Fresenius Kidney Care Pembroke Pines

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 36734 Based on observation, administrative record review, and interview, the facility failed to have readily available emergency equipment, as evidence by the facility failure to contain medication, equipment, and supplies in the emergency code cart and emergency box as listed per check list located in the in-center dialysis treatment area and home health dialysis training area. The findings included: The facility policy “Emergency Medication, Equipment, and Supplies”, published 07/07/2025, documented, “The following minimum emergency supplies and equipment must be on the premises at all times, clean, functional, accessible, and immediately available; oxygen masks/cannulas, emergency medications, disposable catheters. oral airway, and cardiopulmonary resuscitation (CPR) pocket mask.” 1. An observation of the in-center dialysis treatment area emergency code cart and emergency box was conducted on 12/08/25 at 12:35 PM with staff nurse (C). The following items were missing from the check list inventory: 14F catheter, oxygen face mask, Trach Mask oxygen adapter, Nitrite gloves (large) 1 box, pocket mask, sterile gloves, and fistula needle 17g. 2. An observation of the home therapy training Emergency Code Cart was conducted on 12/10/25 at 12:00 PM. The observation revealed missing medication of Calcium Chloride, Sodium Bicarbonate, and Naloxone. An interview conducted on 12/08/2025 at 12: 35 PM with staff nurse (C) at the time of observation, she acknowledged the above information.”

“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: 51535 Based on administrative record review, observation, and staff interview, the facility failed to ensure supplies were maintained and operated in accordance with the manufacturer’s recommendations, as evidenced by supplies available for use beyond the manufacturer’s documented expiration date. The findings included: The facility policy “Expiration Dates Sterile Supplies”, published 07/04/2012, documented, “Sterile items will be checked before use to ensure that they have not expired. Appropriately dispose of sterile items that have reached the expiration date.” 1) An observation of the treatment area conducted on 12/08/25 at 11:38 AM revealed the following: Cirrus Gloves (4 boxes) with expiration date of 09/2025 currently available for use in the treatment area. An interview conducted at the time of observation with staff Nurse (B) who acknowledged the expired supplies, removed, and discarded the supplies. 2) An observation of the supply room was conducted on 12/10/25 at 11:38 AM revealed the following: Naturalyte 3K 3.0 Ca (one-gallon container) x 9 expired on 01/31/2024, Naturalyte 1K 2.5 Ca (one-gallon container) x 1 expired on 09/20/2025. An interview conducted on 12/10/25 at 11:38 AM with the Biomedical Technician who acknowledged the expired supplies and removed them from the area.”

“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: 40153 Based on interviews and record review, the facility failed to provide Hepatitis B vaccination in a timely manner for 1 of 10 patients reviewed (Patient #1). The findings included: A review of the facility’s titled “Patient Vaccination for Hepatitis B” dated 2/7/2022 revealed the Hepatitis B vaccine shall be offered to all susceptible patients. Patient #1 was admitted to the facility for in-center Hemodialysis on 10/14/2025. Labs drawn on 10/14/2025, 10/28/25 and on 11/20/25 revealed Patient #1 was negative for Hepatitis B. A record review showed that on 10/14/25, Patient #1 consented to receiving the Hepatitis B vaccine. The vaccine was given on 11/25/2025, 42 days after his admission. In an interview conducted on 12/09/2025 at 11:00 AM, with the Clinical Manager she stated that at the time of Patient #1’s admission they were in the process of changing labs. She further said that they were waiting on the lab result from 11/20/2025 to provide the Hepatitis B vaccination.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to address a patient with severe protein malnutrition for 1 of 10 sampled patients (Patient #9) The findings included: Record review revealed Patient #9 was admitted to the facility for treatment on 10/22/24. A review of Patient #9’s labs revealed an albumin level of 2.7 on 09/20/25, 2.6 on 10/16/25, and 2.8 on 11/14/25 (normal > 4). Further review of Patient #9’s record revealed the patient was receiving a protein bar with each dialysis (3 days a week). No other interventions were found. An interview as conducted with the Clinical Manager (CM) on 12/10/25 at 12:30 PM. The CM acknowledged the above.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to complete an initial care plan for 1 of 10 sampled patients (Patient #8). The findings included: Record review revealed Patient #8 was admitted to the facility for treatment on 08/28/25. Further review of the patient’s records revealed an initial care plan was not conducted. An interview as conducted with the Clinical Manager (CM) on 12/10/25 at 12:30 PM. The CM acknowledged the above.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 40153 Based on interviews and record review, the facility failed to follow up on a significant low hemoglobin lab result in a timely manner for 1 of 10 patients reviewed (Patient #6), The findings included: A review of the facility policy titled “Care Transitions” dated 7/5/2022 revealed the following: the purpose of this document is to ensure that communication related to dialysis treatments occur between caregivers to maintain continuity of care for the patient. A record review revealed that Patient #6 was admitted to the facility on 10/14/25 for in-center Hemodialysis. A record review showed a medical history of Sickle Cell Anemia. A review of Hemoglobin labs revealed a drop from 8.7 on 10/30/25 to 7.2 on 11/6/2025 and to 4.9 on 11/13/2025. A note dated 11/14/2025 showed that an alert was received for Hemoglobin 4.9 drawn on 11/13/2025 and an attempt was made to call the patient and the emergency contact with no answer. The doctor was notified and patient to go to the emergency department for repeat labs. A note written on 11/14/2025 revealed patient emergency contact was called due to the patient phone going to voicemail. The next follow up note was noted on 11/19/2025 which documented that Patient #6 went to the hospital for blood transfusion. No follow up notes were documented between 11/14/2025 and 11/19/2025. A review of the dialysis treatment flow sheets revealed Patient #6 did not receive the dialysis treatment on 11/15/2025 with no other documentation as to why. The flow sheet dated 11/18/2025 revealed that Patient #6 received the dialysis treatment with no documentation regarding the low hemoglobin that was identified on 11/14/2025. In an interview conducted on 12/09/2025 at 10:30 AM with the Clinical Manager, she acknowledged the missing documentation from the nurses regarding the blood transfusion.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 51535 Based on administrative policy review, clinical record review, and staff interviews, the facility failed to provide evidence of monthly medical progress notes by a medical practitioner. This failure affected 1 of 10 sample patients reviewed (Patient #5). The findings included: The review of the facility policy Comprehensive Interdisciplinary Assessment and Plan of Care, published 07/03/2023, documented, “At a minimum, monthly medical progress notes (which also denotes the site of the visit) must be in every patient’s medical record that document that a physician or non-physician practitioner has seen each patient.” A clinical records review on 12/09/25 at 2:40 PM of patient #5, revealed 2 of 6 months of monthly physician notes available for review. The months of December 2025 and November 2025 are available for review. The following months of physician progress notes were not available for review: October 2025, September 2025, August 2025, and July 2025. An interview conducted with the Clinical Manager (CM) on 12/10/25 at 1:10 PM, who acknowledges 4 months of physician progress notes not available for review.”