Davita Nall Dialysis

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 50529 Based on observation, policy review, document review, and interview, the facility failed to ensure sufficient, operable sinks that are readily available in the patient treatment area to facilitate the hand hygiene needs of staff and patients on 2 of 3 observation days. This deficient practice poses a risk of cross contamination of harmful bacteria that could negatively impact the health and well-being of the 60 patients who receive treatments at the facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “ ...Sinks should be easily accessible and readily available in the treatment area and in other appropriate areas such as the medication area, home training area, and isolation area/room ...Sinks must be plumbed with both hot and cold water ...” An observation on 07/28/25 at 1:23 PM, showed that the hand washing sink in the isolation room was inoperable. During an interview on 07/28/25 at 2:37 PM, Manager of Clinical Services (MCS) confirmed that the sink in the isolation room does not turn on. The unavailability of the sink posed a risk for contamination. During an interview on 07/30/25 at 2:26 PM, Facility Administrator (FA), stated that the water to the isolation room sink had been shut off. The FA was unsure why or how the water was turned off. An observation on 07/30/25 at 2:56 PM, showed that the hand washing sink connected to the clean supply storage was not working appropriately. PCT #6 confirmed malfunction by stating that the sink turns on by itself with very hot water. PCT #6 was unsure if a work ticket had been submitted, but stated the facility administrator had been notified. During an interview on 07/30/25 at 3:03 PM, Facility Administrator, confirmed that the hand washing sink connected to the supply storage was malfunctioning. During an interview on 07/30/25 at 3:42 PM, RN #1, confirmed that the hand washing sink connected to clean supply storage was very hot and was having issues in addition to the isolation room sink no longer working. RN #1 stated that the concerns had been reported to the facility administrator. . During an interview on 07/31/25 at 11:20 AM, Facility Administrator reported that the inoperable clean sink connected to clean supply storage had not been fixed and was not aware that the isolation room sink was not operable.”

“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: 50529 Based on observation, policy review and interview, the facility failed to provide appropriate personal protective equipment, specifically protective gowns, to patient visitors on 2 of 3 observation days. This deficient practice poses a risk for blood exposure and contamination from bacteria that could negatively impact the health and well-being of patients and visitors at this facility. Findings Include: Review of a policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “ ...Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas ...Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment area ...” An observation on 07/28/25 at 1:16 PM, showed a visitor at station #2 was sitting at a patient’s chairside without a gown. An observation on 07/30/25 at 10:22 AM, showed a visitor at station #2 was sitting at a patient’s chairside without a gown. During an interview on 07/30/25 at 12:06 PM, Patient Care Technician (PCT) #6 stated that visitors on the treatment floor are supposed to wear a gown to help prevent cross contamination from possible blood exposure. During an interview on 07/30/25 at 2:26 PM, Manager of Clinical Services (MCS) stated that it is the expectation of staff to provide visitors with necessary PPE upon arrival to the treatment floor to help prevent the spread of infectious bacteria.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility failed to properly store and label reusable acid jugs for later use on 2 of 3 observation days. This deficient practice poses a risk for cross contamination that could negatively impact the health and well-being of the 60 patients who receive treatments at the facility. Findings Include: Review of a policy titled, “Acid Concentrate System, Incoming Acid Concentrate and Use of Acid Concentrate Containers,” revised October 2024, stated, “ ...Acid concentrate is to be stored at room temperature in a secure designated area ...Upon opening an acid concentrate container, label container with date opened, and initials of teammate ...Open, unused acid concentrate solutions remain in original container, are not to be combined and should be capped when not in use ...” An observation on 07/28/25 at 2:39 PM, showed an open, labeled 3K 3.0Ca+ acid jug without a lid on the clean supply storage area for later use. The failure to recap the acid jug posed a risk for contaminants to enter the container. Placing a used jug in a clean storage area posed a risk of cross contamination from exposure to blood or other pathogens that increases risk for infection. An observation on 07/30/25 at 3:42 PM, showed two opened, ¼ full, labeled acid jugs stored on the top of the clean supplies’ storage. During an interview on 07/30/25 at 2:26 PM, Manager of Clinical Services (MCS) stated that acid jugs are reused at this facility but used jugs must be labeled with date and teammate initials, disinfected on the outside and stored away separately than clean supplies and unopened acid jugs. The expectation is for staff to follow policy to avoid cross contamination. During an interview on 07/31/25 at 12:12 PM, Registered Nurse (RN) #1 confirmed that an opened and labeled acid jug should not be sitting on clean supplies storage area.