Davita University Dialysis of Indy

“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: 47343 Based on observations, record review, and interviews, the agency failed to ensure hand hygiene was performed appropriately for 2 of 3 treatment floor observations. (Patients #9 , #11, #14, #16, #19, #20 #22, #23, #24, #25, #26, #27, and #28) (PCTs 1, 2, 3 - twice, 5, 6 - three times, and 7) (LPN 3 - twice) Findings Include: 1. A Davita policy with a revision date of 04/2023 titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” indicated but was not limited to, “ ... All teammates ... will perform hand hygiene, a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious materials, d. after patient and dialysis delivery system contact ... f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. Patients and caregivers will be encouraged to ... b. Perform hand hygiene after treatment before leaving treatment area ... 2. A Davita policy with a revision date of 10/2020 titled “Handwashing” indicated but was not limited to, “ ... 2. Wet hands and apply antibacterial liquid soap ... 3. Cover hands (palms, back of hands, between fingers) and wrists with lather and wash vigorously for a minimum of 20 seconds ... 4. Rinse well using running water flowing from wrists to fingertips. ...” 3. A sign posted on the nurses counter across from the Medication preparation room indicated but was not limited to, “ ... Clean Hands + Clean Gloves = No Bugs ... Good hand hygiene is one of the most important ways to prevent the spread of infections. ...” 4. During an observation on 06/17/2025 at 12:50 PM, PCT 2 discontinued the treatment for Patient #9 at Station #10. PCT 2 disconnected the blood lines from the patient, they failed to remove their gloves before assisting the patient into the wheelchair and wheeling the patient out into the lobby. They failed to perform hand hygiene after returning to the treatment room, removing the blood lines from the machine, and doffing gloves. 5. During an observation on 06/17/2025 at 3:00 PM, PCT 1 discontinued the treatment for Patient #14 at Station #23. After disconnecting the bloodlines, they doffed their gloves and failed to perform hand hygiene. They gave the patient a glove for their right hand to hold pressure on their left upper vascular access site. PCT 1 failed to perform hand hygiene prior to donning new gloves and removed the needles from the access sites. When the patient was ready to exit the facility, PCT 1 removed the patient’s glove on their right hand and failed to offer the patient hand hygiene. PCT 1 doffed their gloves, turned on the sink, scrubbed their hands with soap for three seconds, and rinsed off the soap with water. 6. During an observation on 06/18/2025 at 9:20 AM, PCT 6 discontinued treatment for Patient #25 at Station #23. PCT 6 failed to provide hand hygiene prior to donning gloves to disconnect the patient from the dialysis machine. They doffed the gloves, grabbed 4x4 gauze pad, and donned new gloves without performing hand hygiene. PCT 6 removed the needles from the patient’s right upper vascular access site, doffed gloves, and failed to perform hand hygiene prior to donning new gloves and going to Patient #27 at Station #21. PCT 6 came back to place new gauze and tape on Patient #25’s site after working with Patient #27, and failed to perform hand hygiene prior to donning gloves. PCT 6 discarded all used supplies, doffed gloves and donned new gloves without performing hand hygiene. They proceeded to assist Patient #28 at Station 22. 7. During an observation on 06/18/2025 at 9:32 AM, PCT 2 was observed changing out Patient #26’s bloody gauze at Station #20. The gauze was covered with blood, which came in contact with PCT 2’s gloves. PCT 2 removed their gloves and failed to wash or sanitize their hands prior to entering the code to enter the medication prep room. 8. During an observation on 06/18/2025 at 10:11 AM, PCT 6 was observed accessing Patient #23’s left upper vascular access site at Station #23. They located and wiped the cannulation site, PCT 6 doffed their gloves and failed to perform hand hygiene prior to donning new gloves and inserting the needles. After initiating treatment, PCT 6 doffed gloves and failed to perform hand hygiene. 10. During an observation on 06/18/2025 at 10:18 AM, PCT 7 accessed Patient #24’s vascular access site at Station #12. PCT 7 cleaned the patient’s site, doffed their gloves and failed to perform hand hygiene prior to donning new clean gloves. 