Fkc Livingston

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 48749 Based on observation, interview, and policy review, the facility staff failed to change out the bleach solution used for cleaning surfaces, dialysis machines, and equipment according to facility guidelines. The staff failed to follow the facility’s “Test Strips and Solutions” guidelines. These findings had the likelihood to cause harm due to the risk of infection to patients and staff at the facility by allowing the solutions to deteriorate or break down. This causes the solution to lose its ability to disinfect and eventually become salt and water. A tour was conducted of the in-center treatment floor on 08/26/2024 at 10:20 AM. A container with bleach solution was observed sitting next to the sink in the isolation room. The container was noted to have 1:100, 08/21/24 at 4:20 written on the lid. The facility staff failed to change the bleach solution after 24 hours per the facility’s guidelines. A review of the facility’s “Test Strips and Solutions” guidelines dated 01/19/2015 revealed the following: “Please be aware ALL test strips and solutions must be dated and initialed when first opened. (On the side of the bottle) The reason for this: the products’ stability starts to deteriorate once opened. Below is a current list of the products used in most FMC clinics along with their associated stability timeframes. Note: stability varies by manufacture. Product must be discarded once the timeframe has been reached. Should you come across one that is not listed below the info is generally available with product insert. 1:10 / 1:100 Bleach Solution - 24 hours” An interview with Staff # 1 confirmed the facility staff failed to follow facility guidelines, “Test Strips and Solutions” and did not change the bleach solution after 24 hours.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 48749 Based on observation, record review, and staff interview, the facility staff failed to ensure acid concentrate jugs were labeled with the date and time opened. Also, the facility staff failed to follow the “Concentrate Labeling Requirements” policy. Findings Included: A tour of the in-center treatment floor was conducted at 10:20 AM on 08/26/2024. There were two acid jugs observed sitting on a cart at the nurse’s station. Both jugs were noted to be opened and contained a solution inside. One jug was observed to not have a date of opening, time, or initials written on it. The second jug was observed to have a red wand still attached at the top with the opening exposed. Neither jug was labeled with a patient identifier or patient sticker. A review of the facility’s “ Concentrate Labeling Requirements” policy dated 09/05/2023 revealed the following: “Purpose This document defines Fresenius Kidney Care (FKC) policy for labeling requirements for concentrate storage, mixing equipment, and entering acid concentrate formulas in the hemodialysis machine. Scope This document applies to all FKC Incenter, Inpatient, and Home Programs. Introduction Labeling strategies must allow for the positive identification of the contents of the following: * Mixing Tanks * Storage Tanks * Concentrate “head” tanks * Valve Panels * Concentrate Jugs * Concentrates entered into Hemodialysis Machines Policy: Permanent Labeling: Concentrate Jugs (Incenter, Inpatient and Home) * Bicarbonate and acid concentrate jugs must be labeled to identify their contents. * Bicarbonate jug connectors must be color coded “blue”. * Acid jug connectors must be color-coded “red”. * Secondary Containers into which acid concentrate has been transferred from an original labeled container must be labeled with the product name, and the appropriate hazard warnings (HMIS) label. * Acid concentrate jugs must be identified by acid type catalog number. Acid concentrate jug labels must identify the chemical constituents. See the following example. The manufacturer’s product label may also be copied and applied to the acid concentrate jug. If using a copy of the manufacturer’s label, the expiration date and lot number must be marked through.” An interview was conducted with Staff #1 on 08/26/2024 at 10:30 AM. Staff #1 stated “We reuse the acid jugs for each patient. Each jug is used by the same patient. We are supposed to write their name on the jug.” Staff #1 confirmed that there were no patient identifiers written on the jugs and that the staff did not follow the facility’s policy.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 48749 Based on observation, record review, and staff interview, the facility staff failed to follow the manufacturer’s guidelines and ensure the conductivity solution bottle located in the treatment area was within the stability timeframe and the facility staff failed to ensure the RO (reverse osmosis) water had been labeled with a date. Also, the facility staff failed to follow the facility’s “Test Strips and Solutions” guidelines. These findings had the likelihood to cause harm to all patients if the conductivity solution to verify the conductivity of the dialysis machines was not within the stability guidelines recommended by the manufacturer. Expired conductivity solutions can lose accuracy over time. Findings include: During a tour of the treatment floor on 08/26/2024 at 10:20 AM revealed the following: In the isolation room, a bottle of conductivity standard solution was labeled with an opening date of 07/05/2024. There was no discard date listed. The manufacturer’s label on the bottle reads discard solution 30 days after opening. A review of the facility’s “Test Strips and Solutions” guidelines dated 01/19/2015 revealed the following: “Please be aware ALL test strips and solutions must be dated and initialed when first opened. (On the side of the bottle) The reason for this: the products’ stability starts to deteriorate once opened. Below is a current list of the products used in most FMC clinics along with their associated stability timeframes. Note: stability varies by manufacture. Product must be discarded once the timeframe has been reached. Should you come across one that is not listed below the info is generally available with product insert. Myron L. Conductivity Standard Solutions- Exp.Date” The manufacturer’s instructions for the conductivity standard solution state “Discard solution 30 days after opening. Discard solution if the cap is loose, the bottle has been left open, or the solution has been frozen.” An interview with Staff #1 on 08/26/2024 at 10:45 AM acknowledged that the conductivity solution located in the isolation room was expired per the manufacturer’s guidelines and the facility’s “Test Strips and Solutions” guidelines. 48653 During a tour of the facility’s in-center treatment area with Staff # 1 on 08/26/2024 at 10:50 AM the surveyor observed the facility staff had failed to label the RO (Reverse Osmosis) water located at the conductivity station with a date. There was no way to determine when the RO water had been changed out. In an interview with Staff # 1 on 08/26/2024 at 10:50 AM, Staff # 1 acknowledged the RO water had not been labeled with the date it was changed.”

