Davita Victory Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 33921 Based on observations, staff interviews, a review of Centers for Disease Control and Prevention (CDC) guidelines, and a review of facility Policy and Procedure, it was determined that the facility failed to ensure that four of four Direct Patient Care (DPC) Staff [Registered Nurse (RN) AA, Licensed Practical Nurse (LPN) AA, Patient Care Technician (PCT) AA and PCT BB] observed, practiced infection control techniques to prevent transmission of dangerous pathogens in the hemodialysis unit. This deficient practice had the potential to negatively affect the health and safety of 32 in-center hemodialysis patients who were receiving dialysis treatment at this facility. Findings include: Cross references: V 117 - Failure of Direct Patient Care (DPC) Staff (RN AA, LPN AA, PCT AA and PCT BB) to utilize appropriate infection control techniques to prevent cross contamination. V 122 - Failure of DPC Staff (RN AA, LPN AA, PCT AA and PCT BB) to clean and disinfect surfaces that were contaminated with blood or body fluids.”

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 33921 Based on observation, staff interview, and a review of facility records, it was determined that the facility failed to ensure that there was a safe environment for 32 in-center hemodialysis patients as evidenced by failure of one of one Patient Care Technician (PCT BB) to follow the Manufacturer’s Directions For Use (DFU) and the facility’s Policy and Procedure (P&P) regarding independently testing the machines’ dialysate pH (Acidity) using RPC E-Z Chek K100-0117 6.8 - 8.5CT pH strips, prior to initiating Patient (P) #10’s dialysis treatment at Station (S) 7. This deficient practice had the potential to negatively affect the health and safety of P#10 and the other eight in-center hemodialysis patients (P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#11), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 32. Findingd include: Cross-reference: V 196 - Failure of the Governing Body to ensure that Licensed Nurses [Registered Nurse (RN) AA and Licensed Practical Nurse (LPN) AA] verified the level of Total Chlorine in the water used for dialysis. V 250 - Failure of the facility to ensure that PCT BB followed the Manufacturer’s DFU and the facility’s P&P regarding testing the machines’ dialysate pH (Acidity) using RPC E-Z Chek K100-0117CT 6.8 - 8.5 pH strips.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 33921 Based on observations, facility record review, staff interviews, and a review of the Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 32 in-center hemodialysis patients who were receiving hemodialysis treatment at this facility. Findings include: Cross References: V 117 - Failure of Direct Patient Care (DPC) Staff [Registered Nurse (RN) AA, Licensed Practical Nurse (LPN) AA, Patient Care Technician (PCT) AA and PCT BB), to utilize appropriate infection control techniques to prevent cross contamination. V 122 - Failure of the Governing Body to ensure that all DPC Staff utilized appropriate infection control techniques to prevent cross contamination. V 196 - Failure of the Governing Body to ensure that Licensed Staff (RN AA and LPN AA) verified and validated the level of Total Chlorine in the water used for dialysis. V 250 - Failure of the Governing Body to ensure that one of one Patient Care Technician (PCT BB) followed the Manufacturer’s Directions For Use (DFU) and the facility’s Policy and Procedure (P&P) regarding testing the machines’ dialysate pH (Acidity) using RPC E-Z Chek K100-0117 6.8 - 8.5 pH strips.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 33921 1. Based on observation, staff interviews, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and a review of facility Policy and Procedure (P&P), it was determined that the facility failed to ensure that all Direct Patient Care (DPC) Staff [Registered Nurse (RN) AA, Licensed Practical Nurse (LPN) AA, Patient Care Technician (PCT) AA and PCT BB] who were present during this observation, utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques had the potential to negatively affect the health and safety of nine of nine in-center hemodialysis patients (P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10 and P#11), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 32. Findings include: During observation in the Patient Treatment Room on 1/10/24 between 10:45 a.m. and 2:00 p.m., the following was revealed: - There were three large Biohazard boxes (BHB #1, BHB #2, and BHB #3), with a wheeled base tray and foot mechanism to open the lids, that were being propped open with a bolt and chain. - BHB #2 (considered dirty) was located next to the Emergency Crash Cart, (a rolling set of trays or drawers that carries equipment, medications, and other medical supplies, to transport