Davita Union Plaza Dialysis Center

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 27689 Based on record review and interview, facility staff failed to maintain an updated emergency preparedness plan. The findings include: On May 7, and May 8, 2025, a review of the facility’s emergency preparedness plan, showed that the facility failed to update its plan within the required timeframe of a minimum of two (2) years. The most recent update was February 7, 2022. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 27689 Based on record review and interview, facility staff failed to maintain an updated, facility-based, and community-based Hazard Vulnerability Assessment (HVA) in its emergency preparedness plan. The findings include: During a review of the facility’s emergency preparedness plan on May 7, and May 8, 2025, an updated facility and community-based HVA, using an all-hazards approach, was not available for review. The last documented HVA was dated February 7, 2022. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 27689 Based on record review, and staff interview, facility staff failed to establish an emergency plan to address the specific population served within the facility. The findings include: On May 7, and May 8, 2025, a review of the facility’s Emergency Preparedness Plan, showed that its specific patient population, including persons at-risk, were not identified to ensure their needs are addressed in an emergency. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 27689 Based on record review and interview, facility staff failed to include a method to track on-duty staff and patients who may have been transferred or relocated to other facilities for emergency treatments. The findings include: A review of the facility’s Emergency Preparedness Plan on May 7, and May 8, 2025, showed the facility had not established a process to track the location of its on-duty staff and patients in an emergency. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 27689 Based on record review and interview, facility staff failed to include a facility-based emergency evacuation plan in its emergency preparedness plan, that includes the patient’s treatment needs, patient transportation needs, means of communication, and sources of assistance. The findings include: A review of the facility’s emergency preparedness plan on May 7, and May 8, 2025, failed to reveal a facility specific evacuation plan that considers the patient’s care and treatment needs, their transportation and communication needs, and defines staff responsibilities if the facility had to be evacuated. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 27689 Based on record review and interview, facility staff failed to include a facility-based shelter-in-place policy in its emergency preparedness plan, that considers the needs of patients, staff, volunteers and visitors who may be in the facility during an emergency. The findings include: A review of the facility’s emergency preparedness plan on May 7, and May 8, 2025, failed to reveal a facility specific shelter-in-place policy to address the needs of patients, staff, volunteers and visitors remaining in the facility in an emergency. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 27689 Based on record review, and interview, facility staff failed to participate in a full-scale community-based exercise, or a table-top exercise, to test its emergency preparedness plan. The findings include: During a review of the facility’s emergency preparedness plan on May 7, and May 8, 2025, there was no documented evidence that facility staff participated in a full-scale exercise, and a table-top exercise, the last two (2) years, to test the feasibility of its plan. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“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: 49189 Based on policy review, observations, and interview the facility failed to provide a safe and sanitary environment. Findings Include: A review of the facility ’ s ’ Infection Control for Dialysis Facilities ’ policy, revised 04/2023, revealed: “Supplies: b. Expiration date and package integrity will be verified prior to use.” On 05/06/2025 at approximately 10:00 AM the surveyor conducted an observational tour of the facility ’ s treatment floor. The following was identified: - 48 22gauge needles expired 01/31/2023. - One (1) box of 25 gauge 1mililiter syringes with needle attached expired 06/2020. - One (1) 21guage needle expired 03/31/2022. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 49189 Based on policy review, observation, and interview, the facility ’ s In-Center Hemodialysis staff failed to provide aseptic care for one (1) out of four (4) patients observed (Patient #24). Findings Include: A review of the facility ’ s ’ Patient Rights and Patient ’ s Standards of Conduct, Responsibilities, and Facility Rules ’ policy, revised 10/2021, revealed: “Your Rights as a Patient: 8.To receive adequate, safe, sanitary and efficient dialysis treatment and respectful care by competent personnel in a comfortable environment.” A review of the facility ’ s ’ Medication Policy ’ policy, revised 10/2023, revealed: “7. All teammates administering medications must utilize aseptic technique.” On 05/06/2025 at approximately 11:00 AM the surveyor observed the administration of parenteral medication. The following was observed: -Employee #6 failed to perform hand hygiene prior to drawing medication out of vial. -Employee #6 failed to perform hand hygiene prior to changing gloves at Patient #24 ’ s hemodialysis station. On 05/06/2025 at approximately 1:00 PM the surveyor observed the discontinuation of dialysis of Patient #24 ’ s fistula. The following was observed: -Employee #7 Patient Care Technician removed one access on Patient #24 ’ s fistula site then interacted with Patient #24 ’ s hemodialysis machine. Employee #7 then removes the second site without changing gloves. Employee #7 then failed to change gloves after removing the second needle. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 49189 Based on policy review, supporting documentation review, medical record review, and interview the facility failed to complete vaccination series for Hepatitis B and Pneumococcal for eight (8) out of 24 patients sampled (Patient #5, #9, #11, #13, #14, #15, #16, and #17). Findings Include: A review of the facility ’ s ’ Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance ’ policy, revised 04/2024, revealed: “Vaccinate per manufactures guidelines.” A review of the medication Engerix-B ’ Highlights of Prescribing Information ’ revealed under Recommended Dosage and Administration Schedules: “Adults on hemodialysis 0, 1, 2, 6 months.” A review of the facility’s ’ Pneumococcal Vaccination for Adult Patients ’ policy, revised 10/2023, revealed: “To provide guidance per CDC [Centers for Disease Control and Prevention] recommendations for pneumococcal vaccination of patients...” A review of the Centers for Disease Control and Prevention ’ Summary of Risk-based Pneumococcal Vaccination Recommendations ’ dated 10/26/2024, revealed for patients who have received the pneumococcal polysaccharide vaccine (PPSV23): “Wait until at least 5 years have passed since they received their first PPSV23 dose.” A review of Patient #5 ’ s Hepatitis B vaccination administration record revealed the following: -Administration of Engerix-B vaccine on 07/26/2023, 09/29/2023, 10/2023, 01/17/2024, and 08/16/2024. There is no documentation of month 1 administration to coincide with 07/26/2023 series initiation. There is no documentation of completion of series restarted on 08/16/2024. A review of Patient #9 ’ s Hepatitis B vaccination administration record revealed the following: -No documentation of Hepatitis B vaccine administration. A review of Patient #11 ’ s Hepatitis B vaccination administration record revealed the following: -No documentation of Hepatitis B vaccine administration attempts since 11/02/2024. A review of Patient #13 ’ s Hepatitis B vaccine administration record revealed the following: -No documentation of Hepatitis B vaccine administration attempts since 08/10/2024. A review of Patient #14 ’ s Hepatitis B vaccine administration record revealed the following: -Administration of Engerix-B vaccine on 03/07/2024, 08/08/2024, 09/26/2024, and 10/29/2024. There is no month 1, 2, and 6 vaccination for the series initiated on 03/07/2024. Theres is no month 6 vaccination documented for the series initiated on 08/08/2024. A review of Patient #15 ’ s Hepatitis B vaccination administration record revealed the following: -No documentation of Hepatitis B vaccine administration attempts since 08/10/2024. A review of Patient #16 ’ s Hepatitis B vaccination administration record revealed the following: -No documentation of Hepatitis B vaccine administration attempts since 08/09/2024. A review of Patient #17 ’ s Hepatitis B vaccination administration record revealed the following: Administration of Engerix-B on 06/05/2024 and 10/16/2024. There is no month 1, 2 and 6 vaccinations for the series initiated on 06/05/2024. There is no documentation of any other administrations after 10/16/2024. On 05/07/2025 at approximately 11:00 AM the surveyor conducted a face to face interview with Employee #4 Registered Nurse. Employee #4 was confirmed as administrator of the facility ’ s vaccination program. Employee #4 acknowledged the above findings and confirmed that if a patient refuses the Hepatitis B vaccine, then nursing is to educate and ask monthly if the patient would like it.”