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 29191 Based on observation, record review, and staff interview: A. the facility staff failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the dialysis center. Also, the facility staff failed to follow the facility’s, “General Cleanliness and Infection Control Guidelines” policy. Cross Refer to Tag V 111 B. the facility’s direct care staff failed to ensure eye protection was worn while performing procedures during which spurting or splattering of patient blood might occur. Cross Refer to Tag V 115 C. it was determined that the facility staff failed to ensure medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. The facility staff failed to comply with the facility’s policy titled, “Receiving and Stocking Medications.” Cross Refer to Tag V 117”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 29191 Based on record review and interview: A. the facility failed to:ensure that staff members were not removing greater than 13 ml/kg/hr of fluid on 1 (#8) of 4 patients’ treatment sheets reviewed. Also, the staff failed to follow the facility’s “Patient Assessment and Monitoring” policy. Cross Refer to Tag V 543 B. the Social Worker failed to complete assessments on 3 ( #4, #18, and #19) of 3 patients to provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. Cross Refer to Tag V 552 C. the governing body failed to have documented evidence that all patients were seen by their nephrologist once a month for 1 of 3 patients (Patients #9, #10, and #20) in the month of May 2024. Cross Refer to Tag V 560”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 29191 Based on record review and interview, A. the governing body and facility staff failed to review the “Dialysis Facility Report for Fiscal Year 2024” in the Quality Improvement meetings. Cross refer to Tag V 628 B. the facility staff failed to set priorities for performance improvement, considering the prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes or patient safety with infection control and missed treatments. Cross refer to Tag V 639”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 48749 Based on record review and interview, the facility staff failed to provide documented evidence that fire drills were conducted with facility staff and patients every quarter. The staff failed to follow the facility’s “Fire Drill “ policy. This deficient practice has the likelihood to cause harm to the health and safety of the 35 in-center and 4 home Peritoneal Dialysis (PD) patients receiving dialysis treatments in the facility. The facility treats patients on Monday, Wednesday, and Friday with 3 shifts on every treatment day. A review of facility policy titled, “Fire Drill “ dated 08/02/2017 revealed the following, “The purpose of this policy is to guide FKC staff when performing a fire drill or in the event of a fire within the facility. Part 494 Conditions for Coverage for End Stage Renal Disease (ESRD) facilities, through the inclusion of the NFP A Life Safety Code (LSC) 2000 requires each facility to have written policies and procedures for handling emergencies related to fire and other potential disasters that may threaten the health and safety of patients. These requirements include a facility-specific plan and the involvement of staff and patients in performing emergency drills. * Quarterly, all FKC facilities shall perform a fire drill for each shift of patients and staff including Home Therapies patients present in the facility and Nocturnal shifts. * In addition to the drill, activation of the fire alarm once per staff shift shall occur to: * Ensure the alarm system is working and simulation of emergency fire conditions. * Ensure each shift of staff working in the facility are familiar with the signals and emergency action required during a fire. * Verification that the fire alarm signal was received by the contracted monitoring service must occur. * When possible, outpatient programs that also provide services to home patients should schedule drills at a time when home patients are in the facility and will be included in the drill. * Patients are not required to be moved during drills to safe areas or to the exterior of the building. * Patients should be able to verbalize how they would disconnect themselves from the machine and evacuate the facility, or if unable, how they will be evacuated. * Upon hire and annually with drills, all staff members will be trained in the policy and procedure, the use of portable fire extinguishers, and their duties under the Facility Fire Safety Plan. * Quarterly with drills, all staff members will review the use of a fire extinguisher per the Environmental, Health & Safety Manual, Fire Prevention, Portable Fire extinguishers, and Means of Egress (exit) Program and the location of the facility fire extinguishers. * Document patient participation in fire and disaster drills on the Patient Participation in Fire and Disaster Drills form. * Patients who are absent during drills shall be provided with a verbal review of fire drill procedures by staff upon their return to the facility. Documentation of the review should be done on the Patient Participation in Fire Drills form. * Document fire drills, alarms, and signals received by the monitoring services or fire department, and patient and staff participation on the QAI checklists.” Surveyor requested fire drills 3 different times on 07/15/2024 and no documentation was provided. Surveyor requested again on the morning of 07/16/2024 of the survey and no documentation was provided. An interview with Staff #1 and Staff #3 on 07/16/2024 at 4:00 PM confirmed the facility staff was unable to provide documented evidence that fire drills and patient education had been conducted.