and dispense emergency medication and equipment at the site of a medical emergency for life support protocols to potentially save someone’s life), which was considered clean. - RN AA and PCT AA stated on 1/10/24 at 10:50 a.m. and 11:00 a.m., respectively, that the three large BHB were propped open all day for easy turnover (shift changes). - This practice of keeping the BHB propped open had the potential for cross-contamination. On 1/11/24 at 10:45 a.m., BHB #3 remained open with the discarded used bloodlines, used dialyzers and other infectious material. According to CDC, any wastes contaminated with blood should be considered “infectious”. A review of the facility’s Policy: 4-03-07, titled, “Segregation of Medical Waste”, with latest revision date of October 2023, stated: Medical Waste Containers are defined as: b. A labeled medical waste transfer container with a wheeled base tray and foot mechanism to open the lid. c. A labelled plastic container with no foot mechanism to open the lid. ... Lid should be put back on the plastic container after medical waste is disposed of... - PCT AA was observed on 1/10/24 at approximately 11:20 a.m., putting his pen on top of the machine at Station (S) 12 (Isolation Room - considered dirty), where P#6 was undergoing hemodialysis treatment. PCT AA then transferred the pen on top of the computer stand (considered clean). PCT AA stated on 1/10/24 at approximately 11:35 a.m., that the computer and stand had been in the Isolation Room for over a year, but the computer was not working for about the same length of time. The computer and stand were not included in cleaning and disinfection of the Isolation Room. - PCT AA was also observed touching the machine (considered dirty), at S10 with a glove that was not donned, to silence the machine’s alarm. PCT AA discarded the glove and without performing hand hygiene, PCT AA touched the computer keys (considered clean) located next to S10, to enter data on the computer. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause the spread of bacteria/infections. 2. Based on observation, a review of the CDC guidelines and recommendations, and staff interview, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN AA) observed during discontinuation of hemodialysis (HD) treatment on a patient (P#3) using a Central Venous Catheter (CVC - dialysis access, femoral), utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of P#3 and the other 10 patients (P#1, P#2, P#5, P#13, P#15, P#16, P#17, P#18, P#19, and P#20), who had a CVC as their primary dialysis access, at this facility. Findings include: - During observation of the discontinuation of hemodialysis treatment of P#3, on 1/10/24 at 2:05 p.m., RN AA removed the cover (protection) of two of two Normal Saline Flush (sterile) syringes and laid them on the blue liner (unsterile). Used alcohol pads and used gauze (dirty) were returned to the blue liner with the sterile and clean supplies. This practice had the potential for cross-contamination. - RN AA acknowledged this observation on 1/10/24 at 2:15 p.m., stating that she did not realize that the practice had the potential for cross-contamination. - According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause the spread of bacteria/infections.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 33921 Based on observation, staff interview, a review of Centers for Disease Control and Prevention (CDC) guidelines, and a review of the facility’s policies and procedures (P & P), it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN AA), one of one Licensed Practical Nurse (LPN AA) and two of two Patient Care Technicians (PCTs AA and BB), who were present during this observation, immediately and thoroughly cleaned and disinfected blood-contaminated surfaces on the cover of two of 12 sharps containers observed at Stations (S) 9 and 10, and one of one hemodialysis chair at S12 (Isolation Room), between patient use. This failure could lead to the transmission of dangerous pathogens through cross contamination; and had the potential to negatively affect the health and safety of nine of nine in-center hemodialysis patients (P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10 and P#11), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 32. Findings include: During observation in the Patient Treatment Room on 1/10/24 between 10:45 a.m. and 2:00 p.m., the following was revealed: - The cover of the sharps containers at S9 and S10, had two - four dried drops of blood on their top covers and were not cleaned and disinfected between patient use. In addition, the hemodialysis chair at S10 had been cleaned and disinfected, and the hemodialysis machine had already gone through alarms testing and was ready for use, but the sharps container cover with the dried drops of blood were not cleaned/disinfected. - PCT AA and LPN AA both