Hammond Dialysis Center

“Establishment of the EP Program Dialysis CFR(s): §494.62 Condition for Coverage: The dialysis facility must comply with all applicable Federal, State, and local emergency preparedness requirements. These emergencies include, but are not limited to, fire, equipment or power failures, care related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. The dialysis facility must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 51199 Based on record review, interview, and observation, the facility failed to maintain compliance with the condition of Emergency Preparedness at 42 CFR 494.62. The requirement was not met as evidenced by: the supplier failed to identify and document and have a system of that secures and maintains availability of patient records (See V0023); facility failed to keep updated and current contact information of staff names and contact information for use in an emergency (See V0030); facility failed to identify in their communication plan, a primary and alternate means of communication for use during an emergency (See V0032); and facility failed to evidence that exercises were conducted to test the emergency plan, annually at a minimum (See V0039). The cumulative effect of these systemic problems resulted in the Dialysis Centers’ inability to ensure the provision of quality health care in a safe environment and resulted in the agency being found out of compliance with condition 42 CfC 494.62 Emergency preparedness.”

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure: disinfecting solutions were covered to prevent transmission of infectious agents (See V111); hand hygiene was performed to maintain aseptic technique (See V113); aseptic techniques were maintained during parenteral medication administration (See V143); and CVC standard infection control precautions were implemented (See V147). The cumulative effect of these systemic problems has resulted in the dialysis facility’s inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFC 494.30 Infection Control.”

“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 evidence they followed their policy and had a system of medical documentation that secures and maintains availability of patient records in 1 of 1 dialysis facility. Findings include: A revised policy, dated 06/01/2023, titled “RM700 Disaster and Emergency Preparedness”, indicated that items needed for immediate access during an evacuation include monthy updated reports for all patients. During an observation, on 07/28/2025 beginning at 11:55 AM, a review of the dialysis facility emergency preparedness kit failed to evidence a current list of patients, with their demographics and dialysis prescription. The “kit” included a patient report, most recently dated 08/01/2024. During an interview, on 07/31/2025 beginning at 2:38 PM, the FA indicated that patient information for the emergency preparedness kit is probably updated annually, and should be done more often.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 51199 Based on record review, observation, and interview, the dialysis facility failed to keep updated and current contact information of staff names and contact information for use in an emergency in 1 of 1 dialysis facility. Findings include: A revised policy, dated 06/01/2023, titled “RM700 Disaster and Emergency Preparedness,” indicated that the communication plan will include a roster of all center associates with home phone numbers and addresses. During an observation, on 07/28/2025 beginning at 11:55 AM, the emergency preparedness failed to evidence a roster to include their staff, nor their current home phone numbers or their current addresses. The Information Emergency Contacts List was dated 08/24/2024 and failed to evidence their current staff and patients. During an interview, on 07/31/2025 beginning at 2:38 PM, the FA indicated that staff information for the emergency preparedness kit is probably updated annually, and should be done more often.”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to identify in their communication plan, a primary and alternate means of communication for use during an emergency in 1 of 1 dialysis facility. Findings include: A revised policy, dated 06/01/2023, titled “RM700 Disaster and Emergency Preparedness”, indicated that the communication plan should define how associates and patient will be notified of emergency conditions at the center. The Emergency Preparedness Plan for Hammond Dialysis Center, failed to list primary nor their alternate means of communication for use during an emergency. During an interview, on 07/31/2025 beginning at 2:38 PM, the FA indicated that the facility does not have any other alternate means of communication in the event that phones are unavailable.”

“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 that exercises were conducted to test the emergency plan, annually at a minimum, in 1 of 1 dialysis facility. Findings include: A revised policy, dated 06/01/2023, titled “RM700 Disaster and Emergency Preparedness”, indicated that each associates will participate in quarterly disaster exercises and each shift will have a minimum of one disaster exercise annually. During a record review of Hammond Dialysis Center’s Emergency Preparedness Plan, the documentation failed to evidence the clinic tested their emergency plan at least annually nor participated in a full scale community event. During an interview, on 07/31/2025 beginning at 1:15 PM, the FA indicated there were no exercise or test of their emergency plan that occurred within the last 2 years time, and further relayed the facility does not participate in community-wide full scale exercises.”