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 48749 Based on observation and interview, the facility’s staff failed to ensure one oxygen E-cylinder was secure in an oxygen tank holder. This deficient practice had the likelihood to cause harm to a dialysis patient if an unsecured oxygen tank was knocked over, it can break and release pressurized oxygen rapidly, which could cause the tank to fly through the air. The escaping gas can also damage the cylinder’s valves, which can propel the tank like a missile. Damaged cylinders can have enough force to break through walls and pose a serious risk of injury or death. Findings included: During a tour of the facility on 07/16/2024 at 9:30 AM, it was observed that one oxygen E-cylinder was free-standing on the treatment floor and not secured in an oxygen tank holder. An interview with Staff #13 and Staff # 15 on 07/16/2024 at 9:40 AM confirmed that one oxygen E-cylinder was not secure in an oxygen tank holder.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 48749 Based on observation, record review, and staff interview, the facility staff failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the dialysis center. Also, the facility staff failed to follow the facility’s, “General Cleanliness and Infection Control Guidelines” policy. This deficient practice had the likelihood to cause harm to patients, staff members, and the public by increasing the risk of transmission of infectious agents within the facility. During a tour of the facility on 07/15/2024 at 10:30 AM, the surveyor observed the following infection control issues in the supply room, in-center treatment area, and the laboratory. Findings Include: SUPPLY ROOM: * Observed a buildup of a dried white liquid substance and paper trash on a cart holding chemical jug supplies. *Observed open cardboard boxes were sitting on top of the containers with sterile supplies. * Observed cardboard boxes mixed in together with sterile supplies on the shelf. There was an open bag of gowns sitting on top of the container. *Observed a build-up of dust and dead insects on the lids of the containers storing sterile supplies. *Observed an accumulation of open cardboard boxes on the floor in front of the emergency exit in the storage area. “External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust.” (AAM1 ST46-Section 5.2 Receiving items). IN-CENTER TREATMENT AREA: *Observed an unknown clear substance dried on the base of the blood pressure machine. The tubing that connects the blood pressure cuff to the blood pressure machine was lying on the floor. *Observed the sling for the Hoyer lift (medical equipment used for lifting and transferring patients safely) was lying on top of the oxygen E-cylinders. *Observed a metal rack holding patient supplies. The rack was peeling, corroding, and rusting all along the frame. * Observed 3 expired suction tubes with Yankauer tips dated 06/05/2024 in the airway drawer of the emergency crash cart. *Observed an open bottle of RO (a reverse osmosis system is the primary method for purifying water for dialysis treatment) water sitting on the counter next to the sink. There was no cap found on the RO bottle which allowed contaminates to enter the purified water bottle. *Observed a build-up of dust on the drawer handles and inside the drawers of the refrigerator at the in-treatment nurse’s station. *Observed a build-up of an unknown dried liquid substance on the bottom of the door of the refrigerator at the nurse’s station. Also, there was an unknown spilled substance dried on the inside of the door. *Observed an opened bottle of hand sanitizer that was not labeled with the date of opening or with the staff’s initials that opened the bottle. *Observed a used sink sponge sitting next to the hand soap at the handwashing sink. There was a buildup of an unknown substance on the sponge. LABORATORY: *Observed in the cabinet above the sink, there were 27 expired lab tubes dated 06/30/2024. *Observed an expired Seracult Single Slides (a lab test used for testing blood in fecal matter) box, dated 04/28/2024. *Observed a build-up of dirt and debris on the shelves of the refrigerator in the lab room. Also, there was a dead insect at the bottom of the refrigerator. *Observed in a cabinet, there were two sets of expired blood culture bottles dated 05/11/2024 and 07/13/2024. *Observed an expired bottle of glucometer test strips dated 12/17/2022. Also, there was an expired set of glucometer control solutions dated 06/01/2022. All 3 bottles were opened and did not have a date of opening or a staff member’s initials written on the outside of the bottles. A review of the facility’s policy titled, “General Cleanliness and Infection Control Guidelines” dated July 1, 2024, revealed the following: “The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staff, and visitors. * All areas must be kept clean and organized, including but not limited to the treatment area, water/supply room, and offices. Walkways must be kept clear of debris and free of clutter. * Facilities must adhere to any state-specific regulations that pertain to facility cleaning and disinfection. * Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. * Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or benchtops where blood or other potentially infectious materials are present. * Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. * Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility. * Supplies or patient’s belongings should not be kept or stored behind the machine at the patient station.” An interview with Staff #1, Staff #13, and Staff #15 on 07/16/2024 at 8:30 AM confirmed the infection control and safety issues found in the storage room, in-center treatment area, and laboratory.”