acknowledged this observation on 1/10/24 at 1:45 p.m., and at 1:50 p..m., respectively. During a follow up observation of the Patient Treatment Room on 1/11/24 (Thursday) between 10:45 a.m. and 11:00 a.m., (when there were no patients scheduled to dialyze), the following was revealed: - A drop of dried blood on the backseat upholstery of the hemodialysis chair, as well as a blood stain on the inside upholstery of the hemodialysis chair’s left armrest wing, were observed at S12 (Isolation Room). A Hepatitis B Virus positive patient (P#6) had undergone hemodialysis treatment at this station, (S12) on 1/10/24. In addition, the floor of the Isolation Room was littered with wrappers and torn paper. - There were small, dried splatters of blood on the left side of the dirty sink in the Laboratory area. Right next to the splattered blood was a large Biohazard Box that was propped open with a bolt and chain, that had been left open since 1/10/24. - The Manager of Clinical Services acknowledged the presence of dried blood and blood stain on the hemodialysis chair as well as the trash on the floor of the Isolation Room on 1/11/24 at 10:45 a.m., as well as the dried blood splatters on the left side of the dirty sink. She stated that the cleaning crew (Janitor) usually came the night before (Tuesdays, Thursdays, and Saturdays) the scheduled patient dialysis treatment which were on Mondays, Wednesdays, and Fridays. According to CDC guidelines, failure in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including floors, patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces, etc., especially with blood splatters) must be performed between patient uses to prevent transmission of dangerous pathogens. A review of the facility’s Policy #1-05-01 titled, “Infection Control for Dialysis Facilities” with latest revision date of April 2023, stated: Disinfection: 12. Cleaning and disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials...”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 33921 Based on observation, staff interview, a review of facility Policies and Procedures (P&P), a review of Food and Drug Administration (FDA) Guidelines and a review of Centers for Disease Control and Prevention (CDC) Guidelines, it was determined that the facility failed to ensure that two of two Licensed Personnel, [Registered Nurse (RN) AA and Licensed Practical Nurse (LPN) AA], who were responsible for administering medications, discarded and not made available for use, an opened and expired vial of Tuberculin Purified Protein Derivative (PPD Mantoux - a diagnostic antigen to aid in the detection of infection with Mycobacterium Tuberculosis) testing, in accordance with the manufacturer’s set time frames for use, as well as failure to initial and date a multi-dose vial of Heparin Injection (Anticoagulant), when first opened. This failure had the potential to negatively affect 32 patients who were under the care of this facility. Findings include: During a tour of the Patient Treatment Room on 1/10/24 at 10:50 a.m., it was revealed that: 1. An opened and expired vial of Tuberculin PPD Mantoux that was dated as first opened on 11/1/23 (70 days since), was found in one of one Medication Refrigerator. - RN AA stated on 1/10/24 at 10:55 a.m., that she didn’t realize the Tuberculin PPD vial had expired. - A review of the facility’s P & P, Procedure: 1-06-01 M, titled, “Intradermal Tuberculin Skin Test (TST) - Purified Protein Derivative (PPD) Mantoux Testing”, with latest revision date of October 2021, stated: NOTES: Tubersol manufacturer product insert states “A vial of Tuberculin PPD which has been entered and in use for 30 days should be discarded because oxidation and degradation may have reduced the potency...” 7. ... A vial of TB skin test antigen which has been in use for 30 days or more must not be used and must be discarded... - A review of FDA recommendations stated: A vial of Tuberculin PPD (Mantoux) Tubersol, which has been entered and in use for 30 days should be discarded... Do not use after expiration date. 2. An approximately half-full of 30-mL (milliLiters) vial of Heparin Injection 1000 units/mL, that was not initialed nor dated when first opened/accessed, was found in one of three medication drawers. RN AA stated on 1/10/24 at 11:00 a.m., that she was rushing today. A review of Policy: 1-06-02, titled, “Anticoagulation” with latest revision date of October 2023, stated: 9. Each vial is labeled with the initials of the person opening the vial and the expiration date. According to CDC Guidelines, multi-dose vials typically contain an antimicrobial preservative to help prevent the growth of bacteria. If a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 33921 Based on observation, staff interview, and a review of facility records, it was determined that two of two licensed nurses [Registered Nurse (RN) AA