on 12/11/25 between 10:20 AM-10:30 AM revealed: Obs # 8: Anise eighty-five (85) no perfume or coloring (NC) hand sanitizing gel hand rub with expiration date 2/28/24. Review of facility ’ s isolation room supplies on 12/11/25 between 11:15 AM-11:30 AM revealed: Obs. # 9: Health guard foaming advanced antibacterial hand soap with expiration date 1/31/25. An interview with the facility ’ s administrator on 12/11/25 at 1:15 PM confirmed the above findings.”

“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: 39848 Based on review of medical records (MR), policies and procedures and interviews with facility director of operations and facility administrator, it was determined that the facility failed to adequately monitor prescribed blood flow during treatment in one (1) of five (5) MR reviewed. (MR # 1) Findings: Review of Fresenius Kidney Care Clinical services safety checks on 12/15/25 at approximately 2:10 PM revealed: “ Purpose: The purpose of this policy is to provide guidance on safety checks to prevent, detect, and treat complications; Policy: Safety checks will be performed pretreatment and every thirty (30) minutes or more frequently as needed once the treatment has begun. “ Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 12/15/25 at approximately 2:10 PM revealed: “ Purpose: The purpose of this policy is to provide guidance to Fresenius kidney care (FKC) direct patient care staff on assessment and monitoring patients before, during and after treatment.; Definitions: Date Collection: Gathering of objective and subjective information related to the patient ’ s health status as it corresponds to the ordered renal replacement.; During treatment: Obtain blood pressure and pulse rate every thirty (30) minutes or more as needed but not to exceed forty-five (45) minutes or per state regulations. Document machine parameters and safety checks every thirty (30) minutes or more often as needed but not to exceed forty-five (45) minutes or per state regulations.. “ ; “ Follow the steps below for monitoring patient and machine parameters during treatment: Blood pressure: record blood pressure. Machine parameters and extracorporeal circuit: Check machine settings and measurements: check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. “ MR # 1: Start of care (SOC): 5/13/24; Review of treatment flow sheets from 11/28/25-12/10/25 revealed: a. Treatment flow sheet from 11/28/25: Prescribed Blood flow rate (BFR) four hundred (400); BFR from 6:20 AM through 10:23 AM: four hundred fifty (450) with no documentation for the lower BFR (four (4) hours and three (3) minutes). An interview with the facility ’ s director of operations and facility administrator on 12/15/25 at 1:05 PM confirmed the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 39848 Based on review of medical records (MR), policies and procedures and interviews with facility director of operations and facility administrator, it was determined that the facility failed ensure staff monitored blood pressures and pulses every thirty (30) minutes, per policy, during treatment for three (3) of five (5) MR reviewed. (MR #1-MR #3) Findings: Review of Fresenius Kidney Care Clinical services safety checks on 12/15/25 at approximately 2:10 PM revealed: “ Purpose: The purpose of this policy is to provide guidance on safety checks to prevent, detect, and treat complications; Policy: Safety checks will be performed pretreatment and every thirty (30) minutes or more frequently as needed once the treatment has begun. “ Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 12/15/25 at approximately 2:10 PM revealed: “ Purpose: The purpose of this policy is to provide guidance to Fresenius kidney care (FKC) direct patient care staff on assessment and monitoring patients before, during and after treatment.; Definitions: Date Collection: Gathering of objective and subjective information related to the patient ’ s health status as it corresponds to the ordered renal replacement.; During treatment: Obtain blood pressure and pulse rate every thirty (30) minutes or more as needed but not to exceed forty-five (45) minutes or per state regulations. Document machine parameters and safety checks every thirty (30) minutes or more often as needed but not to exceed forty-five (45) minutes or per state regulations.. “ ; “ Follow the steps below for monitoring patient and machine parameters during treatment: Blood pressure: record blood pressure. Machine