11. During an observation on 06/18/2025 at 10:30 AM, PCT 2 initiated the treatment for Patient #22 at Station #12. PCT 2 set up the dialysis machine, doffed gloves and failed to perform hand hygiene prior to donning new gloves. They returned to the machine again, doffed gloves, retrieved tape from the clean supply counter, and donned gloves without performing hand hygiene. They obtained the stethoscope to listen to the patient’s right upper vascular access site, placed it on the computer stand and changed gloves without performing hand hygiene or cleaning the stethoscope. After cannulating the patient, they doffed gloves and failed to perform hand hygiene prior to touching the computer keyboard. 12. During an interview with PCT 1 on 06/17/2025 at 12:30 PM, they indicated hand hygiene was supposed to be performed when changing tasks and gloves. They explained hands were supposed to be washed with soap after every patient and when interacting with blood. 14. During an interview with PCT 6 on 06/18/2025 at 1:30 PM, they indicated hand hygiene was supposed to be performed when moving from the machine and from patient to patient. They explained if they had blood on their gloves, they were to wash their hands with soap for 15 to 20 seconds. They indicated they did not use hand sanitizer every time they put new gloves on, it was only when their hands felt “grimy”. 15. During an interview with PCT 2 on 06/18/2025 at 3:30 PM, they explained they were to change their gloves after every patient, before they touched the keyboard, and switched out gloves. They explained they were to wash their hands with soap every 30 minutes to an hour. 51279 16. On 06/17/2025 at 12:44 PM, PCT 3 was observed putting on gloves, responding to an alarm, removing their gloves, and performing hand hygiene. PCT 3 failed to perform hand hygiene at appropriate intervals. 17. On 06/17/2025 at 1:07 PM, PCT 3 discontinued the treatment for Patient #11. PCT 3 obtained water for Patient #11 with gloved hands, removed their gloves, touched the computer, put on gloves, removed their gloves, performed hand hygiene, adjusted the blood pressure cuff, put on a glove on their right hand, initiated a blood pressure reading with their right hand, put on the left glove, adjusted the blood pressure cuff, touched the dialysis machine, removed their gloves, and performed hand hygiene. PCT 3 put on gloves, gathered Patient #11’s belongings, removed their gloves, and provided Patient #11 hand sanitizer. PCT 3 failed to perform hand hygiene at appropriate intervals. 18. On 06/18/2025 at 10:00 AM, LPN 3 was observed initiating the dialysis treatment for Patient #16. LPN 3 donned their gloves, applied the blood pressure cuff, removed their gloves, touched the computer, put on gloves, touched the dialysis machine, set supplies out on side table, assessed the patient’s fistula, and cleaned the fistula. LPN 3 removed their gloves, put on gloves, accessed the fistula, started the dialysis treatment, removed their gloves, and performed hand hygiene. LPN 3 failed to perform hand hygiene at appropriate intervals. 19. On 06/18/2025 at 10:15 AM, PCT 5 was observed putting on gloves, obtaining gauze, and assisted Patient #19 with holding pressure to their access site. They removed their gloves, and performed hand hygiene. PCT 5 failed to perform hand hygiene at appropriate intervals. During an interview on 06/18/2025 at 1:22 PM, PCT 5 indicated hand hygiene should be performed between patients, if you can visibly see blood, every time they exit the isolation room, and every time they put on gloves or change gloves. 20. On 06/18/2025 at 11:38 AM, LPN 3 was observed initiating the dialysis treatment for Patient #1 in isolation room #1. LPN 3 flushed the CVC, removed their gloves, touched the computer, performed hand hygiene, put on gloves, placed items in the biohazard bin, removed their gloves, put on gloves, touched the dialysis machine, removed their gloves, and then performed hand hygiene. LPN 3 failed to perform hand hygiene at appropriate intervals. 21. During an interview on 06/19/2025 at 3:40 PM, RN 2 indicated “they are working on it” when queried about when hand hygiene should be performed. RN 2 indicated hand hygiene should be performed after touching something and with glove changes. 22. During an interview on 06/19/2025 at 4:06 PM, the FA of Plainfield and Carmel indicated hand hygiene should be performed before starting care, after any glove change, before leaving the floor, touching the computer, going from patient to patient. When queried about how long hands should be washed when using soap and water, the FA of Plainfield and Carmel indicated they were not sure of the exact length of time and they go by the song, but the length of time should be long enough to scrub fingers and nails.