“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: 48653 Based on observation, the facility’s direct care staff failed to ensure eye protection was worn while performing procedures during which spurting or splattering of patient blood might occur. During a tour of the facility’s in-center treatment area on 07/15/2024 at 10:56 AM, the surveyor observed Staff # 18 without eye protection at Station # 13. Staff # 18 was observed with the eye shield on upside down and Staff # 18’s eyes and face were not protected from the splattering of blood. The staff member then went to Station # 11 and Station # 12 without eye protection. Staff # 18 had a total of 3 separate patient encounters without eye protection. During an interview with Staff # 14 on 07/15/2024 at 11:15 AM, Staff # 14 acknowledged Staff # 18 did not have proper eye protection and instructed Staff # 18 to place eye protection on correctly while providing direct patient care.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48653 Based on observation, record review, and interview, it was determined that the facility staff failed to ensure medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. The facility staff failed to comply with the facility’s policy titled, “Receiving and Stocking Medications.” Findings Include: During a tour of the facility’s in-center treatment area on 07/15/2024 at 11:45 AM, the surveyor observed the following medications unlocked and accessible to unauthorized persons. *Fifty-one vials of Heparin (a blood thinner) *Eighteen vials of Vancomycin (antibiotic) *Eighteen vials of Gentamycin (antibiotic) *Twenty vials of Cefepime (antibiotic) *Twenty-five vials of promethazine (antiemetic) A review of the facility’s policy titled, “Receiving and Stocking Medications” with a revision date of 11/7/2022 stated, “Ensure that all medications are secured in a lockable cabinet or medication refrigerator. Ensure that the medication cabinet and medication refrigerator are properly locked for the security of medications and that the medication keys are kept in the care of the responsible nurse.” During an interview with Staff # 13 on 07/15/2024 at 11:45 AM, Staff # 13 was asked why the medications were unlocked and accessible to unauthorized persons. Staff # 13 acknowledged the medications should have been locked up and safeguarded. Staff # 13 then proceeded to lock the drawers that contained the medications.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 48749 Based on observation and interview, the facility staff failed to check and maintain the salt pellets above the water halfway mark in the brine tank. This deficient practice had the likelihood to cause the water to become hard, failure to ensure adequate salt levels in the brine tank can lead to water hardness in the system at levels unacceptable for dialysis being performed on patients. Findings include: During a tour of the facility’s water room on 07/15/2024 at 10:40 AM observed the salt pellets were below the water level in the brine tank. An interview was conducted with Staff # 15 on 07/15/2024 at 10:45 AM. Staff # 15 visualized and confirmed the salt pellets in the brine tank were below the water line.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48749 Based on observation, record review, and interview, the facility’s staff failed to ensure the filters on 4 of 4 oxygen concentrators were cleaned weekly per the facility’s “Routine Administration of Oxygen” policy and available for patient use. During a tour of the facility on 07/15/2024 at 10:30 AM, it was observed that 1 of 4 oxygen concentrators on the in-center floor were being used for patient care. A review of the oxygen concentrator filter weekly cleaning log for May and June 2024 revealed the following: Concentrator #1(Serial Number (SN) 0102) in the month of May, the filter was not cleaned the 3rd week of May. Concentrator #1(SN-0102) in the month of June, the filter was not cleaned the 3rd week of June. Concentrator #2(SN- 0104) in the month of May, the filter was not cleaned the 3rd week of May. Concentrator #2(SN-0104) in the month of June, the filter was not cleaned the 3rd week of June. Concentrator #3(SN-0114) in the month of May, the filter was not cleaned the 3rd week of May. Concentrator #3(SN-0114) in the month of June, the filter was not cleaned the 3rd week of June. Concentrator #4(SN-4369) in the month of May, the filter was not cleaned the 3rd week of May. Concentrator #4(SN-4369) in the month of June, the filter was not cleaned the 3rd week of June. A review of the facility’s “Routine Administration of Oxygen” policy dated 11/01/2021 revealed the following: “The purpose of this policy is to provide guidance for the safe use and handling of oxygen concentrators when used in the dialysis facility. * Oxygen concentrators will be used for routine non-emergent administration of oxygen therapy. * A physician’s order is required to administer oxygen routinely to a patient in the dialysis facility. * No smoking is allowed in any area where oxygen is in use or in dialysis facilities. * Oxygen concentrators must be maintained in accordance with the manufacturer’s instructions for use. * Shall be serviced according to the facility’s preventive maintenance schedule. * Should be placed away from furniture and walls to allow fresh air into the air inlet on the concentrator. * Are surfaces disinfected after patient use. (See additional cleaning guidelines on page 5 Cleaning the Oxygen Concentrator). 3. Remove each filter and clean filters with warm soapy water and rinse thoroughly on a weekly basis. 4. Dry filters and reinstall. 5. Include concentrator equipment on a preventative maintenance schedule to be evaluated by a qualified technician.” A review of the manufacturer’s guidelines revealed the following: “Routine Maintenance: At a minimum, preventative maintenance must be performed according to the maintenance record guidelines. In places with high dust or soot levels, maintenance may be performed more often. 1. Remove filter and clean at least once a week depending on environmental conditions. 2. Clean the cabinet filter with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry filter thoroughly before reinstalling.” An interview with Staff #14 on 07/16/2024 at 4:00 PM confirmed the air intake filters on the oxygen concentrators were not cleaned weekly per the facility policy. Staff #4 reported “I am the one who takes care of the filters. If I am out or at another clinic, they don’t get done.””