parameters and extracorporeal circuit: Check machine settings and measurements: check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. “ Review of treatment flow sheets on 12/15/25 between 9:30 AM-12:00 PM revealed: Medical record (MR) # 1: start of care (SOC): 5/13/24; Review of treatment flow sheets from 11/28/25-12/10/25 revealed: a. Treatment flow sheet from 11/28/25: Blood pressure: 103/73; pulse: 93 at 6:21 AM; next blood pressure and pulse check were completed at 7:16 AM and were Blood pressure: 114/69 and pulse: 92. (fifty-five (55) minutes between checks) b. Treatment flow sheet from 11/28/25: Blood pressure: 147/68; pulse: 82 at 9:00 AM; next blood pressure and pulse check were completed at 9:44 AM and were Blood pressure: 115/58 and pulse: 87. (forty-four (44) minutes between checks) c. Treatment flow sheet from 12/1/25: Blood pressure: 142/75; pulse 99 at 9:05 AM; next blood pressure and pulse check were completed at 9:38 AM and were blood pressure: 122/67 and pulse 81. (thirty-three (33) minutes between checks) d. Treatment flow sheet from 12/1/25: Blood pressure: 124/67; pulse 81 at 9:38 AM; next blood pressure and pulse check were completed at 10:13 AM and were blood pressure: 124/72 and pulse 100. (thirty-five (35) minutes between checks) e. Treatment flow sheet from 12/5/25: Blood pressure: 112/57; pulse 103 at 6:31 AM; next blood pressure and pulse check were completed at 7:06 AM and were blood pressure: 124/73 and pulse 95. (thirty-five (35) minutes between checks) f. Treatment flow sheet from 12/5/25: Blood pressure: 136/83; pulse 86 at 9:00 AM; next blood pressure and pulse check were completed at 9:43 AM and were blood pressure: 123/76 and pulse 90. (forty-three (43) minutes between checks) g. Treatment flow sheet from 12/8/25: Blood pressure: 148/64; pulse 101 at 9:00 AM; next blood pressure and pulse check were completed at 9:37 AM and were blood pressure: 132/69 and pulse 101. (thirty-seven (37) minutes between checks) h. Treatment flow sheet from 12/10/25: Blood pressure: 100/59; pulse 78 at 8:34 AM; next blood pressure and pulse check were completed at 9:08 AM and were blood pressure: 107/92 and pulse 59. (thirty-four (34) minutes between checks) i. Treatment flow sheet from 12/10/25: Blood pressure: 127/90; pulse 79 at 9:37 AM; next blood pressure and pulse check were completed at 10:30 AM and were blood pressure: 118/67 and pulse 96. (fifty-three (53) minutes between checks) Medical record (MR) # 2: (SOC): 4/19/22; Review of treatment flow sheets from 11/28/25-12/10/25 revealed: a. Treatment flow sheet from 11/28/25: Blood pressure: 134/82; pulse: 69 at 10:01 AM; next blood pressure and pulse check were completed at 10:37 AM and were Blood pressure: 122/72 and pulse: 71. (thirty-six (36) minutes between checks) b. Treatment flow sheet from 11/28/25: Blood pressure: 122/72; pulse: 71 at 10:37 AM; next blood pressure and pulse check were completed at 11:12 AM and were Blood pressure: 128/73 and pulse: 69. (thirty-five (35) minutes between checks) c. Treatment flow sheet from 11/28/25: Blood pressure: 112/53; pulse: 71 at 12:03 PM; next blood pressure and pulse check were completed at 12:42 PM and were Blood pressure: 118/66 and pulse: 71. (thirty-nine (39) minutes between checks) d. Treatment flow sheet from 12/1/25: Blood pressure: 142/74; pulse: 68 at 10:02 AM; next blood pressure and pulse check were completed at 10:41 AM and were Blood pressure: 127/70 and pulse: 69. (thirty-nine (39) minutes between checks) e. Treatment flow sheet from 12/1/25: Blood pressure: 127/70; pulse: 69 at 10:41 AM; next blood pressure and pulse check were completed at 11:13 AM and were Blood pressure: 128/76 and pulse: 69. (thirty-two (32) minutes between checks) f. Treatment flow sheet from 12/1/25: Blood pressure: 122/72; pulse: 73 at 12:03 PM; next blood pressure and pulse check were completed at 12:37 PM and were Blood pressure: 114/70 and pulse: 73. (thirty-four (34) minutes between checks) g. Treatment flow sheet from 12/3/25: Blood pressure: 146/85; pulse: 70 at 9:36 AM; next blood pressure and pulse check were completed at 10:33 AM and were Blood pressure: 154/90 and pulse: 71. (fifty-seven (57) minutes between checks) h. Treatment flow sheet from 12/3/25: Blood pressure: 154/90; pulse: 71 at 10:33 AM; next blood pressure and pulse check were completed at 11:08 AM and were Blood pressure: 137/87 and pulse: 70. (thirty-five (35) minutes between checks) i. Treatment