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47343 Based on observations, record review, and interviews, the facility failed to ensure proper personal protective equipment (PPE) was worn in the appropriate designated areas for 3 of 3 observation days. (PCT 2) Findings Include: 1. A Davita policy with a revision date of 04/2023 titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” indicated but was not limited to, “ ... PPE (i.e., gowns, eye protection, face shield) ... PPE is to be: a. Removed prior to leaving the treatment area ...” 2. A Davita policy with a revision date of 04/2024 titled “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE” indicated but was not limited to, “ ... 17. PPE, a. When entering the isolation room/area or station for any reason ... all other teammates will wear long-sleeved fluid resistant/fluid impervious gowns in addition to gloves, face shield, or mask and eye protection ... c. PPE will be removed, gloves discarded, and hand hygiene performed immediately when leaving the room or area. ...” 3. During the flash tour on 06/17/2025 at 9:30 AM, a sign was observed on the door to the stock room and the lobby. The sign indicated, “NO PPE: IN THE STOCK ROOMS AND IN THE HALLWAYS”. 4. On 06/17/2025 at 12:50 PM, PCT 2 was observed wheeling Patient #9 into the lobby after their dialysis (a treatment where bodily waste and excess fluids are removed from the body through a machine when the kidneys are unable to work appropriately). PCT 2 wore their gown, face shield, and gloves into the lobby and walked back into the treatment room and removed the tubing from the machine. On 06/18/2025 at 9:00 AM, PCT 2 was observed wheeling a patient out of the treatment floor into the lobby in a gown and face shield. On 06/19/2025 at 3:11 PM, PCT 2 was observed entering the stock room in their treatment floor gown. On 06/19/2025 at 3:26 PM, PCT 2 was observed entering the stock room in a treatment gown to find Biotechnician 1. PCT 2 failed to remove their PPE prior to leaving the treatment room. During an interview with PCT 2 on 06/18/2025 at 3:30 PM, they indicated when they leave the treatment area, they did not remove PPE if they planned on coming right back into the treatment room. 51279 5. On 06/18/2025 at 10:52 AM, LPN 3 was observed discontinuing dialysis treatment for Patient #18 in isolation room 3. LPN 3 changed their gown before entering isolation room 3 and continued to wear the same face mask and face shield from the treatment room floor. LPN 3 removed the isolation gown, put on their treatment floor gown, and returned to the treatment room floor. LPN 3 failed to change their face mask or face shield before entering or exiting the isolation room and returning to the treatment room floor. On 06/18/2025 at 11:38 PM, LPN 3 was observed initiating dialysis treatment for Patient #1 in isolation room 3. LPN 3 removed their gown and put on the isolation gown and continued to wear the same face mask and face shield from the treatment room floor. LPN 3 removed the isolation gown, put on their treatment floor gown, and returned to the treatment room floor. LPN 3 failed to change their mask or face shield before entering or exiting the isolation room and returning to the treatment room floor. 6. During an interview on 06/18/2025 at 10:35 AM, PCT 5 indicated when carrying for an isolation patient a different gown and head gear should be used. 7. During an interview on 06/18/2025 at 12:00 PM, LPN 3 indicated when caring for an isolation patient the staff ensures to wash their hands, change their gown, and verify the patient has no blood on them before exiting the isolation room. 8. During an interview on 06/19/2025 at 3:40 PM, RN 2 indicated no PPE should cross over. When queried where can staff wear PPE, RN 2 indicated PPE can be worn anywhere unless there is blood on the PPE. 9. During an interview on 06/19/2025 at 4:06 PM, the FA of Plainfield and Carmel indicated the gown needed to be changed when entering or exiting an isolation room. When queried if a face mask and face shield are considered PPE, the FA of Plainfield and Carmel indicated a face mask and face shield are considered PPE. When queried about where PPE can be worn, the FA of Plainfield and Carmel indicated only a facemask can be worn outside of the treatment room floor, and everything else should be removed prior to exiting the floor.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 51279 Based on observation, record review, and interview the facility failed to ensure infection control practices were maintained when cleaning and disinfecting the treatment center stations for 1 of 3 observation days. (Employee: PCT 2, PCT 5 - twice, PCT 6 - twice, and PCT 7). Findings Include: 1. A Davita policy with a revision date of 04/2023 titled “INFECTION CONTROL FOR DIALYSIS FACILITIES” indicated but was not limited to, “ ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by the healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. ... ii. Priming containers are to be emptied prior to disinfection. ...” 