“IC-HBV-TEST PTS/STAFF POST LAST DOSE CFR(s): 494.30(a)(1)(i) Hepatitis B Screening: Patients and Staff Test all vaccines [patients and staff] for anti-HBs 1-2 months after last primary vaccine dose. -- If anti-HBs is <10 mIU/mL, consider patient or staff member susceptible, revaccinate with an additional three doses, and retest for anti-HBs. -- If anti-HBs are =10 mIU/mL, consider immune, and retest patients annually. -- Give booster dose of vaccine to patients if anti-HBs declines to <10 mIU/mL and continue to retest patients annually. This Standard is not met as evidenced by: 49189 Based on facility policy review, medical record review, and interview, the facility failed to monitor Hepatitis B Antigen testing per policy for patients with antibody results identifying them as susceptible for 11 out of 24 patients sampled (Patient #5, #8, #10, #11, #12, #13, #14, 15, #16, #17, #18, and #19). Findings Include: A review of the facility ’ s ’ Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance ’ policy, revised 04/2024, revealed under Routine Surveillance Testing that Susceptible patients are defined as having a serum antibody count less than 10. Further policy review revealed that susceptible patients require monthly antigen testing. A review of Patient #5 ’ s Hepatitis B surveillance record revealed the following: -On 08/16/2024 Patient #5 ’ s Hepatitis B antibody is less than 3 making them susceptible. -On 12/09/2024 Patient #5 ’ s Hepatitis B antibody is less than 3 making them susceptible. -There is no documentation of monthly antigen testing till 11/06/2024. -There is no monthly antigen testing for 02/2025. A review of Patient #8 ’ s Hepatitis B surveillance record revealed the following: -On 09/20/2024 Patient #8 ’ s Hepatitis B antibody is documented as 3 making them susceptible. -On 10/25/2024 Patient #8 ’ s Hepatitis B antibody is documented as 4 making them susceptible. -On 12/20/22024 Patient #8 ’ s Hepatitis B antibody is documented as 4 making them susceptible. -There is no monthly antigen testing from 09/2024 to 12/2024 and from 01/2025 to 03/2025 and no testing for 04/2025. A review of Patient #10 ’ s Hepatitis B surveillance record revealed the following: -On 01/15/2024 Patient #10 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -On 08/22/2024 Patient #10 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 01/2024 to 12/2024. A review of Patient #11 ’ s Hepatitis B surveillance record revealed the following: -On 08/17/2024 Patient #11 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 08/2024 to 11/2024. A review of Patient #12 ’ s Hepatitis B surveillance record revealed the following: -On 08/07/2024 Patient #12 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 08/2024 to 11/2024. A review of Patient #13 ’ s Hepatitis B surveillance record revealed the following: -On 06/06/2024 Patient #13 ’ s Hepatitis B antibody is documented as 8 making them susceptible. -There is no documentation of monthly antigen testing from 06/2024 to 11/2024. A review of Patient #14 ’ s Hepatitis B surveillance record revealed the following: -On 09/05/2024 Patient #14 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 09/2024 to 12/2024. A review of Patient #15 ’ s Hepatitis B surveillance record revealed the following: -On 06/06/2024 Patient #15 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 06/2024 to 11/2024. A review of Patient #16 ’ s Hepatitis B surveillance record revealed the following: -On 02/16/2024 Patient #16 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 02/2024 to 11/2024. A review of Patient #17 ’ s Hepatitis B surveillance record revealed the following: -On 01/22/2024 Patient #17 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -On 08/08/2024 Patient #17 ’ s Hepatitis B antibody is documented as less than 3 making them susceptible. -There is no documentation of monthly antigen testing from 01/2024 to 11/2024. A review of Patient #18 ’ s Hepatitis B surveillance record revealed the following: -On 07/09/2024 Patient #18 ’ s Hepatitis B antibody is documented as negative making them susceptible. -There is no documentation of monthly antigen testing from 07/2024 to 11/2024. A review of Patient #19 ’ s Hepatitis B surveillance record revealed the following: -On 03/19/2025 Patient #19 ’ s Hepatitis B antibody is documented as 7 making them susceptible. -There is no documentation of monthly antigen testing for 04/2025. On 05/07/2025 at approximately 11:00 AM the surveyor conducted a face to face interview with Employee #4 Registered Nurse. Employee #4 was confirmed as the administrator of the facility ’ s Hepatitis B screening program. Employee #4 acknowledged the above findings and confirmed that susceptible patients to Hepatitis B require monthly antigen testing.”