“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: 51199 Based on record review, observation, and interview, the dialysis facility failed to ensure bleach/water solution was covered with a lid to minimize transmission of infectious agents in 1 of 3 observations on the dialysis treatment floor [observation period #1] . Findings include: A revised policy, dated 06/20/2024, titled “G45 Cleaning and Disinfection of Equipment, Supplies, and Treatment Area,” indicated that bleach solutions must be covered with a lid to prevent contamination. During observation period #1, on 07/28/2025 from 10:10 AM - 12:10 PM, a container of clear solution, labeled as 1:100 was left uncovered, with the lid on the counter beside the container, throughout the duration of the observation period from 10:10 AM - 12:12 PM. During an interview, on 07/30/2025 beginning at 1:51 PM, PCT 4 indicated the clear solution was 1:100 bleach, and should remain covered.”

“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 record review, observation, and interview, the dialysis facility failed to ensure their staff removed contaminated gloves and performed hand hygiene at the appropriate times to maintain aseptic technique in 2 of 3 (PCT 1) observations of central venous catheter [CVC] (catheter into large vein)exit site care, 1 of 2 (PCT 6) observations of discontinuation of dialysis with a CVC, and 1 of 3 (PCT 5) observations of accessing of arteriovenous fistula [AVF] (dialysis access) for initiation of dialysis. Findings include: 1. A revised policy, dated 11/29/2025, titled “G40 Infection Control”, indicted that hand hygiene should be performed after touching contaminated items. 2. A revised procedure, dated 09/01/2023, titled “IC05C CVC: Dressing Change”, indicated that once the old dressing is removed, hand hygiene should be performed and new gloves should be donned. 3. A revised procedure, dated 06/11/2025, titled IC05A CVC: Initiation and Discontinuation of Treatment”, indicated that once the patient blood has been returned, contaminated gloves should be removed, hand hygiene should be performed, and new gloves should be donned. 4. During an observation, on 7/28/2025 beginning at 10:35 AM, at station 8, PCT 1 was performing CVC exit site care to Patient 11. After removing the old CVC dressing, PCT 1 failed to remove contaminated gloves, perform hand hygiene, and don clean gloves prior to disinfecting the CVC exit site. 5. During an observation, on 7/28/2025 beginning at 11:00 AM, at station 5, PCT 1 was performing CVC exit site care to Patient 12. After removing the old CVC dressing, PCT 1 failed to remove contaminated gloves, perform hand hygiene, and don clean gloves prior to disinfecting the CVC exit site. 6. During an observation, on 07/30/2025 beginning at 1:55 PM, at station 16, PCT 6 was performing discontinuation of dialysis with a CVC on Patient 2. After returning the patient blood, PCT 6 failed to remove contaminated gloves, perform hand hygiene, and don new gloves prior to disinfecting the CVC connections and disconnecting the blood lines. 7. During an observation, on 07/28/2025 beginning at 11:24 AM, at station 4, PCT 5 was performing access of AVF for initiation of dialysis on Patient 13. PCT 5 located and palpated the AVF cannulation sites and failed to perform hand hygiene and don clean gloves prior to disinfecting cannulation sites. 8. During an interview, on 07/30/2025 beginning at 1:15 PM, PCT 6 indicated that hand hygiene and glove change should be performed after contamination. 9. During an interview, on 07/30/2025 at 3 PM, PCT 1 described how she cleans a CVC exit including when she would change her gloves. She described she would continue to wear the same gloves to clean the CVC exit site as she wore to removed the soiled dressing.”

