Fmc - Crown Point

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[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. This Standard is not met as evidenced by: 51199 Based on record review, observation, and interview, the dialysis facility failed to have a system of medical documentation that secures and maintains availability of patient records and staff information in an emergency/ evacuation. Findings include: A revised policy, dated 07/03/2023, titled “Guidelines for Emergency Preparedness”, indicated that staff and patient emergency information contact lists should be updated quarterly and be kept locked in the emergency supply box. During an observation on 04/02/2025, beginning at 10:37 AM, a review of the dialysis facility emergency preparedness kit failed to evidence a current list of patients/ demographics/ dialysis prescription/ staff emergency contact information. An Emergency Disaster Patient Contact List, dated 03/27/2023 and an Emergency Disaster Staff Contact Information Sheet, dated 03/13/2023, was found in the emergency preparedness kit. During an interview, on 06/11/2025 beginning at 11:45 AM, the Facility Administrator [FA] indicated patient and staff emergency information was located in a binder in an office room and that staff would need to obtain this binder during an evacuation. The FA additionally indicated that the same information is located in the emergency preparedness kit. During an interview on 06/11/2025, beginning at 1:35 PM, RN 3 indicated that the staff would find patient and staff emergency information in the emergency preparedness kit in the event of an evacuation. Additionally, RN 3 relayed there was no other binder that she was aware of that would need to be obtained in the event of an evacuation.”

“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: 51199 Based on record review and interview, the dialysis facility failed to evidence exercises were conducted to test the emergency plan, annually at minimum, in 1 of 1 dialysis facility. Findings include: A revised policy, dated 07/03/2023, titled “Guidelines for Emergency Preparedness”, indicated that annually, the dialysis facility must participate in a community-based disaster drill as well as a table-top drill for an event of high likelihood. Clinic documents provided for review included a loss of water tabletop exercise including scenario and staff sign-in log dated 04/17/2025 and 04/18/2025. Additionally, a flooded roads tabletop exercise information and staff sign-in log dated 03/07/2024 was provided. During an interview on 06/11/2025, beginning at 2:55 PM, the Facility Administrator [FA] indicated that these two trainings were the only training exercises completed in the last two years. The FA indicated that no community-based or full-scale exercise has been completed since approximately 2020, and no real-world events that would cause the facility to activate the emergency preparedness plan had occurred in the last two years.”

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure staff performed hand hygiene and changed their gloves in 1 of 3 observations of accessing of an arteriovenous fistula [AVF] (dialysis access) for initiation of dialysis [PCT 5] and in 1 of 4 observations of discontinuation and post dialysis access care for AVF [PCT4]. Findings include: 1. A revised policy, dated 11/06/2023, titled “Hand Hygiene”, indicated that hand hygiene should be performed before and after direct contact with patients, before performing vascular access, and after contact with dialysis equipment. 2. During an observation on 06/09/2025, beginning at 11:29 AM, PCT 5, at station # 17, was accessing an AVF for initiation of dialysis and palpated the AVF cannulation sites of Patient 7. PCT 5 failed to perform hand hygiene and don new gloves prior to disinfecting the cannulation site and inserting the needles. 3. During an observation on 06/09/2025, beginning at 10:45 AM, PCT 4, at station #10, was discontinuing hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) for Patient 9. PCT 4 reinfused the HD machine and failed to perform hand hygiene and don new gloves prior to removing the needles from Patient 9. 4. During an interview, on 06/11/2025 beginning at 11:56 AM, PCT 4 indicated that hand hygiene should be performed frequently before contact with the patient and equipment.”

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure RN 1 demonstrated aseptic techniques when administering parenteral medications in 2 of 2 observations of parenteral medication preparation and administration. Findings include: 1. A revised policy, dated 02/06/2025, titled, “Medication Preparation and Administration” indicated aseptic technique was to be used to administer medications and IV ports should be disinfected prior to accessing. 2. During an observation, on 06/10/2025 beginning at 1:09 PM, RN 1 failed to disinfect the injection port prior to administering parenteral medication to Patient 18. 3. During an observation, on 06/10/2025 beginning at 1:16 PM, RN 1 failed to disinfect the injection port prior to administering parenteral medication to Patient 3. 4. During an interview, on 06/11/2025 beginning at 1:35 PM, RN 3 indicated that the injection port should be cleaned and disinfected prior to administering parenteral medication.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 41135 Based on observation and interview, the facility failed to ensure the softener brine tank was at least half filled with salt pellets in 1 of 1 observation of the water room. The findings include: During an observation on 06/10/2025, beginning at 11:26 AM, the softener brine tank failed to contain salt pellets. On 06/10/2025, at 11:33 AM, Corporate Person 2 indicated there was not any salt pellets in the softener brine tank, because the facility had run out of salt pellets and the delivery truck had just arrived with more.”