“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: 27689 Based on observations and staff interview, facility staff failed to provide dialysis patients with a safe, comfortable, and stable environment as evidenced by one (1) of two (2) handicap entrance door opener that failed to function as expected, and 10 of 16 dialysis treatment chairs that were torn. The findings include: 1. The handicap door opener located on the outside of the entrance door to the facility failed to automatically open the door when engaged, to allow easy handicap/wheelchair access to the facility. 2. 10 of 16 dialysis chairs on the treatment floor were torn in several areas. The Facility Administrator acknowledged the findings on May 9, 2025, at approximately 3:00 PM.”

“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: 49189 Based on policy review, observations, and interview, the facility failed to ensure equipment maintained for direct patient care was ready to be used. Finidngs Include: A review of the facility ’ s ’ Blood Glucose Testing ’ policy, revised 04/2025, revealed: “Quality Control [QC] : 3. Expired control solutions and test are not used to perform QC procedures.” On 05/06/2025 at approximately 10:00 AM the surveyor conducted an observational tour of the facility ’ s treatment floor. The following was identified: - Glucometer controls opened undated - Two (2) bottles of one touch glucometer strips expired 03/31/2025 On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 27689 Based on observations and staff interview, facility staff failed to comply with Life Safety Code requirements as stated in the 2012 edition of NFPA 101, as evidenced by one (1) of two (2) fire sprinklers in the electrical room, two (2) of two (2) fire sprinklers in the water treatment room, one (1) of four (4) fire sprinklers in the hallway, in front of the water treatment room, and one (1) of one fire sprinkler at the entrance of the facility that did not have an escutcheon ring. The findings include: During a life safety walkthrough of the facility on May 6, 2025, at approximately 10:00 AM, one (1) of two (2) fire sprinklers in the electrical room, two (2) of two (2) fire sprinklers in the water treatment room, one (1) of four (4) fire sprinklers in the hallway, in front of the water treatment room, and one (1) of one fire sprinkler at the entrance of the facility were not equipped with an escutcheon ring, to prevent the passage of smoke or heat in a fire emergency. This deficient practice could potentially delay the fire sprinkler from activating in a timely manner during a fire event. The 2012 edition of NFPA 101 Life Safety Code states: 9.7 Automatic Sprinklers and Other Extinguishing Equipment 9.7.1 Automatic Sprinklers 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: NFPA 13, Standard for the installation of Sprinkler Systems NFPA 13, 2010 Edition states: 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly. The Facility Administrator acknowledged the findings on May 8, 2025, at approximately 12:00 PM.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 49189 Based on policy review, observation, and interview, the facility failed to prominently display current State agency and End Stage Renal Disease Network mailing address and telephone complaint numbers. Findings Include: A review of the facility ’ s ’ Patient Rights and Patient ’ s Standards of Conduct, Responsibilities, and Facility Rules ’ policy, revised 10/2021, revealed: “4. The facility will prominently display a copy of the patient rights in the facility, including the current State agency and ESRD network mailing address and telephone complaint numbers.” On 05/06/2025 at approximately 9:30 AM the surveyor conducted a tour of the facility. It was determined that the State agency and ESRD network mailing address and telephone complaint numbers were not displayed. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 confirmed that the State agency and ESRD Network mailing address and telephone complaint numbers were not present in the waiting area.”

“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: 27513 Based on record review for one (1) sampled patient and interview with the Facility administrator and Clinical Specialist, the facility failed to ensure that the prescribe medication order for Clonidine was administered and documented in the appropriate prescribe route and method. (Patient #7) The findings include ... Review of the physician order reads “Clonidine 0.1 milligram Transdermal”. Review of Patient #7 Dialysis treatment Details report showed undermedication administered Clonidine 0.1 Milligram Transdermal administered: yes. Route and method: Transdermal. Given:0.1 milligram 05/07/2025 13:43 for BP [blood pressure] 182/112. On the treatment record, the nurse wrote “B/P [blood pressure] elevated Clonidine 0.1mg PO PRN given. The documentations of the order for Clonidine route/method were discussed with Employee#1 [Facility Administrator] on 05/9/2025 at approximately 2:00PM and she acknowledged the findings.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 49189 Based on hospital policy review, supporting documentation review, medical record reviews, and interview, the facility failed to track and appropriately administer vaccination for Pneumococcal vaccines for six (6) patients sampled (Patient #20, #21, #22, #23, #24, and #25). Findings Include: A review of the facility’s ’ Pneumococcal Vaccination for Adult Patients ’ policy, revised 10/2023, revealed: “To provide guidance per CDC [Centers for Disease Control and Prevention] recommendations for pneumococcal vaccination of patients...” A review of the Centers for Disease Control and Prevention ’ Summary of Risk-based Pneumococcal Vaccination Recommendations ’ dated 10/26/2024, revealed for patients who have received the pneumococcal polysaccharide vaccine (PPSV23): “Wait until at least 5 years have passed since they received their first PPSV23 dose.” A review of Patient #20 ’ s vaccination administration record revealed the following: -Patient #20 was administered the pneumococcal vaccine on 08/07/2021, 06/25/2022, and 03/30,2025. A review of Patient #21 ’ s vaccination administration record revealed the following: -Patient #21 was administered the pneumococcal vaccine on 02/28/2017, but did not receive the 5 year repeat till 04/14/2022. A review of Patient #22 ’ s vaccination administration record revealed the following: -Patient #22 was administered the pneumococcal vaccine on 04/16/2021 and 06/25/2022. A review of Patient #23 ’ s vaccination administration record revealed the following: -Patient #23 was administered the pneumococcal vaccine on 04/03/2020. There is no documentation of Patient #23 receiving the update dose in 04/2025. A review of Patient #24 ’ s vaccination administration record revealed the following: -Patient #24 was administered the pneumococcal vaccine on 02/28/2017 but did not receive the 5 year repeat till 04/14/2022. A review of Patient #25 ’ s vaccination administration record revealed the following: -Patient #25 was administered the pneumococcal vaccine on 06/20/2019 and 04/14/2022. On 05/07/2025 at approximately 11:00 AM the surveyor conducted a face to face interview with Employee #4 Registered Nurse. Employee #4 confirmed that patients that receive the pneumococcal vaccine are to receive repeat doses 5 years after administration.”