“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 record review, observation, and interview, the dialysis facility failed to ensure LPN 1 demonstrated aseptic techniques when administering parenteral medications in 1 of 2 observations of parenteral medication preparation and administration. Findings include: A revised policy, dated 11/29/2022, titled “G40 Infection Control”, indicated that blood line ports will be disinfected with an appropriate disinfectant prior to entry with needles. During an observation on 07/30/2025, beginning at 10:58 AM, at station 1, LPN 1 performed parenteral medication administration to Patient 4. LPN 1 failed to disinfect the blood line port prior to entry of needle for medication administration. During an interview on 07/30/2025, beginning at 2:20 PM, RN 2 indicated that the blood line port should be disinfected prior to administering parenteral medication.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 51199 Based on record review, observation, and interview, the dialysis facility failed to ensure central venous catheter [CVC] (catheter into large vein) standard infection control precautions were implemented to prevent catheter related infections in 2 of 2 (PCT 1) observations of initiation of dialysis with a CVC and 3 of 3 (PCT 1 and PCT 4) observations of CVC exit site care. Findings include: 1. A revised policy, dated 11/29/2022, titled “G40 Infection Control”, indicated that aseptic technique will be used to clean the CVC exit site and all CVC connections will be handled using aseptic technique. 2. A revised procedure, dated 06/11/2025, titled “IC05A CVC: Initiation and Discontinuation of Treatment” indicated that CVC limbs, caps, and hubs should be disinfected prior to attaching a sterile syringe for initiation of dialysis. 3. A revised procedure, dated 09/01/2023, titled “IC05C CVC: Dressing Change”, indicated that after removal of the old dressing for CVC exit site care, the old dressing and contaminated gloves should be discarded. 4. During an observation, on 07/25/2025 beginning at 10:36 AM, PCT 1 was performing initiation of dialysis to Patient 11. PCT 1 failed to disinfect the CVC limbs, caps, and hubs prior to attaching the sterile syringes to each CVC port. 5. During an observation, on 07/28/2025 beginning at 11:05 AM, PCT 1 was performing initiation of dialysis to Patient 12. PCT 1 failed to disinfect the CVC limbs, caps, and hubs prior to attaching the sterile syringes to each CVC port. 6. During an observation, on 07/25/2025 beginning at 10:35 AM, PCT 1 was performing CVC exit site care to Patient 11. PCT 1 failed to discard the old dressing and contaminated gloves, instead placing them onto a clean field that contained unused supplies needed for initiation of dialysis for Patient 11. PCT 1 then proceeded to use the clean supplies for initiation of dialysis on Patient 11. 7. During an observation, on 07/25/2025 beginning at 11:00 AM, PCT 1 was performing CVC exit site care to Patient 12. PCT 1 failed to discard the old dressing and contaminated gloves, instead placing them onto a clean field that contained unused supplies needed for initiation of dialysis for Patient 12. PCT 1 then proceeded to use the clean supplies for initiation of dialysis on Patient 12. 8. During an observation, on 07/25/2025 beginning at 11:18 AM, PCT 4 was performing CVC exit site care to Patient 4. PCT 4 failed to discard the old dressing, instead placing it onto a clean field that contained unused supplies needed for initiation of dialysis for Patient 4. PCT 4 then proceeded to use the clean supplies for initiation of dialysis on Patient 4. 9. During an interview, on 07/30/2025 beginning at 1:15 PM, PCT 6 indicated that during CVC care, the old dressing and contaminated gloves should be discarded in the trash, and that the CVC catheter limbs/caps/and hubs should be cleaned prior to connecting syringes. 10. During an interview, on 07/30/2025 beginning at 2:59 PM, PCT 1 indicated that she does not discard old dressing and contaminated gloves, instead places them on the clean field containing clean supplies. PCT 1 additionally indicated that she connects the syringes to the CVC ports without disinfecting first. PCT 1 indicated she disinfects ports after withdrawing heparin from the CVC port and prior to connecting the blood lines to the CVC port afterwards.”

“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: 41135 Based on observation, record review, and interview, the dialysis facility failed to ensure the safety of the patients was maintained by properly storing medications in 1 of 3 observations on the treatment floor (observation period 1). The findings include: A policy revised 06/11/2025 titled “Medications: Administration, Storage, [and] Disposal” indicated medications must never be left unsecured or unattended. During an observation on the treatment floor on 07/28/2025, at 11:25 AM, an open box of 10 ampules of epinephrine (an emergency medication) were observed unsecured and unattended on top of the crash cart on the treatment floor until the conclusion of the observation on the treatment floor at 12:15 PM. On 07/28/2025, at 11:45 AM, the FA was directed to the open box of epinephrine on top of the crash cart, and the FA indicated the medication should not be left on top of the crash cart but locked inside.”