“PR-PTS INFORMED OF RIGHTS WHEN BEGIN TX CFR(s): 494.70 The dialysis facility must inform patients (or their representatives) of their rights (including their privacy rights) and responsibilities when they begin their treatment and must protect and provide for the exercise of those rights. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility staff failed to ensure a properly executed informed consent for hemodialysis treatment was completed for 4 (# 3, # 4, # 8, and # 9) of 4 patient medical records reviewed. Patient # 3 A review of medical records for Patient # 3 revealed the patient was admitted to the facility on July 3rd, 2024. A review of the patient’s “Confirmation of Consent for In-Center Hemodialysis Treatment” revealed there was no time on the informed consent. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no time on the consent form. Patient # 4 A review of medical records for Patient # 4 revealed the patient was admitted to the facility on February 2nd, 2023. A review of the patient’s “Confirmation of Consent for In-Center Hemodialysis Treatment” revealed there was no time on the informed consent. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no time on the consent form. Patient # 8 A review of medical records for Patient # 8 revealed the patient was admitted to the facility on September 13th, 2023. A review of the patient’s “Confirmation of Consent for In-Center Hemodialysis Treatment” revealed there was no time on the informed consent. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no time on the consent form. Patient # 9 A review of medical records for Patient # 9 revealed the patient was admitted to the facility on May 17th, 2023. A review of the patient’s “Confirmation of Consent for In-Center Hemodialysis Treatment” revealed there was no time on the informed consent. It was unknown if the consent form was signed before the patient’s first dialysis treatment because there was no time on the consent form. A review of the facility’s policy, “Informed Consent” with a revision date of 06/20/2018 revealed the following, “PURPOSE: The purpose of this policy is to ensure each patient or authorized decision maker has authorized to perform designated procedures. RESPONSIBILITY: Nephrologist, physician extended, or licensed nurse (as defined by job description, license, certification, and State and Federal Regulation). Prior to starting dialysis, the patient will have spoken to his or her physician(s), a physician extended, who will have explained dialysis therapy, alternatives, and associated risks, benefits, and consequences. The nurse may reinforce this information while obtaining a signature on the consent and answer any questions raised by the patient. It is inappropriate to have the consent reviewed with the patient by other non-medical personnel such as a social worker or facility clerical staff. Although these persons may explain various aspects of treatment and have expertise in their area of work, the person reviewing the consent requires a broader scope of knowledge ...” During an interview with Staff # 1 on 07/16/2024 at 10:30 AM, Staff # 1 acknowledged the Informed Consents for Hemodialysis Treatment did not have a time and it could not be determined if the consent was signed by the patient and/or patient’s representative before the first hemodialysis treatment.”

“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: 48749 Based on record review and staff interview, the facility staff failed to follow the physician’s prescribed orders for blood flow rate (BFR) in 2 (#3, #8) of 4 medical records reviewed. Also, the facility staff failed to follow the facility’s “Patient Assessment and Monitoring” policy. This deficient practice had the likelihood to harm patients by not following the physician’s dialysis orders which could negatively impact the effectiveness and adequacy of the dialysis treatment for all 35 in-center hemodialysis patients receiving care at this facility. Findings Include: A review of the facility’s “Patient Assessment and Monitoring” policy” dated 05/01/2023 revealed, “The purpose of this policy is to provide guidance to FKC direct patient care staff on assessment and monitoring patients before, during, and after treatment. Check machine settings and measurements: * Check prescribed blood flow is being achieved or the reason is documented in the medical record if unable to meet prescribed blood flow. * Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” Patient # 3 A review of 2 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR on treatment dates 07/03/2024 and 07/05/2024. A review of the treatment sheet dated 07/03/2024 revealed the following, “Dialysis Prescription: Blood Flow Rate: 350 ml/min (milliliters per minute) Dialysate Flow Rate: 700.00 ml/min” Staff #13 documented the following BFR throughout the patient’s treatment, “ 1:07 PM: BFR- 400 1:35 PM: BFR- 400 1:50 PM: BFR- 400” There was no documented order from the physician to adjust the BFR for this treatment date. A review of the treatment sheet dated 07/05/2024 revealed the following, “Dialysis Prescription: Blood Flow Rate: 400 ml/min (milliliters per minute) Dialysate Flow Rate: 700.00 ml/min” Staff # 20 and Staff #13 documented the following BFR throughout the patient’s treatment, “11:14 AM: BFR- 350 11:34 AM: BFR- 350 12:03 PM: BFR- 350” Staff # 20 documented the following on 07/05/2024 at 11:14 AM: “BFR 350. Treatment started.” There was no documented order from the physician to adjust the BFR for this treatment date. Patient # 8 A review of 1 of 6 treatment sheets revealed facility staff did not follow the physician’s prescribed orders for BFR on treatment dates 07/05/2024. A review of the treatment sheet dated 