and Licensed Practical Nurse (LPN) AA], who were responsible for verifying the Total Chlorine Test result, were present during the actual performance of the Total Chlorine test by Patient Care Technician (PCT AA), to ensure the test was according to the Manuafacturer’s Directions for Use (DFU) and the result was accurate and appropriate. Residual levels of Total Chlorine in the water used for dialysis could result in the destruction of patient’s red blood cells (hemolysis) and had the potential to negatively affect the health and safety of nine of nine in-center hemodialysis patients (P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10 and P#11), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 32. Findings include: During observation of PCT AA’s performance of the Total Chlorine test on 1/10/24 at 1:50 p.m., the following was observed: - RN AA or LPN AA were not present during the actual performance of the Total Chlorine Test by PCT AA. PCT AA did not show the result of the test or the comparison of the test strip to the color chart to RN AA or LPN AA. - According to PCT AA on 1/10/24 at approximately 2:00 p.m., the licensed nurses never came to verify the Total Chlorine test results and he added that he never showed the test strips to the nurses to verify the result. PCT AA also added that the nurses just came to the Water Preparation Room to sign the log. - RN AA stated on 1/10/24 at approximately 2:05 p.m., that she never accompanied the PCTs during the Total Chlorine Test, nor verified if the result was accurate or if the PCT performed it according to the facility policies and procedures and manufacturer’s DFU. She only went to the Water Preparation Room (where the log was located), when she can to sign the log, making sure that it was recorded. - A review of the Total Chlorine Logs from December 2023 to present date, showed the nurses signed the column which read: “Signature of Licensed Nurse Verifying (to prove to be true, confirm, validate, authenticate, corroborate, substantiate, {sic}) Each Test is Documented and Results Appropriate”. - A review of facility Policy: 12-14-03, titled, “Daily Water System Total Chlorine Monitoring” with latest revision date of October 2023, stated: - If the results of Total Chlorine testing from the primary carbon filter or set of tanks indicate a level of less than or equal to 0.1 ppm (< 0.1 ppm), Record results on the “Routine Total Chlorine Testing” log which contains entries for day, date, test number, test time, signature of person performing the test, test results, and signature of licensed nurse verifying that each test on the daily log is complete and results appropriate. If the licensed nurse performs the Total Chlorine test, they may also sign results as verified.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 33921 Based on observation, staff interview, and a review of facility records, it was determined that the facility failed to ensure that there was a safe environment for 32 in-center hemodialysis patients as evidenced by failure of one of one Patient Care Technician (PCT BB) to follow the Manufacturer’s Directions For Use (DFU) and the facility’s Policy and Procedure (P&P) regarding independently testing the machines’ dialysate pH (Acidity) using RPC K100-0117 E-Z Check 6.8 - 8.5CT pH strips, prior to initiating Patient (P) #10’s dialysis treatment at Station (S) 7. This deficient practice had the potential to negatively affect the health and safety of P#10 and the other eight in-center hemodialysis patients (P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#11) who were undergoing hemodialysis treatment at the time of this observation. The facility census was 32. Findings include: During observation in the Patient Treatment Room on 1/10/24 between 10:45 a.m. and 2:00 p.m., the following was revealed: - PCT BB was observed testing the dialysate sample for pH from S#10, at 2:40 pm., using RPC K100-0117 E-Z Check 6.8 - 8.5CT pH strip. PCT BB dipped the strip to the dialysate sample for 15 seconds and immediately compared the color on the strip to the color chart without waiting for 10 seconds for the color to develop. - PCT BB stated on 1/10/24 at 2:50 p.m., that she was not sure how long to dip the strip and how long to wait, but will check the policy. The Facility Administrator was notified of this observation on 1/10/24 at 2:55 p.m., and she stated that the staff should follow the facilty’s P & P for testing the dialysate pH. - A review of the Manufacturer’s DFU and the facility’s Procedure: 2-08-01P titled, “Testing pH of Citric Acid Base Dialysate Using RPC E-Z Chek K100-0117CT 6.8 - 8.5 Test Strips, with latest revision date of October, 2020, stated: 2. Obtain dialysate sample using a disposable collection cup, then dip the strip into the solution for one (1) second... 