San Gabriel Nephrology Services, LLC

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 51860 Based on observation and record review, the facility failed to ensure the facility’s most current CMS (Centers for Medicare and Medicaid Services) QIP (Quality Incentive Program) Performance Score Certificate was posted in a place accessible to the patients. QIP scores penalize facilities for poor performance and rewards high performance, with results publicly reported. The deficient practice had the potential for patients and visitors to not be informed of the facility’s standing in regard to Clinical Measures of Quality ratings. Findings: During an observation on 12/10/2025 at 1:00 p.m. in the facility’s waiting area, a CMS QIP Performance Score Certificate observed. The certificate was dated for the performance year 2014. The certificate indicated the data Clinical Measures of Quality are from the year 2012. During a review of the Code of Federal Regulations (CFR), 42 CFR § 413.178(f)(3) indicated, “CMS will provide each ESRD facility with a performance score certificate on an annual basis that describes the TPS achieved by the facility with respect to a payment year. The performance score certificate must be posted by the ESRD facility within 15 business days of the date that CMS issues the certificate to the ESRD facility, with the content unaltered, in an area of the facility accessible to patients.””

“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: 51860 Based on observation, interview, and record review, the facility failed to ensure one of one sampled rooms in the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) facility was cleaned in accordance to the facility’s policy and procedure (P&P) when debris (scattered pieces of waste) was found in various areas of the Reverse Osmosis (RO - a process of purifying water) room floor. This failure had the potential for the RO room to develop and spread acquired infections to the patients and staff or to attract roaches and rodents to the facility. Findings: During a concurrent observation and interview on 12/10/2025 at 2:40 p.m. with Facility Administrator (FA) 1 in the RO room, the floor of the RO room had various areas with debris. FA 1 stated housekeeping addressed trash in the RO room. FA 1 stated the RO room was not a patient care area and would not be cleaned by housekeeping until the end of day. FA 1 stated the priority for housekeeping was to keep patient care areas clean. FA 1 stated the RO room floor could be better kept, especially with the past history of roaches in the dialysis unit. During a review of the facility’s policy and procedure (P&P) titled, “Dialysis Facility Cleaning,” dated 12/01/2009, the P&P indicated, “Scheduling and Description of Services ...h. Water Treatment Areas, i. Nightly, a.) Dust and wet mop floor.””

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 51860 Based on observation, interview, and record review, the facility failed to perform chlorine (a chemical found in water, which in large amounts can negatively impact the dialysis treatment) testing per the facility’s policy and procedure (P&P) on 45 out of 45 sampled days when either chlorine tests were not done, the testing dates were not entered, or the required licensed person’s signature was not entered in the chlorine log sheets. This deficient practice had the potential to negatively impact the well-being of the patients during their dialysis treatments. Findings: During a concurrent interview and record review on 12/10/2025 at 4:10 p.m. with FA 1, the Daily Total Chlorine Testing Log book was reviewed. The book contained an accumulation the year’s weekly chlorine checks performed daily before each set of patients arrive (shifts). Each Daily Total Chlorine Testing Log sheet (log sheet) represented 6 days of chlorine testing with spaces marked for Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday and 4 chlorine testing times per day with printed entry times marked as Opening, 1st Shift, 2nd Shift, 3rd Shift, 4th shift, and 5th Shift. The Daily Total Chlorine Testing Log sheets indicated: 1. For 43 out of the 45 sampled dates, the dates of testing were missing. 2. For six out of 45 sampled dates, the chlorine checks were missing at the 2nd and 3rd shift times. 3. For 39 out of 45 sampled dates, the “Licensed Person Verifying Result’s Are Appropriate” signature was missing. During an interview on 12/10/2025 at 2:45 p.m. with Registered Nurse (RN) 1, RN 1 stated he had not been able to sign off in the licensed person’s line on the Daily Total Chlorine Testing Log sheet today due to being busy with patient care. RN 1 stated water chlorine checks were important because otherwise the patient could get hemolysis (the breakdown of red blood cells) during the dialysis treatment or patients could develop sepsis (a life-threatening blood infection), fever (a rise in body temperature), or chills (a sensation of cold accompanied by shivering). During a concurrent interview and record review on 12/10/2025 at 4:15 p.m. with FA 1, the facility’s policy and procedure (P&P) titled, “Daily Water System Total Chlorine Monitoring,” dated 12/01/2009, was reviewed. The P&P indicated, “If the results of the Total Chlorine testing from the primary carbon filter or set of tanks indicted a level of less than or equal to 0.1 ppm (</= 0.1 ppm), no additional testing is needed until the next patient shift and the results are recorded in the “Daily Water Treatment Log - Routine Total Chlorine Testing” log which contains entries for day, date, patient shift, test time, results, signature of person performing the test and signature of licensed nurse verifying that daily log is completed and results appropriate.” FA 1 stated the chlorine monitoring was important in the dialysis setting and not having correct testing could hurt the patients badly. FA 1 verified the P&P was not followed. FA 1 stated she knew the chlorine checks were completed although the log sheet was not filled out correctly due to staff error. FA 1 verified the omission of dates on the chlorine log sheets would not allow a person to verify which day the daily log entry corresponded to.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 42937 Based on observation, interview and record review, the facility failed to provide a safe environment by leaving two (2) unsecured oxygen cylinder tank in the patient care area. This deficient practice had the potential risk for trips and fall for staff, patients, and visitors, in the event the unsecured oxygen cylinder tank falls or tip over. In addition, if it falls and breaks, it can cause pressurized oxygen to escape rapidly. This pressure can cause the tank to fly through the air, which may cause patient/staff/visitor injury. Findings: During a concurrent observation and interview, on 10/15/2024 at 3:26 p.m. with the Facility Administrator (FA), it was observed that there were (2) unsecured oxygen cylinder tank in the patient care area. The FA stated that the (2) oxygen cylinder tank should have been strapped to the oxygen wall bracket. Strapping the oxygen tank to the wall bracket keeps the oxygen cylinder secure and prevents it from falling or tipping over. During a concurrent interview and record review on 10/17/2024 at 3:30 p.m. with the FA (Facility Administrator), the Monthly Environmental Building Safety and Fire Inspection Checklist, was reviewed. It was noted that the checklist was completed on 10/1/2024. Securing and strapping oxygen cylinder tank was not part of the checklist. During the same interview on 10/17/2024 at 3:30 p.m. with the FA (Facility Administrator (FA) stated that the purpose of the checklist was for facility leaders to do a monthly environmental round and follow the checklist to ensure the safety and well-being of patients, staff, and visitors. FA added that checking to make sure that oxygen cylinder tank was secured and strapped to the wall bracket should have been part of the checklist.”