07/05/2024 revealed the following, “Dialysis Prescription: Blood Flow Rate: 400ml/min (milliliters per minute) Dialysate Flow Rate: 500.00 ml/min” Staff # 7 and Staff #13 documented the following BFR throughout the patient’s treatment, “ 5:30 AM: BFR- 300 6:02 AM: BFR- 300 6:31 AM: BFR- 400 7:08 AM: BFR- 300 7:33 AM: BFR- 300 8:37 AM: BFR- 400” There was no documented order from the physician to adjust the BFR for this treatment date. An interview was conducted with Staff # 13 on 07/16/2024 at 10:50 AM. Staff # 13 stated, “We follow the prescription and have to verify it is correct before the machine will allow us to push the start button. We also run access testing which will change the BFR” Staff # 13 was unable to verify why the patient’s BFR was not followed or if the listed dates were access testing dates. There was no documentation on the treatment sheets supporting access testing.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility’s interdisciplinary team failed to ensure a comprehensive reassessment was completed within three months of the initial patient assessment on 1 (#20) of 4 patient medical records reviewed. Patient # 20 Patient # 20 was admitted to the facility on 3/4/2024. The initial comprehensive assessment was completed on 3/20/2024. There was no comprehensive assessment completed in 06/2024, three months after the initial, for Patient # 20. During an interview with Staff # 1 on 07/15/2024 at 2:30 PM, Staff # 1 acknowledged there was no three-month comprehensive assessment completed by the facility’s IDT for Patient # 20 in June of 2024.”

“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: 48749 Based on record review and interview, the facility failed to ensure that staff members were not removing greater than 13 ml/kg/hr of fluid on 1 (#8) of 4 patients’ treatment sheets reviewed. Also, the staff failed to follow the facility’s “Patient Assessment and Monitoring” policy. These deficient practices had the likelihood to cause weakness, cramping, and nausea to all patients receiving care at the facility. Findings included: A review of Patient #8’s treatment sheets revealed the facility staff was pulling greater than 13 ml/kg/hr. A review of the treatment sheet for Patient #8 dated 07/12/2024, facility staff removed 15.6 ml/kg/hr of fluid. A review of the facility’s “Patient Assessment and Monitoring” policy revealed, “The purpose of this policy is to provide guidance to FKC direct patient care staff on assessment and monitoring patients before, during, and after treatment. 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 notes 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. Monitor UF rate: NOTE: Ultrafiltration rates greater than 13 ml/kg/hr should be avoided if possible, by providing adequate prescribed dialysis duration, and scheduling of additional treatments if medically necessary. Check machine settings and measurements: * Check prescribed blood flow is being achieved or the reason is documented in medical record if unable to meet prescribed blood flow. * Check dialysate flow rate setting is correct, and the prescribed flow is being delivered. * Check arterial pressure is less than negative 250mmHg. Monitor high venous pressure for infiltration or clotting. * Check the amount of fluid removed. * If heparin pump is used, ensure heparin is infusing at the prescribed rate. * Record value of each KECN obtained after each O LC test.” An interview was conducted with the Staff #1 and Staff # 13 on 07/16/2024 at 1:45 PM. Staff #1 stated “I audit 3 patient treatment sheets a month. When I do my audits, I do not calculate the pull rate manually. The machine tells me how much is pulled off of each patient.” Staff # 13 stated “The machine does the calculations for the pull rate. The nurses rely on the machine to calculate how much fluid is pulled off their patients during treatment.” During the visit, Staff #1 and Staff # 13 could not tell the surveyors a formula for manually checking patient fluid pull or how to use a formula to calculate the machines accuracy in patient fluid pulls.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 29191 Based on record review and interview, the Social Worker failed to complete assessments on 3 ( #4, #18, and #19) of 3 patients to provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. “At regular intervals” means that the assessment survey is administered by the time of the first reassessment (i.e., within 4 months of the initiating treatment). KDQOL -Kidney Disease Quality of Life survey assessment tool Findings include: This facility operates Monday, Wednesday, and Friday. Upon reviewing the medical record of patient #4, it was found that they were admitted on February 3, 2023. The standard KDQOL-36 assessment survey had not been completed. Upon reviewing the medical record of patient #18, it was found that they were admitted on January 29, 2024. The standard KDQOL-36 assessment survey had not been completed by the social worker. Upon reviewing the medical record of patient #19, it was found that they were admitted on March 11, 2024. The standard KDQOL-36 assessment survey had not been completed by the social worker. An interview with the social worker on 7/15/2024 at 2:30 PM confirmed that the assessments were missed. The Social Worker was covering 2 other facilities (a total of 3) and her patient load was 184+. One of the facilities was over an hour and 30 minutes away and the other facility was an hour away. The social worker stated, “I have 75 patients in one facility, the next facility I have 76 plus 10 peritoneal dialysis patients, and in this facility, I have 35 patients plus 4 peritoneal dialysis patients. I only see patients once a week at this facility.””