“RO-MEETS AAMI/MONITORED, RECORDED ON LOG CFR(s): 494.40(a) 5.2.7 Reverse osmosis: meets AAMI/monitored/recorded on log Refer to RD62:2001, 4.3.7 Reverse osmosis: When used to prepare water for hemodialysis applications, either alone or as the last stage in a purification cascade, reverse osmosis systems shall be shown to be capable, at installation, of meeting the requirements of Table 1, when tested with the typical feed water of the user, in accordance with the methods of [AAMI] 5.2.2. 5.2.7 Reverse osmosis Users should carefully follow the manufacturer’s instructions for feed water treatment and monitoring to ensure that the RO is operated within its design parameters. 6.2.7 Reverse osmosis All results of measurements of RO performance should be recorded daily in an operating log that permits trending and historical review. This Standard is not met as evidenced by: 41135 Based on observation, record review, and interview, the facility failed to ensure all the results of the measurements of the reverse osmosis (RO) performance were documented correctly in 1 of 1 observation of the water room. The findings include: During an observation on 06/10/2025, beginning at 11:26 AM, the softener brine tank failed to contain salt pellets. On 06/10/2025, at 11:33 AM, Corporate Person 2 indicated the agency ran out of salt pellets the day prior. The Water Pre-Treatment Opening document completed by PCT 4 indicated the softener brine tank was at least half full on 06/10/2025. On 06/10/2025, the BioMed Technician indicated PCT 4 notified him the day before on 06/09/2025 that the salt pellet level was low in the softener brine tank and indicated PCT 4 should not have documented the salt pellet level was at least half full in the softener brine tank on 06/10/2025. On 06/11/2025, at 11:55 AM, PCT 4 indicated there were no salt pellets in the softener brine tank but marked the level was at least half full, because he knew the shipment of salt pellets would be delivered that day.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 41135 Based on observation, record review, and interview, the facility failed to ensure the patient’s hemodialysis (HD, a process to filter the blood in a patient whose kidneys do not work normally) access site was in view while receiving HD treatment in 1 of 2 treatment floor observations. (Patient #14) The findings include: A policy titled “Patient Assessment and Monitoring” dated 05/01/2023 indicated the access site was to remain uncovered during the treatment. During an observation on 06/09/2025, from 10:30 AM to 11:32 AM, Patient #14 had multiple blankets covering the central venous catheter (CVC, dialysis access) while treatment was provided. During an interview on 06/09/2025, at 11:55 AM, Patient #14 indicated they were unaware the access site had to be visible and uncovered during the treatment. On 06/12/2025, at 11:55 AM, the FA indicated staff should have removed the blankets covering the Patient’s access site.”