“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: 49189 Based on policy review, medical record review, and interview, the facility ’ s In-Center Hemodialysis staff failed to (1) document transducer status or interventions for fluid introduced for two (2) out of eight (8) patients sampled (Patient #1 and #3), (2) failed to meet prescribed estimated dry weights (EDW) for three (3) out of eight (8) patients sampled (Patient #1, #2, and #3), (3) failed to assess pre and post treatment standing blood pressures for three (3) out of eight (8) patients sampled (Patient #1, #2, and #3), and failed to adhere to the prescribed ultrafiltration rate and went beyond 13militers per kilogram per hour (ml/kg/hr) for one (1) out of eight (8) patients sampled (Patient #1), and facility staff failed to ensure that four (4) patients prescribed dry weight were achieved post their dialysis treatment. (Patient #5, #6, #7, and #8.) Findings Include: 1a. A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “External transducer protectors will be inspected for the presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. If blood or saline is observed in the external transducer protector refer to policy changing transducer protectors.” 1b. A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed failure to monitor transducer status as evidenced by the following: -On 04/21/2025 there is no documentation of every 30 minute transducer inspection at 12:00 PM and 1:30 PM. 1c. A review of Patient #3 ’ s hemodialysis treatment record from 04/17/2025 to 04/22/2025 revealed failure to monitor transducer status as evidenced by the following: -On 04/19/2025 there is documentation of fluid being present on inspection of the transducer at 1:11 PM and 1:31 PM. There is no documentation of interventions done. 1d. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 2a. A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: c. Target weight.” 2b. A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 04/09/2025 revealed that they had an ordered Estimated Dry Weight of 74.9kgs. Further review revealed failure to achieve Estimated Dry Weight as evidenced by the following: -On 04/07/2025 post treatment weight was measured as 82kgs. -On 04/09/2025 post treatment weight was measured as 83kgs. A review of Patient #1 ’ s hemodialysis treatment records from 04/14/2025 to 04/18/2025 revealed that they had an ordered Estimated Dry Weight of 82 kgs. Further review revealed failure to achieve Estimated Dry Weight as evidenced by the following: -On 04/14/2025 post treatment weight was measured as 83.2kgs. -On 04/18/2025 post treatment weight was measured as 79.9kgs. A review of Patient #1 ’ s hemodialysis treatment records from 04/21/2025 to 05/05/2025 revealed that they had an ordered Estimated Dry Weight of 80 kgs. Further review revealed failure to achieve Estimated Dry Weight as evidenced by the following: -On 04/25/2025 post treatment weight was measured as 82.3kgs. -On 04/28/2025 post treatment weight was measured as 82.5kgs. 2c. A review of Patient #2 ’ s hemodialysis treatment records from 04/10/2025 to 05/03/2025 revealed that they had an ordered Estimated Dry Weight of 73kgs. Further review revealed failure to achieve Estimated Dry Weight as evidenced by the following: -On 04/24/2025 post treatment weight was measured as 76.9kgs. 2d. A review of Patient #3 ’ s hemodialysis treatment record from 04/17/2025 to 04/22/2025 revealed that they had an ordered Estimated Dry Weight of 68.5kgs. Further review revealed failure to achieve Estimated Dry Weight as evidenced by the following: -On 04/17/2025 post treatment weight was measured as 62.5kgs. -On 04/19/2025 post treatment weight was measured as 65.7kgs. -On 04/22/2025 post treatment weight was measured as 64.6kgs. 2e. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. Employee #1 confirmed that any difference greater than 1kg from Estimated Dry Weight in post treatment weight should prompt intervention by the medical team. 3a. A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “Sitting and standing BP [Blood Pressure] measurement required pre and post treatment.” 3b. A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed a lack of post treatment standing BPs on 04/09/2025 and 04/28/2025. 3c. A review of Patient #2 ’ s hemodialysis treatment records from 04/08/2025 to 05/03/2025 revealed a lack of post treatment standing BPs on 04/08, 04/10, 04/24, 04/26, 04/29, 05/01, and 05/03/2025. 3d. A review of Patient #3 ’ s hemodialysis treatment record from 04/17/2025 to 04/22/2025 revealed a lack of post treatment standing BPs on 04/19/2025. 3e. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 4a. A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: d. UFR [ultrafiltration rate] and Max UFR.” 4b. A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed that they had an ordered maximum ultrafiltration rate of 13ml/kg/hr. Further review revealed failure to adhere to prescribed ultrafiltration rate as evidenced by the following: -On 04/17/2025 UFR is documented as 15.8 ml/kg/hr. -On 04/25/2025 UFR is documented as 14.9 ml/kg/hr. 4c. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 5. Facility staff failed to ensure that four (4) patients prescribed dry weight were achieved post their dialysis treatment. (Patient #5, #6, #7, and #8. Facility staff failed to ensure that four (4) sampled patient achieved their prescribed estimated dry weight. (Patient #5, #6, #7, and #8). 5a. A review of Patient #5 ‘s treatment flow sheet records dated 04/07/2025, to 05/05/2025 with a prescribed dry weight of 62.0kg showed the following dry weights: 04/07/2025, Post dry weight 63.5kg 04/14/2025, Post dry weight 62.7kg 04/18/2025, Post dry weight 62.9kg 04/21/2025, Post dry weight 62.8kg 04/23/2025, Post dry weight 63.1kg 5b. A review of Patient #6’s treatment flow sheet records dated 04/10/2025, to 05/06/2025 with a prescribed dry weight of 76 and then change to76.5kg showed the following dry weights: 04/15/2025, Post dry weight 77.6 04/17/2025, Post dry weight 77.5 04/19/2025, Post dry weight 76.8 04/26/2025, Post dry weight 77.0kg 05/01/2025, Post dry weight 76.9kg 05/03/ 2025, Post dry weight 77.4kg 05/06/2025, Post dry weight 79.3kg 5c. A review of Patient #7’s treatment flow sheet records dated 04/07/2025, to 05/07/2025 with a prescribed dry weight of 48kg and then change to 49kg showed the following dry weights: 04/11/2025, Post dry weight 50.0kg 04/14/2025, Post dry weight 51.0kg 04/21/2025, Post dry weight 50.4kg 04/23/2025, Post dry weight 50.8kg 04/28/2025, Post dry weight 50.3kg 05/02/2025, Post dry weight 47.8kg 05/07/2025, Post dry weight 44.8kg 5d. A review of Patient #8’s treatment flow sheet records dated 04/07/2025, to 05/05/2025 with a prescribed dry weight of 109.5 showed the following dry weights: 04/18/2025, Post dry weight 111.4kg 04/21/2025, Post dry weight 111.4kg 04/25/2025, Post dry weight 112.8kg 