“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: 51199 Based on record review, observation, and interview, the dialysis facility failed to ensure patient safety by ensuring the hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) access sites were visible during HD treatment in 2 of 3 observation periods of in-center HD treatment (observation periods #1 and #2). Findings include: 1. A revised policy, dated 11/29/2022, titled “IC08 Monitoring & Documentation of Patient Care During Treatment” indicated that a patient’s vascular access should remain uncovered and visible throughout the course of the patient’s treatment. 2. During an observation on 07/28/25, at station 6, Patient 10 had his/her dialysis access site covered with a blanket at 10:35 AM, and the access site remained covered throughout the observation period that ended at 12:10 PM. 3. During an observation on 07/28/2025, at station 5, Patient 12 had his/her dialysis access site covered with a disposable PPE gown at 11:10 AM, and the access site remained covered throughout the observation period that ended at 12:10 PM. 4. During an observation on 07/28/2025, at station 8, Patient 11 had his/her dialysis access site covered with a blanket at 11:10 AM, and the access site remained covered throughout the observation period that ended at 12:10 PM. 5. During an observation on 07/30/2025, at station 8, Patient 10 had his/her dialysis access site covered with a blanket at 10:30 AM, and the access site remained covered throughout the observation period that ended at 11:45 AM. 6. During an interview on 07/30/2025, beginning at 11:29AM, PCT 4 indicated that HD access sites must be visible at all times during HD treatment. 7. During an interview on 07/30/2025, beginning at 10:40 AM, Patient 10 indicated that he/she is aware that access should be visible, but states he often gets cold and uses a blanket.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 41135 Based on record review and interview, the agency failed to ensure patients had the right to recognition of individual needs and the ability to question procedures without fear of reprisal in 1 of 1 clinical record listed as unstable related to missed visits in a total sample of 6 clinical records reviewed. (Patient #6) The findings include: A policy dated 06/11/2025 titled “Grievance Process: Patients” indicated patients using the grievance process would not be threatened or intimidated. A review of a Patient Complaint or Grievance Form dated 05/15/2025 indicated Patient #6 informed the MSW he/she felt unsafe on the treatment floor. The MSW indicated she offered to refer the Patient to another facility; the document failed to evidence the resolution. A Progress Note completed by the MSW, dated 05/15/2025, indicated Patient 6 did not feel safe at the facility and wanted to transfer to another facility. The note indicated Patient was unsure if he would be able to transfer due to past behaviors at other dialysis facilities and did not want to pursue a transfer to another facility. On 07/28/2025, at 10:41 AM, Patient #7 indicated the FA had not followed up on his/her complaints. Patient #7 indicated management was a problem, and the attitude of the staff changed when management come out onto the treatment floor. Review of the Quality Assurance and Performance Improvement (QAPI) program indicated Patient #6 had the following number of missed HD treatment visits: January 2025: 1, February 2025: 0, March 2025: 5, April 2025: 4, May 2025: 5, June 2025: 3, and July 2025: 2. During an interview on 07/29/2025, at 12:37 PM, the MSW indicated Patient 6 did not feel safe at the facility, Patient did not like their physician. The MSW indicated the facility did not provide a referral to or contact information for another physician. On 07/29/2025, at 1:54 PM, Patient #6 indicated he/she missed treatments due to not feeling safe at the facility and indicated the reason for feeling unsafe was because he/she felt “targeted” by the FA for making complaints about his/her concerns regarding treatment(s) initiated late, not seeing their physician, and staff changing her/his dry weight and the amount of fluid being pulled off. The Patient indicated the FA does not speak to him/her since the Patient has spoken up about his/her concerns. On 07/30/2025, beginning at 12:11 PM, Person 1 (former employee) indicated Patient #6 felt unsafe because Patient #6 voiced a complaint about treatment(s) being started late and the FA then “had it out for [Patient #6].” On 07/30/2025, beginning at 2:20 PM, RN 2 