“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: 51199 Based on observation and interview, the dialysis facility failed to ensure Patients’ Rights were posted where it could be easily seen and read by all patients in 1 of 1 facility. Findings include: During an observation upon entrance to the dialysis facility on 06/09/2025, beginning at 10:25 AM, the lobby failed to evidence posting of Patient’s Rights. During an interview on 06/09/2025, beginning at 4:40 PM, the Facility Administrator indicated that the Patient Rights should be posted in the lobby and will need to determine why they are not posted.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure that policies and procedures relative to patient care, infection control, and safety were adhered to by the dialysis facility staff in 3 of 3 personnel records reviewed [PCT 4, PCT 5, and RN1], in 1 of 3 [PCT 5] observations of accessing an arteriovenous fistula [AVF] (dialysis access) or arteriovenous graft [AVG] (dialysis access) for initiation of hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally), 1 of 4 observations [Patient 16] of HD treatment prescription delivery verification, and 1 of 1 clinical record review of an unstable patient [Patient 3]. Findings include: 1. A revised policy, dated 01/23/2019, titled “Color Blindness Testing”, indicated that the staff member being tested record test answers on the answer sheet and the direct supervisor should score the test overall as “pass” of “fail”. Additionally, the policy indicated that 10 or more answers correct on questions 1-11 would indicate a “pass” result, and 9 or less correct answers would indicate a “fail” result. Answers to questions 12-14 will not be factored into the final test score. 2. A revised policy, dated 05/05/2025, titled “Access Assessment and Cannulation”, indicated that prior to cannulating, an AVF or AVG should be checked for adequate bruit (sound generated by the flow of blood) to confirm patency by listening for abnormal or absent sounds by auscultation with a stethoscope. 3. A revised policy, dated 05/01/2023, titled “Patient Assessment and Monitoring”, indicated thatrequired patient monitoring included checking that the dialysate flow rate [DFR] setting is correct, and that the prescribed flow rate is being delivered. 4. During a review of personnel records provided by the dialysis facility on 06/10/2025, the following observations were made regarding the color-blind testing results: A. A Color and Quality Test Screen Results form, dated 06/03/2025, for RN 1, failed to evidence a score, nor a “pass” result, nor a “fail” result. B. A Color and Quality Test Screen Results form, dated 08/22/2024, for PCT 5, did not contain a score, nor a “pass” result, nor a “fail” result. The form indicated a “pass” result in the “home therapy use only” section. The form additionally indicated that questions 12-14 were answered correctly, but no score was noted for questions 1-11. C. A Color Deficiency Test form, dated 09/30/2016, for PCT 4, did not contain a score, nor a “pass” result, nor a “fail” result in the designated results section. D. During an interview, on 06/10/2025 beginning at 2:45 PM, the Facility Administrator [FA] indicated that all the color-blind tests had been passed by staff, even if it had not been marked so on the test forms. The FA agreed that based on the documentation given to the surveyor, clear results could not be interpreted. 5. During an observation, on 06/09/2025 beginning at 11:29 AM, PCT 5 was at station # 17, performing access of an AVF to Patient 7. PCT 5 located and palpated the cannulation site and failed to auscultate bruit of the AVF prior to cannulation of the AVF site. During an interview, on 06/11/2025 beginning at 11:56 AM, PCT 4 indicated that the bruit of an AVF or AVG should be auscultated prior to AVF/AVG cannulation. 6. During an observation, on 06/10/2025 beginning at 1:27 PM, Patient 16 was at station #8, had a DFR running on “autoflow” (a feature that varies DFR rate based on blood flow) during treatment; the prescribed DFR was 800. A Treatment Sheet, dated 06/10/2025, for Patient 16, the DFR had been set to the rate of “autoflow” from the start of treatment at 11:09 AM until 1:35 PM. During an interview, on 06/10/2025 beginning at 1:27 PM, RN 1 indicated that the prescription for DFR was 800, and that the running DFR should have been 800. 7.A clinical record review on 06/12/2025, for Patient 3, indicated the following: A. A Treatment Sheet, dated 05/22/2025, indicated the DFR was run at 500 for the entire treatment, and that the prescribed DFR was 800. B. A Treatment Sheet, dated 06/07/2025, indicated the DFR was run at 500 for the entire treatment, and that the prescribed DFR was 800. During an interview on 06/11/2025, beginning at 1:35 PM, RN 3 indicated that DFR’s should be run at the rate the dialysis prescription specifies and that if a different rate needs to be run, the MD would need to place a new order. 41135 8. A clinical record review for Patient #6 evidenced an order dated 04/30/2025 which indicated the BFR was 350. The Treatment Sheet for 05/26/2025 indicated the BFR was 375 and the Treatment Sheets for 05/14/2025, 05/16/2025, 05/26/2025, and 05/30/2025 indicated the BFR was 400. 9. During an interview on 06/11/2025, beginning at 1:35 PM, RN 3 indicated that DFR’s should be run at the rate the dialysis prescription specifies and that if a different rate needs to be run, the MD would need to place a new order.”

“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: 41135 Based on observation, record review, and interview, the facility failed to ensure medical records were accurate in 1 of 1 clinical record review of a patient who did not have the access site in view while receiving hemodialysis (HD, a process to filter the blood in a patient whose kidneys do not work normally) during observation of the HD treatment floor. (Patient #14) The findings include: During an observation on 06/09/2025, from 10:30 AM to 11:32 AM, Patient #14 had multiple blankets covering the central venous catheter (CVC, dialysis access) while treatment was provided. A Treatment Sheet for Patient #14 dated 06/09/2025 indicated the dialysis access site was visible at 10:33 AM and 11:04 AM. On 06/12/2025, at 11:55 AM, the FA indicated the staff should have documented the access site was covered by the blankets, and the Patient was re-educated on leaving the access site visible.”