04/28/2025, Post dry weight 112.3kg 04/30/2025, Post dry weight 110.7kg 05/02/2025, Post dry weight 111.0kg 05/05/2025, Post dry weight 110.9kg The evidence showed that facility staff failed to achieve Patient #5, #6, #7, and #8 prescribed estimated dry weight according to the post treatment flow sheets reviewed. A face-to-face interview was conducted on 05/09/2025, at approximately 2:00PM with Employee #1[Facility Administrator], she acknowledged the findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49189 Based on policy review, medical record reviews, and interviews, the facility ’ s In-Center Hemodialysis staff failed to adhere to prescribed blood and dialysate flow rate for eight (8) out of eight (8) patients sampled (Patient #1, #2, #3, #4, #5, #6, #7, and #8), (2) failed to adhere to prescribed treatment times for two (2) out of eight (8)patients sampled (Patient #1 and #3), and (3) failed to administer medications are ordered for one (1) out of eight (8) patients sampled (Patient #1). Findings Include: 1a. A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: f .Blood flow rate and g. Dialysate flow rate.” and “If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate.) the reason will be documented and the licensed nurse informed.” 1b. A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed that they had an ordered Blood Flow Rate (BFR) of 450 and Dialysate Flow Rate (DFR) of 800. Further review revealed failure to achieve prescribed BFR and DFR as evidenced by the following: -On 04/07/2025 DFR is set to 600 from 12:00 PM to 1:03 PM and BFR is set to 400 for entire treatment. -On 04/09/2025 DFR is set to 500 from 2:31 PM to 3:40 PM. -On 04/18/2025 BFR is set to 430 for entire treatment. -On 04/28/2025 BFR is set to 400 for entire treatment. -On 05/05/2025 BFR is set to 400 from 1:59 PM to 3:00 PM. 1c. A review of Patient #2 ’ s hemodialysis treatment records from 04/08/2025 to 05/03/2025 revealed that they had an ordered BFR of 450 and DFR of 500. Further review revealed failure to achieve prescribed BFR and DFR as evidenced by the following: -On 04/08/2025 BFR is set to 300 for the entire treatment. -On 04/10/2025 DFR is set to 800 for the entire treatment. -On 04/15/2025 BFR is set to 400 for the entire treatment. -On 04/24/2025 BFR is set to 300 for the entire treatment. -On 04/26/2025 BFR is set to 350 for the entire treatment. -On 04/29/2025 BFR is set to 400 from 4:01PM to 6:30 PM and DFR is set to 800 for entire treatment. -On 05/03/2025 BFR is set to 300 from 3:30 PM to 4:00 PM and then to 400 for the rest of treatment. 1d. A review of Patient #3 ’ s hemodialysis treatment record from 04/17/2025 to 04/22/2025 revealed that they had an ordered BFR of 400 and DFR of 600. Further review revealed failure to achieve prescribed BFR and DFR as evidenced by the following: -On 04/17/2025 DFR is set to 500 for the entire treatment. -On 04/19/2025 DFR is set to 500 for the entire treatment and BFR is set to 300 for the entire treatment. -On 04/22/2025 DFR is set to 500 for the entire treatment and BFR is set to 350 from 12:30 PM to 2:49 PM. 1e. A review of Patient #4 ’ s hemodialysis treatment record from 04/07/2025 to 05/07/2025 revealed that they had an ordered BFR of 350 and DFR of 500. Further review revealed failed to achieve prescribed BFR and DFR as evidenced by the following: -On 04/10/2025 DFR is set to 800 for the entire treatment. -On 04/25/2025 DFR is set to 600 for the entire treatment. 1f. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 2a. A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: b. Treatment time.” 2b. A review of the facility ’ s ’ Prescribed Treatment Time Not Met ’ policy, revised 04/2024, revealed: “If shortened/early termination of treatment time exceeds 30 or more minutes, the RN [Registered Nurse] will notify the patient ’ s attending nephrologist to discuss the appropriate intervention (if any) including what additional medical orders may be necessary to address the patient ’ s specific needs.” 2c. A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed that they had an ordered treatment time of 3 hours and 45 minutes. Further review revealed failure to achieve prescribed treatment time as evidenced by the following: -On 04/07/2025 treatment time was 3 hours and 33 minutes. -On 04/16/2025 treatment time was 3 hours and 30 minutes. -On 04/21/2025 treatment time was 3 hours and 30 minutes. -On 05/05/2025 treatment time was 2 hours and 1 minute due to infiltration. There is no documentation of provider being notified. 2d. A review of Patient #3 ’ s hemodialysis treatment record from 04/17/2025 to 04/22/2025 revealed that they had an ordered treatment time of 3 hours and 30 minutes. Further review revealed failure to achieve prescribed treatment time as evidenced by the following: -On 04/17/2025 treatment time was 3 hours and 42 minutes. 2e. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 3a. A review of the facility ’ s ’ Medication Policy ’ policy, revised 10/2023, revealed: “Medications are administered as prescribed and then documented in the patient ’ s medical record. No medications are given without an order from the physician or non-physician practitioner.” 3b. A review of the facility ’ s ’ Physician Orders for Patient Care ’ policy, revised 10/2024, revealed: “7.Unclear or incomplete orders must be clarified with the physician by the licensed nurse teammate or Registered Dietician prior to implementation.” 3c. review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed that they had medication orders for Mircera 60 micrograms intravenous push and Clonidine 0.1 milligrams (mgs) transdermal. Further review revealed failure to administer medications as ordered as evidenced by the following: -On 04/14/2025 there is documentation of 0.1mg of Clonidine by mouth administered. -On 04/16/2025 there is documentation of 0.1mg of Clonidine by mouth administered. -On 04/21/2025 there is documentation of 0.1mg of Clonidine by mouth administered. -On 04/25/2025 there is documentation of 0.1mg of Clonidine by mouth administered. -On 04/28/2025 there is documentation of 0.1mg of Clonidine by mouth administered. -On 05/05/2025 there is documentation of 0.2 mg of Clonidine by mouth administered and documentation of Mircera not administered per order with the reason as “missed administration.” 3d. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. Employee #1 confirmed that the facility does not use transdermal Clonidine. 