indicated on 07/28/2025 Corporate Person 1 “highly encouraged” her to not tell the surveyors of patients wanting to speak to the surveyors. RN 2 indicated patients that made frequent complaints were labeled as “troublemakers” by the FA, and the FA did not investigate and follow-up with the patient’s complaints. RN 2 indicated the FA encouraged staff to write incident reports for the behaviors of certain patients to include Patient #6 and Patient #7 and ignored other patients who made complaints to include Patient #1. RN 2 indicated patient rights were not maintained by treating patients with respect if they were not management’s “favorite.” On 07/31/2025, at 3:26 PM, the Nurse Practitioner 1 indicated the FA shows favoritism to patients and indicated the tension between the FA and nursing staff was palpable on the treatment floor by the patients. On 07/31/2025, at 1:37 PM, the FA indicated she had no idea why Patient #6 felt unsafe at the facility, because the next time she saw the Patient on the floor after making the grievance, Patient #6 referred to the FA as “Sexy Red”, so she did not ask the Patient why he/she felt unsafe.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to ensure the services were provided as directed in the plan of care in 3 of 6 clinical records reviewed. (Patient #1, 4, 6) The findings include: 1. A clinical record review for Patient #1 evidenced a Treatment Flowsheet dated 06/18/2025 (Wednesday) which indicated the Patient’s treatment days were Monday, Wednesday, and Friday and indicated the facility was to administer Mircera (medication to treat low red blood cells) during the second treatment weekly. The record failed to evidence the facility administered Mircera on the second treatment day of the week on 06/18/2025. On 07/28/2025 at 11:00 AM, Patient #1 indicated the facility did not administer Mircera several weeks ago due to “a shipment didn’t come in.” On 07/30/2025 at 2:20 PM, RN 2 indicated Mircera was supposed to be given on the second treatment day of the week, but if the medication was not available, the medication would be given on the third treatment day. RN 2 indicated the staff was instructed by the FA to document the medication as “not due” instead of medication not available. On 07/30/2025, at 3:15 PM, the FA indicated the medication was not given on the second treatment day on 06/18/2025, because the medication was not available. The FA stated, “If a medication isn’t available, I can’t give it. That’s not a medication error; it’s a supply issue.” A Dialysis Order Report dated 07/21/2025 indicated the Patient’s dialysate flow rate (DFR) was 500. A Treatment Sheet dated 07/25/2025 indicated the DFR was 600 beginning at 10:31 AM until the end of treatment at 1:55 PM. The record failed to evidence an order to increase the DFR to 600. On 07/30/2025, at 3:15 PM, RN 2 indicated the DFR should not be higher than what is ordered and indicated there was no order to increase the DFR to 600. 2. A clinical record review for Patient #4 evidenced a Treatment Flow Sheet dated 07/08/2025 which indicated the blood flow rate (BFR) was ordered at 350, the treatment was initiated with a BFR of 400. The record failed to evidence an order for a BFR increase to 400. On 07/31/2025, at 3:44 PM, the FA indicated the BFR must have been initiated incorrectly and indicated there was no order for a BFR increase to 400. 3. A clinical record review for Patient #6 evidenced a Treatment Flow Sheet dated 07/28/2025 which indicated the BFR was ordered at 400, the treatment was initiated with a BFR of 450. The record failed to evidence an order for a BFR increase to 450. On 07/31/2025, at 1:41 PM, the FA indicated the treatment must have been started incorrectly with a BFR of 450. 51199”

“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: 41135 Based on record review and interview, the facility failed to administer the pneumonia (a contagious infection) vaccine after patient consent was obtained in 1 of 1 clinical record review for a patient with an admission to the facility in the past 90 days in a total sample of 6 clinical records reviewed. (Patient #4) The findings include: A clinical record for Patient #4 evidenced a Patient Vaccination Consent form signed and dated by the Patient on 05/20/2025 which indicated the Patient consented to receiving the pneumonia vaccine, and the record failed to evidence the facility administered the pneumonia vaccine. On 07/31/2025, at 2:56 PM, the FA indicated the facility had not yet administered the pneumonia vaccine due to an oversight.”