3. Remove the strip from the fluid and shake off excess dialysate. At 10 seconds, immediately compare the color reaction on strip to the color chart on bottle to determine the closest match. - A review of Policy: 1-03-02, titled, “Testing pH and Conductivity of Proportioned Dialysate and Verification of Temperature of Proportioned Dialysate”, with latest revision date of April 2020, stated: 6. Independent pH is required to be performed prior to each treatment. A review of PCT BB’s annual competency skills check for testing pH and Conductivity was dated 11/1/23.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 33921 Based on observation and staff interviews, it was determined that the facility failed to ensure that the building in which dialysis services were provided, was maintained free from damage and defects to ensure the safety of the patients and staff. This failure to maintain the integrity of all surfaces could hinder effective cleaning and disinfection of the surfaces, thus providing a potential for microbial growth. This deficient practice was observed in one of one Patient Treatment Room, in one of one Supply Room, and one of one Dialysate Preparation Room. Findings include: During a tour of the facility on 1/10/24 at 2:00 p.m., the following was revealed: In the Patient Treatment Room: - Two of three office chairs in the Nurse’s and Patient Care Technician’s desk (located in the middle of the Patient Treatment Room), had torn and peeled off upholstery on the seat and sides of the chairs. - RN AA acknowledged this observation on 1/10/24 at 2:25 p.m. and stated that the chairs’ upholstery had been this way for a while now. - The surface of the wall next to the Patients’ Entrance door all the way across to the other side of the wall, from mid-section to the floor, had multiple rough marks and some chipped areas on the surface of the wall. - The Biomedical Technician (BMT) stated on 1/10/24 at 11:20 a.m., that there was a work order for the wall to be repaired and painted, but there was no documentary evidence presented regarding this said repair. - The floor behind and around sides of the patients’ hemodialysis chairs at Stations 4, 5, 6, 7 and 8 was covered with dried, white sediments. In the Dialysate Preparation Room: - There were dried, white sediments around the pipes and hose connecting to the Acid Mixing Tank. The floor under and around the Acid Mixing Tank was covered with a thick, dried, white crystalline substance. - The floor behind the Multimedia Tank and the Water Softener tank was covered with dried, white sediment. - There was a brownish discoloration covering the left side wall next to the back (exit/entrance) door. In the Supply Room: - The floor of the Supply Room had multiple chipped and scuffed areas. In addition, there were scattered papers, wrappers littering the floor. - The BMT stated on 1/10/24 at approximately 11:35 a.m., that he cleaned the Supply and Dialysate Preparation Rooms once a month, and the Direct Patient Care Staff (Nurses and Technicians), were responsible for keeping them cleaned the rest of the time.”

“QAPI-INDICATOR-ANEMIA MANAGEMENT CFR(s): 494.110(a)(2)(iv) The program must include, but not be limited to, the following: (iv) Anemia management. This Standard is not met as evidenced by: 33921 Based on a review of facility records and staff interview, it was determined that the facility failed to develop and implement plans of action to improve the effectiveness of the facility’s management of patients with Hemoglobin (Hgb - Protein in red blood cells that carries oxygen throughout the body) less than (<) 10 g/dL, for six of six months of the facility’s Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (July 2023 - December 2023). This deficient practice had the potential to negatively affect the health and safety of 32 in-center hemodialysis (ICHD) patients who were under the care of this facility. Findings include: A review of the Quarterly Update of the Fiscal Year 2024 Dialysis Facility Report (DFR): A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients, revealed that the average hemoglobin <10 g/dL should not exceed 23.4 % for hemodialysis patients. The facility’s FY 2024 QDFR revealed that ICHD patients who had Hemoglobin <10 g/dL was 27.3%. A review of the facility’s QAPI meeting minutes from (July 2023 - December 2023), revealed the following percentage of patients with Hemoglobin <10 g/dL: - July 2023 - 51.9 % - August 2023 - 39.3 % - September 2023 - 46.2 % - October 2023 - 31.8 % - November 2023 - 50 % - December 2023 - 52.2 % A review of the monthly QAPI notes revealed a lack of documentation that the effectiveness of the action plans were evaluated to ensure improvement in the patients’ anemia status. The Facility Administrator stated on 1/12/24 at approximately 2:00 p.m., that the patients’ anemia was managed per protocol and even outside protocol with the doctor’s order.”