4. Facility staff failed to ensure that the patient’s adequacy goals are following current professionally accepted clinical practice to achieve and sustain the prescribed BFR [blood flow rate], and DFR [dialysis flow rate] during the patient’s dialysis treatment, and failed to ensure the patient treatment was scheduled to run on the appropriate prescribed treatment time. (Patients #5 #6, #7, and #8). “During the HD procedure, blood and dialysate flow through the dialyzer in a countercurrent manner, thus preventing concentration equilibration and maximizing solute transfer. This ensures that the blood is constantly exposed to fresh dialysate fluid, enabling passive diffusion of toxins from the blood to the dialysate through the semipermeable membrane of the dialyzer. Diffusion is a passive movement of solutes “down” their concentration gradients. Solutes move from a region of higher solute concentration to a region of lower solute concentration. In terms of HD, simple passive diffusion enables clearance of endogenous waste and other solutes such as toxins from blood into the dialysate. Diffusion and clearance of solutes depend on factors such as blood and dialysate flow rates, the dialyzer membrane composition, and solute characteristics. For instance, higher blood flow rate increases clearance by increasing the amount of blood being cleared per minute7. In addition, faster dialysate flow rate causes increased removal of solutes from the dialysate fluid resulting in a higher concentration gradient and a higher clearance rate8-10. Of note, the impact of blood flow is limited to small molecular weight (MW) molecules and is further complicated by patient specific access issues7,11. The blood flow rates may range from 250-500 mL/min while a typical dialysate flow rate is 500-800 mL/min.” https://advancedrenaleducation.com/wparep/article/hemodialysis/“ A review of four (4) sampled resident Hemodialysis flow sheets showed the following: 4a.Patient #5 Hemodialysis Treatment Flow Sheet showed in the spaces allotted for the BFR/DFR documentation post dialysis treatment on 04/09/2025 DFR was 800 and on 04/16/2025 BFR was 300. The prescription on the Dialysis Order Report directs “BFR 350/ DFR 600”. 4b.Patient #6 Hemodialysis Treatment Flow Sheet showed in the spaces allotted for the BFR/DFR documentation post dialysis treatment on 04/10/2025 DFR was 800, 04/22/2025 BFR was 300, 04/26/ 2025 BFR was 300, 05/01/2025 BFR was 360, and 05/03/2025 BFR was 350. The prescription on the Dialysis Order Report directs “BFR 400/ DFR 500”. 4c. Patient #7 Hemodialysis Treatment Flow Sheet showed in the spaces allotted for the BFR/DFR documentation post dialysis treatment on 04/09/2025 DFR was 800, 04/16/2025 BFR was 350, 04/21/ 2025 BFR was 350, and 05/07/2025 BFR was 350. The prescription on the Dialysis Order Report directs “BFR 400/ DFR 500”. 4d. Patient #8 Hemodialysis Treatment Flow Sheet showed in the spaces allotted for the BFR/DFR documentation post dialysis treatment on 04/28/2025 BFR/DFR was 300/600, and 05/02/2025 DFR was 800. The prescription on the Dialysis Order Report directs “BFR 350/ DFR 500”. The evidence showed that facility staff failed to ensure that the adequacy plan for the prescribed BFR [blood flow rate], and DFR [dialysis flow rate] was achieved and sustained during the dialysis treatment of the patients (5, #6, #7, and #8) as mentioned above. Each treatment is documented to be “started with no complications: patient access cannulated without difficulty”. A face-to-face interview was conducted on 05/09/2025 at approximately 02:00PM with the Employee #1 [Facility Administrator] and she acknowledged the findings.”

“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: 49189 Based on policy review, medical record reviews, and staff interview, the facility ’ s interdiscplinary team failed to document psychosocial needs in the Plan of Care for one (1) out of eight (8) patients sampled that was deemed unstable due to psychosocial needs (Patient #1). Findings Include: A review of the facility ’ s ’ Interdisciplinary Team (IDT) Patient Assessment and Plan of Care ’ policy, revised 10/2024, revealed: “The facility ’ s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient ’ s needs as identified by the comprehensive assessment and changes in the patient ’ s condition, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes.” A review of Patient #1 ’ s Plan of Care dated 10/24/2024 revealed the following: -Under Patient status, Patient #1 is deemed unstable due to psychosocial; housing instability. -Under the psychosocial prompt the following is documented: “Patient displays effective coping skills and verbalizes understanding and ability to follow treatment regimen for preferred modality. Patient has adequate resources to meet psychosocial goals.” There is no documentation regarding what psychosocial needs have deemed Patient #1 unstable. A review of Patient #1 ’ s Plan of Care dated 04/09/2025 revealed the following: -There is no documentation on if Patient #1 is deemed stable or unstable. -Under the psychosocial prompt the following is documented: “Patient displays effective coping skills and verbalizes understanding and ability to follow treatment regimen for preferred modality. Patient has adequate resources to meet psychosocial goals.” There is no documentation regarding what psychosocial needs have deemed Patient #1 unstable. On 05/08/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #8 Social Worker. Employee #8 confirmed that from October 2024 to present Patient #1 was deemed unstable due to housing insecurity. Employee #8 acknowledged confliction in documentation with Plan of Care not specifying the needs required for Patient #1 ’ s psychosocial concerns.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 49189 Based on policy review, medical record reviews, and interview, the facility ’ s interdiscplinary team failed to ensure that Plans of Care (POCs) were signed for seven (7) out of eight (8) patients sampled (Patient #1, #3, #4, #5, #6, #7, and #8) Findings Include: A review of the facility ’ s ’ Interdisciplinary Team (IDT) Patient Assessment and Plan of Care ’ policy, revised 10/2024, revealed: “14.The patient ’ s plan of care will be completed by the facility ’ s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.” 1. The facility ’ s interdiscplinary team failed to ensure that Plans of Care (POCs) were signed for seven (7) out of eight (8) patients sampled (Patient #1 #3 and #4). 1a. A review of Patient #1 ’ s Plan of Care dated 10/24/2024 revealed the following: -Plan of Care is unsigned by the medical provider. -Plan of Care is unsigned by Patient #1 or a patient representative. There is no documentation for reason. -There is no documentation of Plan of Care being reviewed with Patient #1. A review of Patient #1 ’ s Plan of Care dated 04/09/2025 revealed the following: -Plan of Care is unsigned by the medical provider. -Plan of Care is unsigned by Patient #1 or a patient representative. There is no documentation for reason. -There is no documentation of Plan of Care being reviewed with Patient #1. 1b. A review of Patient #3 ’ s Plan of Care dated 01/21/2025 revealed the following: -Plan of Care is unsigned by the medical provider. -Plan of Care is unsigned by Patient #3 or a patient representative. There is no documentation for reason. -There is no documentation of Plan of Care being reviewed with Patient #3. 