“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: 41135 Based on record review and interview, the facility failed to follow agency policy and obtain a standing blood pressure prior to the initiation of hemodialysis (HD, the process to filter the blood when the kidneys do not function properly) to manage the patient’s volume status in 3 of 6 clinical records reviewed. (Patient #1, 4, 6) The findings include: 1. A policy revised May 2022 titled “Ongoing Patient Monitoring” indicated the facility would obtain a standing blood pressure before initiation of HD for all ambulatory patients. 2. A clinical record review for Patient #1 evidenced Treatment Flowsheets dated 07/07/2025, 07/09/2025, 07/11/2025, 07/14/2025, 07/25/2025, and 07/28/2025 which failed to evidence a standing blood pressure prior to initiation of HD. On 07/28/2025, at 11:00 AM, Patient #1indicated the staff didn’t typically obtain a standing blood pressure. On 07/30/2025, beginning at 2:20 PM, RN 2 indicated Patient #1 was ambulatory with a walker and was not sure why the standing blood pressure was not obtained prior to treatment. 3. A clinical record review for Patient #4 evidenced Treatment Flowsheets dated 07/08/2025, 07/10/2025, 07/12/2025, 07/17/2025, 07/19/2025, 07/22/2025, 07/25/2025, and 07/28/2025 which failed to evidence a standing blood pressure prior to initiation of HD. On 07/31/2025, at 3:42 PM, the FA indicated the Patient is ambulatory and the standing blood pressure was not documented prior to initiation of treatment. 4. A clinical record review for Patient #6 evidenced Treatment Flowsheets dated 07/03/2025, 07/12/2025, and 07/19/2025 which failed to evidence a standing blood pressure prior to initiation of HD. On 07/31/2025, at 1:39 PM, the FA indicated the Patient was ambulatory and the standing blood pressure was not documented.”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to ensure the interdisciplinary team adjusted the plan of care when the expected outcome was not achieved and failed to identify and document the potential causes of patient non-adherence and efforts to address those causes in 1 of 1 unstable clinical record reviewed in a total sample of 6 clinical records reviewed. (Patient #6) The findings include: A revised policy dated May 2022 titled “Treatment Plans” indicated the treatment plan would be adjusted if the treatment outcomes were not met and indicated the interdisciplinary team would document the reasons why the goals were not met. A clinical record review for Patient #6 evidenced a POC dated 02/03/2025 which failed to evidence any concerns with the Patient’s ability to meet the goal for hemodialysis (HD, the process to filter the blood when the kidneys do not function properly) related to the Patient’s compliance with the HD treatment schedule. Review of the Quality Assurance and Performance Improvement (QAPI) program indicated the Patient had the following number of missed HD treatment visits: January 2025: 1, February 2025: 0, March 2025: 5, April 2025: 4, May 2025: 5, June 2025: 3, and July 2025: 2. A Social Work Quarterly Review document dated 04/24/2025 indicated the Patient received ongoing education regarding compliance and was offered the option to reschedule treatments as needed. A Progress Note completed by the MSW on 05/15/2025 indicated the Patient did not feel safe at the facility and wanted to transfer to another facility. The note indicated the Patient was unsure if he would be able to transfer due to past behaviors at other dialysis facilities so did not want to pursue a transfer to another facility. A Progress Note completed by the MSW on 07/01/2025 indicated the Patient’s barriers to compliance with treatment were related to diarrhea and waking up late. The record failed to evidence the POC was revised with interventions to address the identified barriers to treatment. A Nursing Monthly Progress Note dated 06/18/2025 completed by the FA indicated the Patient’s compliance with treatment was poor, indicated the Patient had erratic behavior and generally missed one HD treatment per week, and failed to evidence any interventions to encourage Patient compliance. A Nursing Monthly Progress Note dated 07/21/2025 completed by the FA indicated the Patient’s treatment compliance was poor and failed to evidence any reasons for the poor compliance and any interventions to encourage Patient compliance. During an interview on 07/29/2025, at 12:37 PM, the MSW indicated the Patient did not feel safe at the facility, because the Patient did not like the physician. The MSW indicated the facility did not provide a referral to or contact information for another physician. On 07/31/2025, at 1:35 PM, the FA indicated since the Patient was made unstable effective 07/01/2025 due to missed treatments and indicated there was no documented communication with the Patient regarding the Patient’s missed treatments and inability to reach the Patient for rescheduling efforts. The FA indicated there was no documented efforts to reach the Patient through alternate means of communication to reschedule the Patient and indicated there were no revised interventions to address the Patient’s continued noncompliance with attending ordered HD treatments.