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 29191 Based on record review and interview, the governing body failed to have documented evidence that all patients were seen by their nephrologist once a month for 1 of 3 patients (Patients #9, #10, and #20) in the month of May 2024. Findings included: There was no documented evidence in Patient’s #20 clinical record that the patient had been seen by their nephrologist in the month of May 2024. Physician #2 had documented that a chairside visit had been made per the “Provider Rounding Note Basic” “I met a face to face with the patient today.” A review of the treatment sheet for patient #20 revealed the patient was a no show and there was no documentation on the treatment flow sheet. A review of Governing Body meeting minutes revealed that the facility’s policy was that the Medical Director (which was the patient’s nephrologist) was to visit the facility twice a month and this had not been met. An interview with Staff #3 (Director of Operations) on 7/16/2024 at 1:35 PM, confirmed the patient had not been seen by their nephrologist in the monthly timeframe and the facility Medical Director’s policy was not followed. Also, the Physician #2 documented a chairside visit that did occur due to the patient was a no show at the facility.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 29191 Based on record review and interview, the governing body and facility staff failed to review the “Dialysis Facility Report for Fiscal Year 2024” in the Quality Improvement meetings. These deficient practices had the likelihood to harm all patients receiving care in the facility. Findings: A review of the Quality Improvement meeting minutes from May through June 2024 revealed the facility had failed to acknowledge the findings reported in the “Dialysis Facility Report for Fiscal Year 2024”. The following were some outcomes that were revealed in the “Dialysis Facility Report for Fiscal Year 2024” and not discussed in the quality meetings. * 33% of these patients were not under the care of a nephrologist before starting dialysis, compared to 21% in your State, 21% in your Network, and 16% nationally. * 67% of these patients were informed of their transplant options, compared to 95% in your State, 95% in your Network, and 93% nationally. * 99% of eligible hemodialysis patient months had a Kt/V >=1.2 reported, compared to 97% in your State, 97% in your Network, and 96% nationally. * At this facility, the 2019-2022 SMR (Standardized Mortality Ratio) is 1.60, which is 60% more deaths than expected at this facility. Among all U.S. facilities, 96% of facilities had a four-year SMR lower than 1.60. * At this facility, the 2019-2021 first-year SMR of observed to expected deaths is 2.28, which is 128% more deaths than expected at this facility. Among all U.S. facilities, 96% of facilities had a first-year SMR lower than 2.28. * The percentage of Medicare dialysis patients at this facility hospitalized with septicemia during 2019-2022 is 20%, compared to 14% in your State, 14% in your Network, and 12% nationally. In an interview with the Facility Administrator on 07/16/2024 at 3:00 PM; while going through the Quality indicators revealed the Dialysis Facility Report for the facility outcomes had not been discussed in quality meetings or with the Governing body.”

“QAPI-PRIORITIZING IMPROVEMENT ACTIVITIES CFR(s): 494.110(c) The dialysis facility must set priorities for performance improvement, considering prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes or patient safety. This Standard is not met as evidenced by: 29191 Based on record review and interview, the facility failed to set priorities for performance improvement, considering the prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes or patient safety with infection control and missed treatments. Findings included: A review of the quality dashboard for the month of June 2024. The dashboard system referenced 2 (#5 and #18) patient infections. There were 8 more patients listed on the infection control log that were presented to the surveyor. Patients #10, #11, #12, #13, #14, #15, #16, and #17 had various types of infections. The infections were sepsis, Arterial vascular grafts, Urinary tract, and gangrene of the toe. The gangrene of the toe which ended with an amputation of the leg. None of the 8 patients were listed on the quality dashboard. Further review of the quality dashboard showed missed treatments with 62.5% of missed treatments. The only action for correcting the missed treatments was education. The social worker at the facility had over 184 + patients and was covering 3 dialysis facilities. Leadership had appointed Staff #5 a new registered nurse with the title, “Champion” (champion was a staff member that takes accountable for a facility problem ). Staff #5 works the treatment floor full time There was no leadership involved in investigating and prioritizing the problems. There was no evidence in the quality meeting that the leadership had identified problems and given priority to improvement activities that would affect clinical outcomes. An interview with the Facility Administrator on 07/16/2024 at 3:30 PM acknowledged that the facility staff had identified problems and given priority to improvement activities that would affect clinical outcomes.”