flow sheet from 12/5/25: Blood pressure: 133/63; pulse: 89 at 9:34 AM; next blood pressure and pulse check were completed at 10:32 AM and were Blood pressure: 140/75 and pulse: 70. (fifty-eight (58) minutes between checks) j. Treatment flow sheet from 12/5/25: Blood pressure: 140/75; pulse: 70 at 10:32 AM; next blood pressure and pulse check were completed at 11:07 AM and were Blood pressure: 125/72 and pulse: 67. (thirty-five (35) minutes between checks) k. Treatment flow sheet from 12/5/25: Blood pressure: 128/69; pulse: 71 at 11:35 AM; next blood pressure and pulse check were completed at 12:35 PM and were Blood pressure: 127/71 and pulse: 69. (sixty (60) minutes between checks) l. Treatment flow sheet from 12/5/25: Blood pressure: 127/71; pulse: 69 at 12:35 PM; next blood pressure and pulse check were completed at 1:34 PM and were Blood pressure: 125/74 and pulse: 74. (fifty-nine (59) minutes between checks) m. Treatment flow sheet from 12/8/25: Blood pressure: 153/78; pulse: 66 at 9:35 AM; next blood pressure and pulse check were completed at 10:33 AM and were Blood pressure: 134/82 and pulse: 65. (fifty-eight (58) minutes between checks) n. Treatment flow sheet from 12/8/25: Blood pressure: 139/74; pulse: 65 at 11:02 AM; next blood pressure and pulse check were completed at 11:37 AM and were Blood pressure: 132/71 and pulse: 69. (thirty-five (35) minutes between checks) o. Treatment flow sheet from 12/10/25: Blood pressure: 114/65; pulse: 70 at 10:00 AM; next blood pressure and pulse check were completed at 10:37 AM and were Blood pressure: 101/56 and pulse: 68. (thirty-seven (37) minutes between checks) p. Treatment flow sheet from 12/10/25: Blood pressure: 101/56; pulse: 68 at 10:37 AM; next blood pressure and pulse check were completed at 11:31 AM and were Blood pressure: 111/74 and pulse: 68. (fifty-four (54) minutes between checks) q. Treatment flow sheet from 12/10/25: Blood pressure: 121/73; pulse: 71 at 12:00 PM; next blood pressure and pulse check were completed at 12:37 PM and were Blood pressure: 120/72 and pulse: 76. (thirty-seven (37) minutes between checks) Medical record (MR) # 3: (SOC): 3/25/20; Review of treatment flow sheets from 11/28/25-12/10/25 revealed: a. Treatment flow sheet from 11/28/25: Blood pressure: 177/89; pulse: 60 at 5:32 AM; next blood pressure and pulse check were completed at 6:14 AM and were Blood pressure: 165/74 and pulse: 60. (forty-two (42) minutes between checks) b. Treatment flow sheet from 12/1/25: Blood pressure: 140/70; pulse: 60 at 5:32 AM; next blood pressure and pulse check were completed at 6:04 AM and were Blood pressure: 151/70 and pulse: 60. (thirty-two (32) minutes between checks) c. Treatment flow sheet from 12/1/25: Blood pressure: 151/70; pulse: 60 at 6:04 AM; next blood pressure and pulse check were completed at 7:01 AM and were Blood pressure: 139/65 and pulse: 59. (fifty-seven (57) minutes between checks) d. Treatment flow sheet from 12/3/25: Blood pressure: 148/75; pulse: 60 at 5:29 AM; next blood pressure and pulse check were completed at 6:07 AM and were Blood pressure: 141/67 and pulse: 60. (thirty-eight (38) minutes between checks) e. Treatment flow sheet from 12/3/25: Blood pressure: 160/72; pulse: 60 at 6:34 AM; next blood pressure and pulse check were completed at 7:09 AM and were Blood pressure: 139/68 and pulse: 60. (thirty-five (35) minutes between checks) f. Treatment flow sheet from 12/3/25: Blood pressure: 145/71; pulse: 60 at 8:31 AM; next blood pressure and pulse check were completed at 9:05 AM and were Blood pressure: 144/71 and pulse: 60. (thirty-four (34) minutes between checks) g. Treatment flow sheet from 12/8/25: Blood pressure: 173/89; pulse: 59 at 6:34 AM; next blood pressure and pulse check were completed at 7:11 AM and were Blood pressure: 162/89 and pulse: 62. (thirty-five (35) minutes between checks) h. Treatment flow sheet from 12/8/25: Blood pressure: 163/90; pulse: 60 at 7:33 AM; next blood pressure and pulse check were completed at 8:07 AM and were Blood pressure: 167/84 and pulse: 59. (thirty-four (34) minutes between checks) i. Treatment flow sheet from 12/8/25: Blood pressure: 177/85; pulse: 59 at 8:33 AM; next blood pressure and pulse check were completed at 9:13 AM and were Blood pressure: 148/83 and pulse: 60. (forty (40) minutes between checks) An interview with the facility ’ s director of operations and facility administrator on 12/15/25 at 1:05 PM confirmed the above findings.”