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility’s Quality Assessment and Performance Improvement (QAPI) Program failed to monitor, analyze, and track personnel qualifications and issues in 1 of 1 facility. The findings include: A revised policy, dated 01/13/2025, titled “G09 Quality Assurance and Performance Improvement (QAPI)”, indicated that the QAPI program must continually look at indicators for patients and associates as they are available, develop an improvement plan when indicated by the data, and monitor the effectiveness of the plan. During an interview on 07/31/2025, beginning at 7:55 AM, the FA indicated that the facility does not monitor personnel qualifications and personnel issues during QAPI meetings.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and addressed medical errors in 1 of 1 clinical record reviewed with a missed medication (Patient #1) and identified and addressed infiltrated (the leaking of fluid out of the blood vessel and into the surrounding tissues) hemodialysis (HD, the process to filter the blood when the kidneys do not function properly) lines in 1 of 1 clinical record reviewed with an infiltration (Patient #6) in a total sample of 6 clinical records reviewed. The findings include: 1. A policy revised 05/2022 titled “Incident/Event Reporting” identified a medication omission and an infiltration requiring treatment as events/incidents requiring an incident report to be completed which was to be reviewed by the FA and Medical Director and reviewed at the QAPI meeting. 2. A clinical record review for Patient #1 evidenced a Treatment Flowsheet dated 06/18/2025 (Wednesday) which indicated the Patient’s treatment days were Monday, Wednesday, and Friday and indicated the facility was to administer Mircera (medication to treat low red blood cells) during the second treatment weekly. The record failed to evidence the facility administered Mircera on the second treatment day of the week on 06/18/2025. A review of the facility’s incidents/adverse events failed to evidence an incident/adverse event report for the missed medication. On 07/28/2025, at 11:00 AM, Patient #1 indicated the facility did not administer Mircera several weeks ago due to “a shipment didn’t come in.” The Patient indicated she informed the nurse practitioner that the medication was not given on the scheduled day. On 07/30/2025, at 2:20 PM, RN 2 indicated Mircera was supposed to be given on the second treatment day of the week, but if the medication was not available, the medication would be given on the third treatment day. RN 2 indicated the staff was instructed by the FA to document the medication as “not due” instead of medication not available. On 07/30/2025, at 3:15 PM, the FA indicated the medication was not given on the second treatment day on 06/18/2025, because the medication was not available. The FA stated, “If a medication isn’t available, I can’t give it. That’s not a medication error; it’s a supply issue.” On 07/31/2025, at 12:53 PM, the FA indicated a medication that is not available at the time the medication is ordered to be administered is not an adverse event if the medication can be given at the next treatment day. 3. A clinical record for Patient #6 evidenced a Treatment Flowsheet dated 07/10/2025 which indicated the Patient’s arterial line infiltrated for which the Patient stopped treatment 1 hour and 47 minutes early. A review of the facility’s incidents/adverse events failed to evidence an incident/adverse event report for the infiltration. On 07/31/2025, beginning at 12:53 PM, the FA indicated an arterial line infiltration should have been an adverse event/incident and indicated there was no incident reporting for the adverse event.”

“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 record review and interview, the dialysis facility failed to ensure policies and procedures were followed in regards to patients leaving treatment early against medical advice (AMA) in 4 of 6 clinical records reviewed (Patient 1, 2, 4, 6) and in regards to the new patient assessments in 1 of 1 clincal record reviewed with an admission date in the last 90 days (Patient #4) in a total sample of 6 clinical records reviewed. Findings include: 1. A revised policy, dated 01/13/2025, titled “G26 Against Medical Advice”, indicated that when a patient decides to leave AMA, a detailed progress note must be entered on the patient’s treatment sheet that explains the situation each time it occurs and that each note must provide details of patient counseling of the potential risks to the patient of not following medical orders/advice and the patient’s response, and notification of the patient’s physician. 2. During a clinical record review on 07/31/2025, HD Treatment Flow Sheets for Patient 2 indicated the following: A. On 07/04/25, Patient 2 requested to leave AMA. No detailed explanation of the situation, counseling of potential risks, patient response, or MD notification was documented. B. On 07/07/2025, Patient 2 requested to leave AMA. No counseling of potential risks, patient response, or MD notification was documented. C. On 07/11/2025, Patient 2 requested to leave AMA. No detailed explanation of the situation, counseling of potential risks, patient response, or MD notification was documented. D. On 07/14/2025, Patient 2 requested to leave AMA. No detailed explanation of the situation, counseling of potential risks, or MD notification was documented. E. On 07/16/2025, Patient 2 requested to leave AMA. No detailed explanation of the situation, counseling of potential risks, patient response, or MD notification was documented. F. On 07/18/2025, Patient 2 requested to leave AMA. No counseling of potential risks, patient response, or MD notification was documented. 