2. On 06/18/2025 at 10:32 AM, PCT 5 was observed cleaning and disinfecting dialysis station 11. PCT 5 failed to empty the prime container and disinfect the interior or exterior of the container. On 06/18/2025 at 1:17 PM, the prime container at station 11 had a clear liquid, and the dialysis machine was being heat disinfected. PCT 5 failed to empty the prime container and disinfect the interior or exterior of the container. 3. On 06/18/2025 at 11:31 AM, PCT 5 was observed cleaning and disinfecting dialysis station 4. PCT 5 failed to empty the prime container and disinfect the interior or exterior of the container. On 06/18/2025 at 1:17 PM, the prime container had a clear liquid, and the dialysis machine was being heat disinfected. PCT 5 failed to empty the prime container and disinfect the interior or exterior of the container. 4. During an interview on 06/18/2025 at 12:00 PM, LPN 3 indicated the dialysis machine should be cleaned from top to bottom, then they open up the chair to clean all sides of the chair, and then the blood pressure cuff and television. When queried about when the prime container was disinfected, LPN 3 indicated once the blood lines are taken off, they dump and disinfect the prime container. 5. During an interview on 06/18/2025 at 1:22 PM, PCT 5 indicated they clean the dialysis machine from top to bottom, then the sides. They indicated they will dump the prime container, and clean the prime container if there is blood on the prime container. PCT 5 failed to indicate the prime container should be disinfected after every patient treatment. 6. During an interview on 06/19/2025 at 3:40 PM, RN 2 indicated the dialysis machine should be cleaned top to bottom, and the prime container should be “wiped down at the end of the day” RN 2 failed to indicate the prime container should be emptied and disinfected after every patient treatment. 47343 7. On 06/18/2025 at 9:42 AM, PCT 6 was observed cleaning and disinfecting Station #23’s dialysis machine and chair. They failed to empty and sanitize the inside and the outside of the prime container on the cleaned dialysis machine. They cleaned the blood pressure cuff and placed it on the uncleaned chair. PCT 6 was observed using the same sanitizing cloth they used on the dialysis machine to clean the chair. The PCT failed to fully recline and extend the chair when wiping the chair down with bleach. PCT 6 failed to clean the television screen which was attached to the wall box and able to be close to the patient for them to maneuver it. 8. On 06/18/2025 at 9:48 AM, PCT 6 was observed cleaning and disinfecting Station #22’s dialysis machine and chair. They failed to perform hand hygiene prior to donning clean gloves. They failed to empty and sanitize the inside and the outside of the prime container on the cleaned dialysis machine. They cleaned the blood pressure cuff and placed it on the unclean chair. PCT 6 was observed using the same sanitizing cloth they used on the dialysis machine to clean the chair. The PCT failed to fully recline and extend the chair when wiping the chair down with bleach. PCT 6 failed to clean the television screen which was attached to the wall box and able to be close to the patient for them to maneuver it. 9. On 06/18/2025 at 9:50 AM, PCT 2 was observed cleaning and disinfecting Station #19’s dialysis machine and chair. PCT 2 failed to empty and wipe the inside and the outside of the prime container located on the cleaned dialysis machine. The PCT had not opened the sides of the chair to clean the inside. 10. On 06/18/2025 at 10:02 AM, PCT 7 was observed cleaning and disinfecting Station #10’s dialysis machine and chair. The PCT failed to fully recline and extend the chair to clean the whole chair and clean the television. 11. During an interview with PCT 2 on 06/18/2025 at 3:30 PM, they explained they were to bleach the entire dialysis machine and chair down when cleaning the station. They indicated the television was supposed to be wiped down. They explained the prime containers were supposed to be emptied and cleaned each time the station was cleaned. They used the same bleach cloth to wipe down the dialysis machine and chair. The chair was to be laid completely back and the sides of the chair opened to ensure all parts of the chair were cleaned. 12. During an interview with PCT 6 on 06/18/2025 at 1:30 PM, they explained when they only emptied and cleaned the prime container at the end of the day when they rinsed the container out. They indicated only one bleach cloth was used to clean both the dialysis machine and the chair. PCT 6 explained they only fully extended and reclined the chair when there was blood or drippage. They indicated the televisions were only wiped at the end of the day. 13. During an interview with the Facility Administrator and the FA of another Davita facility on 06/19/2025 at 4:05 PM, they indicated the cleaning of the dialysis machine was to be done as follows: cleaned from top to bottom, including the back of it, and the prime bucket emptied and cleaned inside and out after every treatment. They explained the chair should be fully opened up and extended to ensure everything was cleaned.”