1c. A review of Patient #4 ’ s Plan of Care dated 08/15/2024 revealed the following: -Plan of Care is unsigned by the medical provider. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 2.Facility staff failed to ensure that the Plan of Care (POC) for the four (4) dialysis patients was completed with the interdisciplinary (IDT) signatures. (Patients #5, # 6, #7 and #8). 2a. A review of Patient #5’s clinical record showed that the patient was admitted to the dialysis center on 05/11/2023. The initial POC dated 12/09/2024 and the 90-day POC dated 05/09/2025, was found on patient #5 clinical record without the Physician’s signature, the patient or patient responsible party signature or a reason for the patient refusal to sign the POC. 2b. A review of Patient #6’s clinical record showed that the patient was admitted to the dialysis center on 08/31/2020. The Annual POC dated 04/01/2025, was found on patient #6 clinical record without the Physician signatures, and the patient or patient responsible party signature or a reason for the patient refusal to sign the POC. 2c. A review of Patient #7’s clinical record showed that the patient was admitted to the dialysis center on 03/06/2025. There was no POC signed by the IDT [interdisciplinary team] found on patient #7’s clinical record. 2d. A review of Patient #8’s clinical record showed that the patient was admitted to the dialysis center on 08/22/2013. The Transfer POC dated 04/01/2025 was found on patient #8 clinical record without the Physician’s signature, and the patient or patient responsible party signature or a reason for the patient refusal to sign the POC. A face-to-face interview was conducted on 05/09/ 2025, at approximately 2:00 PM with Employee#1 [Facility Administrator] who acknowledged the findings.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 49189 Based on policy review, supporting documentation review, and interview, the facility ’ s Quality Assurance Performance Improvement (QAPI) program failed to monitor and track quality indicators of discrepancies for immunizations and Hepatitis B screening. The Findings Include: A review of the facility ’ s ’ Continuous Quality Improvement Program ’ policy, revised 04/2021, revealed: “The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following: vaccination rates for Hepatitis B, Influenza, and Pneumococcal and Infection Control.” A review of the facility ’ s Hepatitis B surveillance log identified 11 out of 24 susceptible patients sampled with discrepancies in monthly antigen testing. A review of the facility ’ s vaccination administration tracking log revealed 13 out of 24 patients sampled with discrepancies in vaccination administration for Hepatitis B and Pneumococcal. A review of the facility ’ s 2024 QAPI program meeting minutes revealed no documentation of tracking or trending for Hepatitis screening, Hepatitis B vaccination, or Pneumococcal vaccination. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 reported that online QAPI minutes for 2025 are not obtainable due to an external malware attack. Employee #1 confirmed that QAPI has not tracked Hepatitis B screening, Hepatitis B vaccination, and Pneumococcal vaccination for 2024 or 2025.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 49189 Based on policy review, medical record review, and interview, the facility ’ s In-Center staff failed to accurately document intradialytic fluid management for eight (8) out of eight (8) patients sampled (Patient #1, #2, #3, #4, #5,#6, #7 and #8). Findings Include: 1.The facility ’ s In-Center staff failed to accurately document intradialytic fluid management for four (4) patients sampled (Patient #1, #2, #3,and #4) A review of the facility ’ s ’ Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment ’ policy, last revised 04/2024, revealed: “At a minimum, obtain and document the following: iv. Fluid removal and/or replacement.” 1a.A review of Patient #1 ’ s hemodialysis treatment records from 04/07/2025 to 05/06/2025 revealed that they had an ordered 250 milliliter (ml) saline prime and rinse back order. Further review revealed failure to accurately document fluid administration as evidenced by the following: -On 04/07/2025 there is no documentation of 250ml rinse back being administered. -On 04/09/2025 total saline administered is documented as “NA [not applicable].” There is no documentation of saline prime or rinse back administered. -On 04/14/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/16/2025 total saline administered is documented as “NA.” There is documentation of rinse back and prime administered, but amount is not captured. -On 04/18/2025 total saline administered is documented as “NA.” There is no documentation of saline prime administered. There is no documentation of amount of saline given during rinse back. -On 04/21/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/25/2025 total saline administered is documented as “NA.” There is no documentation of saline prime administered. There is no documentation of amount of saline given during rinse back. -On 04/28/2025 total saline administered is documented as “250mls.” There is no documentation of saline prime or rinse back administered. -On 04/30/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 05/05/2025 total saline administered is documented as “250mls.” There is no documentation of saline prime administered. 1b.A review of Patient #2 ’ s hemodialysis treatment records from 04/08/2025 to 05/03/2025 revealed that they had an ordered 250 milliliter (ml) saline prime and rinse back order. Further review revealed failure to accurately document fluid administration as evidenced by the following: -On 04/08/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/10/2025 total saline administered is documented as “250mls.” There is no documentation of saline prime or rinse back administered. -On 04/15/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/24/2025 total saline administered is documented as “NA.” There is documentation stating, “given additional 200ml saline at start of Tx [treatment].” and “BP low extra 200ml saline given.” Amounts are not captured in total saline administered and are less than ordered 250. -On 04/26/2025 total saline administered is documented at “250mls.” There is no documentation of saline rinse back given. -On 04/29/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 05/01/2025 total saline administered is documented as “NA.” There is documentation of saline prime administered but amount of saline is not captured. There is no documentation of saline rinse back administered. -On 05/04/2025 total saline administered is documented as “250mls.” There is no documentation of saline prime or rinse back administered. 