3. During an interview on 07/31/2025, beginning at 1:50 PM, the Facility Administrator [FA] indicated that she was unaware that the AMA policy states that patients should be counseled about risks of leaving AMA, or that the MD should be notified. The FA indicated that the MD is only notified when the patient leaves AMA when it involves the patient leaving via EMS/911. 41135 4. A clinical record review for Patient #6 evidenced the Patient’s HD treatment time was ordered for 4 hours. The Treatment Flowsheets evidenced: treatment ended 1 hour and 50 minutes early on 07/28/2025 and failed to evidence patient education on the risks of not following treatment orders; treatment ended 31 minutes early on 07/26/2026 and failed to evidence documentation for the reason why treatment ended early; treatment ended 1 hour and 46 minutes early on 07/10/2025 and failed to evidence patient education on the risks of not following treatment orders; and treatment ended 1 hour and 30 minutes early on 07/03/2025 and failed to evidence patient education on the risks of not following treatment orders. On 07/31/2025, at 1:38 PM, the FA indicated the reasons for early termination were not documented. 5. A clinical record review for Patient #4, start of care 05/20/2025, evidenced an initial Treatment Flowsheet dated 05/20/2025 which indicated treatment was initiated at 6:04 AM. The Nursing Initial Assessment dated 05/20/2025 indicated the assessment was at 7:00 AM and failed to evidence the assessment was completed before the initiation of treatment. On 07/31/2025, at 3:46 PM, the FA indicated the initial assessment for a new patient had to be completed within a couple of days of the initial treatment. The FA indicated the new patient did not necessarily get a different assessment than an established patient. The Treatment Flowsheets evidenced the Patient’s HD treatment time was ordered for 3 hours and 30 minutes and evidenced: treatment ended 22 minutes early on 07/17/2025 and failed to evidence patient education on the risks of not following treatment orders; treatment ended 18 minutes early on 07/19/2025 and failed to evidence patient education on the risks of not following treatment orders; treatment ended 30 minutes early on 07/22/2025 and failed to evidence the reason treatment ended early and the patient education on the risks of not following treatment orders; and treatment ended 40 minutes early on 07/28/2025 and failed to evidence patient education on the risks of not following treatment orders. 6. During an observation on 7/28/2025, at 10:30 AM, Patient #1 was heard telling staff that he/she would not be staying late since the staff started his/her treatment late and to end his/her treatment at the normal time. During an interview on 7/28/2025, at 11:00 AM, Patient #1 indicated he/she arrived at the facility early and was scheduled to begin treatment at 10:15 AM. Patient #1 indicated he/she was not called back for treatment until 10:20 AM and treatment was not started until 10:35 AM. Patient #1 indicated his/her ride was already arranged, and he/she could not stay longer to get the full treatment time. Patient #1 indicated his/her treatment was delayed, because staff was doing things that were not typically done when the surveyors were not present such as having the patients wash their hands and taking standing blood pressures prior to beginning treatment. A review of the Treatment Flowsheet dated 07/28/2025 indicated the Patient was to receive dialysis treatment for 3 hours and 30 minutes but ended treatment 27 minutes early. The record failed to evidence the staff indicated the reason for why treatment was ended early and the education provided to the patient on the risks of not following treatment orders. On 07/30/2025, at 3:18 PM, RN 2 indicated the treatment sheet did not include the reason for why treatment ended early. 7. On 07/31/2025, at 1:46 PM, the FA indicated the risk of ending treatment early was “the patient dies.” When queried if the risk of ending treatment early was educated to the patients, the FA indicated the patient should be educated to limit fluids and watch potassium intake.”

“GOV-STAFF HAVE ACCESS TO CONTINUING ED CFR(s): 494.180(b)(4) The governing body or designated person responsible must ensure that- (4) All employees have an opportunity for continuing education and related development activities This Standard is not met as evidenced by: 41135 Based on record review and interview, the administration failed to provide evidence they provided an opportunity for continuing education of their staff. The findings include: A policy revised 12/22/2023 titled “Associates Training [and] In-Services” indicated the FA will identity in-service needs and establish a plan to address the needs. On 07/31/2025, at 12:53 PM, the FA indicated the staff did not report all the incidents, because staff did not want to get each other “in trouble”. The FA indicated she had not provided any additional training/in-service to staff on the reporting of incidents.”