“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: 51279 Based on record review and interview, the facility failed to ensure the pre-assessment was completed in a timely manner or the post assessment was completed at the conclusion of dialysis treatment for 7 of 7 active clinical records reviewed (Patient #: 1, 2, 3, 4, 5, 6, 7) Findings Include: 1. A Davita policy with a revision date of 04/2024 titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT” indicated but was not limited to, “ ... 2. The Nursing assessment will be performed and document by a licensed nurse ... 3. Patient identity, prescription, and machine settings are verified ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment ...” 2. A review of Patient #1’s clinical record evidenced documents titled “Treatment Details Report” A review of the treatment sheets dated 05/23/2025 through 06/16/2025 evidenced the following: The treatment sheet dated 05/28/2025 indicated PCT 7 started the dialysis treatment at 6:58 AM and LPN 3 completed the pre-assessment at 8:23 AM. The treatment sheet dated 05/30/2025 indicated PCT 7 started the dialysis treatment at 6:22 AM and LPN 3 completed the pre-assessment at 7:53 AM. The treatment sheet dated 06/11/2025 indicated PCT 7 started the dialysis treatment at 6:26 AM and LPN 3 completed the pre-assessment at 8:34 AM. The treatment sheets dated 05/28/2025, 05/30/2025, and 06/11/2025 failed to evidence the pre-assessment was completed within one hour of the start of the dialysis treatment. 3. A review of Patient #3’s clinical record evidenced documents titled “Treatment Details Report” A review of the treatment sheets dated 05/26/2025 through 06/16/2025 evidenced the following: The treatment sheet dated 05/26/2025 indicated PCT 1 started the dialysis treatment at 9:50 AM and RN 2 completed the pre-assessment at 11:13 AM. The treatment sheet dated 05/28/2025 indicated PCT 10 started the dialysis treatment at 10:21 AM and RN 2 completed the pre-assessment at 1:55 PM. The treatment sheet dated 06/04/2025 indicated PCT 2 started the dialysis treatment at 9:50 AM and RN 2 completed the pre-assessment at 10:06 AM. PCT 2 ended the dialysis treatment at 1:59 PM. The treatment sheet failed to evidence a post-assessment was completed. The treatment sheet dated 06/09/2025 indicated PCT 1 started the dialysis treatment at 9:59 AM and RN 2 completed the pre-assessment at 3:16 PM. The treatment sheet dated 06/11/2025 indicated PCT 2 started the dialysis treatment at 9:11 AM and RN 2 completed the pre-assessment at 12:54 PM. The treatment sheet dated 06/16/2025 indicated PCT 2 started the dialysis treatment at 9:45 AM and RN 2 completed the pre-assessment at 10:54 AM. The treatment sheets dated 05/26/2025, 05/28/2025, 06/09/2025, 06/11/2025, and 06/16/2025 failed to evidence the pre-assessment was completed within one hour of the start of dialysis treatment. The treatment sheet dated 06/04/2025 failed to evidence a post assessment was completed at the conclusion of the dialysis treatment. 4. A review of Patient #4’s clinical record evidenced documents titled “Treatment Details Report” A review of the treatment sheets dated 05/27/2025 through 06/14/2025 evidenced the following: The treatment sheet dated 06/05/2025 indicated RN 2 started the dialysis treatment at 6:08 AM, and the pre-assessment was completed at 7:50 AM. The treatment sheet failed to evidence a post assessment was completed. The treatment sheet dated 06/07/2025 indicated PCT 1 started the dialysis treatment at 6:05 AM and RN 2 completed the pre-assessment at 8:59 AM. The treatment sheet dated 06/12/2025 indicated PCT 5 started the dialysis treatment at 6:18 AM and RN 2 completed the pre-assessment at 9:46 AM. The treatment sheets dated 06/05/2025, 06/072025, and 06/12/2025 failed evidence the pre-assessment was completed within one hour of the start of dialysis treatment. The treatment sheet dated 06/05/2025 failed to evidence a post assessment was completed at the conclusion of the dialysis treatment. 