1c. A review of Patient #3 ’ s hemodialysis treatment record from 04/17/2025 to 04/22/2025 revealed that they had an ordered 250 milliliter (ml) saline prime and rinse back order. Further review revealed failure to accurately document fluid administration as evidenced by the following: -On 04/17/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/19/2025 total saline administered is documented as “NA.” There is documentation of saline rinse back administered but amount is not captured. There is no documentation of saline prime administered. -On 04/22/2025 total saline administered is documented as “NA.” There is documentation of saline prime administered, but amount is not captured. 1d. A review of Patient #4 ’ s hemodialysis treatment record from 04/07/2025 to 05/07/2025 revealed that they had an ordered 250 milliliter (ml) saline prime and rinse back order. Further review revealed failure to accurately document fluid administration as evidenced by the following: -On 04/07/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/10/2025 total saline administered is documented as “250mls.” There is no documentation of saline prime or rinse back administered. -On 04/14/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/16/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 04/18/2025 total saline administered is documented as “NA.” There is documentation of saline prime and rinse back given but amount is not captured. -On 04/21/2025 total saline administered is documented as “200mls.” There is no documentation of saline prime administered. Saline rinse back is 200mls, not the ordered 250mls. -On 04/25/2025 total saline administered is documented as “NA.” There is documentation of saline prime and rinse back given but amount is not captured. -On 04/28/2025 total saline administered is documented as “NA.” There is no documentation of saline prime administered. There is documentation of rinse back administered but amount is not captured. -On 04/30/2025 total saline administered is documented as “NA.” There is documentation of saline prime and rinse back given but amount is not captured. -On 05/02/2025 total saline administered is documented as “200mls.” There is no documentation of saline prime administered. Saline rinse back is 200mls, not the ordered 250mls. -On 05/05/2025 total saline administered is documented as “NA.” There is no documentation of saline prime or rinse back administered. -On 05/07/2025 total saline administered is documented as “NA.” There is documentation of 250ml saline prime and rinse back but it is not captured in total saline administered. On 05/09/2025 at approximately 2:00 PM the surveyor conducted a face to face interview with Employee #1 Facility Administrator. Employee #1 acknowledged the findings. 2. Facility staff failed to accurately document intradialytic fluid management record of four patients’ replacement fluid as it pertains to the dialysis treatment record. (Patient #5, #6, #7, and #8) 2a.A review of Patient #5’s Treatment Details Report records dated from April 7, 2025, to May 5, 2025, showed that the patient had 10 treatment records completed. Review of the Pre-Treatment Fluid Calculation Section on the Treatment Details Reports showed the “Prime [initiation of dialysis treatment] 250ml saline fluid and Rinse-back [termination of dialysis treatment] 250 saline fluids. On the ten completed treatment records the space allotted to record the documentation of saline fluid administration for Patien#5 dialysis treatment showed the amount of saline use for “Prime” and for “Rinse-back” were left “blank” and under the section Post Treatment Vitals total saline was documented as “N/A”. 2b. A review of Patient #6’s Treatment Details Report records dated from April 10, 2025, to May 3, 2025, showed that the patient had 10 treatment records completed. Review of the Pre-Treatment Fluid Calculation Section on the Treatment Details Reports showed the “Prime [initiation of dialysis treatment] 250ml saline fluid and Rinse-back [termination of dialysis treatment] 250 saline fluids. On the ten completed treatment records the space allotted to record the documentation of saline fluid administration for Patien#6 dialysis treatment showed the amount of saline use for “Prime” and for “Rinsed-back” were left “blank” and under the section Post Treatment Vitals total saline was documented as “N/A”. 2c. A review of Patient #7’s Treatment Details Report records dated from April 9, 2025, to May 7, 2025, showed that the patient had 10 treatment records completed. Review of the Pre-Treatment Fluid Calculation Section on the Treatment Details Reports showed the “Prime [initiation of dialysis treatment] 250ml saline fluid and Rinse-back [termination of dialysis treatment] 250 saline fluids. On the ten completed treatment records the space allotted to record the documentation of saline fluid administration for Patien#7 dialysis treatment showed the amount of saline use for “Prime” and for Rinse back were left “blank”, under the section Post Treatment Vitals total saline was documented as “N/A” with the following dates 04/09/2025, 04/23/2025, 04/25/2025 and 04/30/2025 documented total saline as 200ml. 2d. A review of Patient #8’s Treatment Details Report records dated from April 7, 2025, to May 5, 2025, showed that the patient had 10 treatment records completed. Review of the Pre-Treatment Fluid Calculation Section on the Treatment Details Reports showed the “Prime [initiation of dialysis treatment] 250ml saline fluid and Rinse-back [termination of dialysis treatment] 250 saline fluids. On the ten completed treatment records the space allotted to record the documentation of saline fluid administration for Patien#8 dialysis treatment showed the amount of saline use for “Prime” and for Rinse back were left “blank”, under the section Post Treatment Vitals total saline was documented as “N/A” with the following dates 04/07/2025 documented total saline as 200ml. It should be noted that the space allotted on the Treatment Detail Reports for documenting the administration of the use saline fluids “left blank indicates “not done” and the total saline 200ml use for treatment indicates incorrect amount of saline administered for dialysis treatment. The saline fluid was not documented on Treatment Detail report as to the date, the amount and he time the normal saline were administered. The Treatment Details Report records mentioned above for Patient’s #5, #6, #7, and #8 showed evidence that facility staff failed to maintain a complete, and accurate record of the patients’ replacement fluid as it pertains to the dialysis treatment record during the priming at the initiation of dialysis, throughout dialysis, and for rinse back at the termination of dialysis treatment. The area allotted for the documentation of the amount of saline fluid administer during treatment was left Blank indicating “not done” and “total saline documented as 200ml. A face-to-face interview was conducted on 05/09/2025 at approximately 2:00 PM with Employee #1 [Facility Administrator] she acknowledged the findings.”