“LAB-CLIA LABS/MEET NEEDS OF PTS CFR(s): 494.130 The dialysis facility must provide or make available, laboratory services (other than tissue pathology and histocompatibility) to meet the needs of the ESRD patient. Any laboratory services, including tissue pathology and histocompatibility must be furnished by or obtained from, a facility that meets the requirements for laboratory services specified in part 493 of this chapter. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure 12 of 12 patient blood specimens were refrigerated, packaged, and shipped to the laboratory for processing. Also, the facility’s direct care staff failed to follow the facility’s policy, “Drawing Labs Pre and Post Treatment Procedure”. This deficient practice had the likelihood of delaying care and treatment due to the facility’s failure to properly handle and process patient blood specimens. The facility was open Monday, Wednesday, and Friday for patient treatments and was closed on Tuesday, Thursday, Saturday, and Sunday. During a tour of the facility’s in-center treatment area on Monday, 07/15/2024 at 11:30 AM the surveyor observed the following: One yellow-top blood specimen for Patient # 18 sat at room temperature for more than 4 hours. The surveyor first observed the lab tube sitting out at room temperature at 11:31 AM. The surveyor went back at 3:30 PM to check if the specimen had been placed in the refrigerator and the specimen remained sitting out at room temperature. During a tour of the facility’s in-center treatment area on Tuesday, 07/16/2024 at 9:30 AM the surveyor observed the following: One green-top blood specimen for Patient # 5 was found sitting in the lab centrifuge (a device that separates materials of different particle sizes and compositions) at room temperature. The blood specimen had been sitting out at room temperature overnight for more than 12 hours. The surveyor opened the laboratory refrigerator at 9:35 AM and observed 10 patient blood specimen lab tubes in the refrigerator. The 10 lab tubes had not been shipped off for processing as required by the facility’s policy. The labs were not processed and therefore caused a delay in the results of the blood specimens. A review of the facility’s policy, “Drawing Labs Pre and Post Treatment Procedure” with a publication date of 09/05/2023 revealed, “PURPOSE: The purpose of this document is to provide guidance for drawing labs pre and post-treatment using a central venous catheter (CVC) or arteriovenous fistula or graft (AVF/AVG). POLICY: Labs will be drawn prior to heparin administration and prior to initiation of treatment as ordered by the treating physician, unless labs are ordered for intra and post-treatment. All labs will be obtained following the same process to ensure the consistency and accuracy of results ... PREPARING LAB DRAWS FOR TRANSPORT: 2. Ensure all blood specimen tubes/bottles are labeled, placed in the appropriate specimen bag, and sent to the lab according to Contracted Entity Policy.” An interview was conducted with the Facility Administrator, Staff # 1 on 07/16/2024 at 9:40 AM in the laboratory area. Staff # 1 acknowledged the lab specimens did not get sent to the laboratory for processing. Staff # 1 acknowledged the deficient practice resulted in a delay of care to the patients receiving treatment at the facility. Staff # 1 stated, “It is my responsibility to make sure the labs get sent. We will get the specimens sent off today.””

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 29191 Based on record review and staff interview, the facility’s social worker had a patient load of 184+ patients, which exceeds her limit per the State guidelines are 1 social worker to 100 patients with up to 125 patients with clerical support. This deficient practice had the likelihood to cause harm to patients due to psychological assessments not being completed. The facility’s failure to allow the social worker the time to address the psychological needs of the patient had the likelihood to cause harm to the patient’s mental support and counseling needs. “ Findings included: This facility was open Monday, Wednesday, and Friday. In an interview with the Social Worker, she stated, “I only come to this facility one day a week.” A review of medical records for patient #4 revealed there was no documentation available for ongoing evaluation and assistance with psychosocial needs for the unstable patient. The patient was deemed unstable in April 2024 by the Interdisciplinary team. There were no social work assessments for the month of May or June. The only documentation was on the annual and initial assessment and 90-day plan of care. There were no periodic updates on the status of the patients from the social worker. Patient #4 had been in the hospital/rehabilitation since April 12, 2024. Patient #4 was in the hospital from April 12, 2024, through 04/23/2024 and then patient #4 was admitted to a rehabilitation hospital from 04/23/2024 through 06/19/2024. Patient #4 then went back into the hospital from 06/19/2024 through 07/01/2024. Patient #4 was staying with his elderly father who has a provider. During the hospital admission patient had surgery consisting of a bilateral amputee with deep wounds on the buttocks to the bone. The patient has not been to the facility since April 12, 2024. The patient was again hospitalized from 07/12/2024 through 07/13/2024. There was no documentation in the medical record from the social worker. The surveyor was able to get information from the administrative assistant by calling and obtaining the discharge summary from the hospital. An interview with the social worker on 7/15/2024 at 2:30 PM confirmed that the assessments were missed. The Social Worker was covering 2 other facilities (a total of 3) and her patient load was 184+. One of the facilities was over an hour and 30 minutes away and the other facility was an hour away. The social worker stated, “I have 75 patients in one facility, in the next facility I have 76 plus 10 peritoneal dialysis patients, and in this facility, I have 35 patients plus 4 peritoneal dialysis patients. I can’t keep up. I probably get 10 calls a day from this unit needing assistance.” In an interview with the Facility Administrator on 07/16/2024 at 11:00 AM surveyor asked about patient #4. The only information obtained was that the patient had not dialyzed since April 12, 2024 (3 months ago), and that the patient had been in the hospital. There was no follow-up or assessment of patient #4’s condition. Patient #4 was listed as an unstable patient, but there was no documentation by the interdisciplinary team of what was the condition or whereabouts of patient #4.”