5. A review of Patient #6’s clinical record evidenced documents titled “Treatment Details Report” A review of the treatment sheets dated 05/24/2025 through 06/14/2025 evidenced the following: The treatment sheet dated 05/27/2025 indicated PCT 12 started the dialysis treatment at 10:07 AM and RN 2 completed the pre-assessment at 12:45 PM. The treatment sheet dated 06/03/2025 indicated PCT 4 started the dialysis treatment at 10:43 AM and RN 2 completed the pre-assessment at 12:08 PM. The treatment sheet dated 06/05/2025 indicated RN 2 started the dialysis treatment at 10:15 AM and completed the pre-assessment at 10:37 AM. The treatment sheet failed to evidence a post assessment was completed. The treatment sheet dated 06/07/2025 indicated PCT 11 started the dialysis treatment at 10:05 AM and RN 2 completed the pre-assessment at 11:40 AM. The treatment sheets dated 05/27/2025, 06/03/2025, and 06/07/2025 failed to evidence the pre-assessment was completed within one hour of the start of dialysis treatment. The treatment sheet dated 06/05/2025 failed to evidence a post assessment was completed at the conclusion of the dialysis treatment. 6. During an interview on 06/19/2025 at 11:29 AM, RN 2 indicated the preassessment should be completed within 30 minutes of dialysis treatment beginning. RN 2 indicated they could also put “late entry, but that doesn’t always happen” During an interview on 06/19/2025 at 3:40 PM, RN 2 indicated there should be a post assessment at the conclusion of the dialysis treatment. 47343 7. A review of Patient #2’s clinical record evidenced the documents titled “Treatment Details Report”. A review of the treatment sheets dated 05/29/2025 to 06/14/2025, for Patient #2, evidenced the following: The treatment sheet dated 06/03/2025 indicated PCT 8 started the hemodialysis treatment at 10:50 AM and RN 2 completed the pre-assessment at 1:00 PM. The treatment sheet dated 06/05/2025 indicated PCT 5 started the hemodialysis treatment at 10:39 AM and LPN 3 completed the pre-assessment at 1:29 PM. The treatment sheet evidenced the patient’s CVC was not functioning properly and the patient chose to leave “Against Medical Advise”. The treatment sheet dated 06/10/2025 indicated PCT 5 started the hemodialysis treatment at 10:35 AM and RN 2 completed the pre-assessment at 11:51 AM. The treatment sheets dated 06/03, 06/05, 06/10/2025 failed to evidence documentation why the RN pre-assessment was no completed within the 1 hour of the hemodialysis start time as per the facility policy. 8. A review of Patient #5’s clinical record evidenced the documents titled “Treatment Details Report”. A review of the treatment sheets dated 05/28/2025 to 06/16/2025, for Patient #5, evidenced the following: The treatment sheet dated 05/28/25 indicated PCT 2 started the hemodialysis treatment at 10:56 AM and RN 2 completed the pre-assessment at 1:48 PM. The treatment sheet dated 06/04/2025 indicated PCT 7 started the hemodialysis treatment at 10:56 AM and RN 2 completed the pre-assessment at 1:21 PM. The treatment sheet dated 06/09/2025 indicated PCT 2 started the hemodialysis treatment at 11:05 AM and RN 2 completed the pre-assessment at 1:08 PM. The treatment sheet dated 06/11/2025 indicated PCT 9 started the hemodialysis treatment at 11:14 AM and RN 2 completed the pre-assessment at 12:37 PM. 9. A review of Patient #7’s clinical record evidenced the documents titled “Treatment Details Report”. A review of the treatment sheets dated 05/26/2025 to 06/16/2025, for Patient #7, evidenced the following: The treatment sheet dated 06/02/2025 indicated PCT 2 started the hemodialysis treatment at 5:04 AM and RN 2 completed the pre-assessment at 6:15 AM. The treatment sheet dated 06/04/2025 indicated PCT 7 started the hemodialysis treatment at 5:42 AM and RN 2 completed the pre-assessment at 9:10 AM. The treatment sheet dated 06/09/2025 indicated PCT 2 started the hemodialysis treatment at 5:17 AM and RN 2 completed the pre-assessment at 8:31 AM. The treatment sheets dated 06/02, 06/04, 06/09/2025 failed to evidence documentation why the RN pre-assessment was no completed within the 1 hour of the hemodialysis start time as per the facility policy. 10. During an interview with the Facility Administrator (FA), Assistant FA, Director of Clinical Services, and the FA of another Davita Facility on 06/19/2025 at 4:05 PM, they indicated pre-assessments were supposed to be performed within 1 hour of the initiation of treatment. The FA of another Davita facility explained the staff were to acknowledge why the assessment was performed late and a pre and post-assessment were to be performed every treatment. They indicated “if you did not document it, it did not happen”.”