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50873 Based on record review, staff interview, and facility document review, the facility failed to follow individualized dialysis prescription and medication orders as prescribed by the medical provider for 3 (Patients #1, #4, and #5) of 7 sampled patients. Failure to follow the medical providers’ dialysis prescription and medication orders had the potential to negatively impact the health and well-being of the 60 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, revealed, “ ...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate [BFR] which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to ...Blood flow rate...” The policy continued, “ ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ...” A facility policy titled, “Medication Policy,” revised 10/2023, indicated, “ ...Medications are administered as prescribed and then documented in the patient’s medical record ...” Patient 1 Patient 1’s “Treatment Details Report,” dated 07/15/2025, revealed a prescribed BFR of 400 milliliters per minute (mL/min). Patient 1’s BFR was documented as 350 mL/min from 7:31 AM until 10:31 AM. There was no rationale documented regarding why the prescribed BFR was not achieved. Patient 1’s “Treatment Details Report,” dated 07/22/2025, revealed a prescribed BFR of 400 mL/min. Patient 1’s BFR was documented as 350 mL/min from 7:18 AM until 9:25 AM. There was no rationale documented regarding why the prescribed BFR was not achieved. Patient 1’s “Treatment Details Report” dated 07/26/2025, revealed the patient had a heparin pump infusion order to run at 1.2 milliliters per hour (mL/hr) at a concentration of 1:1000 units/mL for a rate of 1200 units/hr. The infusion was to run for the full three-hour treatment, equaling a dose of 3600 units if the treatment and the heparin pump were run as ordered. The medications administered section of the report indicated the infusion started at 7:20 AM and ended at 9:32 AM (2 hours and 12 minutes), and the dose of heparin given was documented as 3600 units. During an interview on 07/29/2025 at 2:22 PM, the Manager of Clinical Services (MCS) stated if the heparin were run at the correct rate for the time indicated, the total dose administered should have been 2700 units, not 3600 as documented. Patient 4 Patient 4’s “Treatment Details Report” dated 07/16/2025, revealed the patient had a heparin pump infusion order to run at 0.6 milliliters per hour (mL/hr) a concentration of 1:1000 units/mL for a rate of 600 units/hr. The infusion was to run for the full 3 hour and 30 minute treatment, equaling a dose of 2100 units, if the treatment and the heparin pump were run as ordered. The medications administered section of the report indicated the infusion started at 11:10 AM and ended at 2:10 PM (3 hours) and the dose given was documented as 2100 units. During an interview on 07/30/2025 at 10:46 AM, the Manager of Clinical Services (MCS) stated if the heparin were run at the correct rate for the time indicated, the total dose should have been 1800 units, not 2100 as documented. Patient 5 Patient 5’s “Treatment Details Report,” dated 07/16/2025, revealed a prescribed BFR of 500 mL/min. Patient 5’s BFR was documented as 400 mL/min from 1:31 PM until 5:01 PM. There was no rationale documented regarding why the prescribed BFR was not achieved. Patient 5’s “Treatment Details Report,” dated 07/21/2025, revealed a prescribed BFR of 500 mL/min. Patient 5’s BFR was documented as 450 mL/min from 1:34 PM until 5:32 PM. There was no rationale documented regarding why the prescribed BFR was not achieved. On 07/30/2025 at 4:14 PM, Registered Nurse (RN) #1 confirmed that RNs verified the ordered BFR for patients at the beginning of the dialysis treatment after the patient care technicians set up the dialysis machines. On 07/29/2025 at 1:58 PM, the Facility Administrator confirmed the facility expectation that there be a documented rationale for any deviations from what was prescribed for the patient.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 50873 Based on interview, record review, and facility policy review, the facility failed to monitor patients during dialysis treatments and failed to report abnormal findings to the licensed nurse per the facility policy for 5 (Patients 1, 2, 3, 4, and 5) out of 7 sampled patients reviewed for monitoring of dialysis treatments. This failure had the potential to negatively impact the health and well-being of the 60 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised 04/2024, revealed, “ ...Interdialytic treatment monitoring and data collection which may be performed by the PCT [patient care technician] or licensed nurse includes ...Vital signs and treatment monitoring ...are completed at least every 30 minutes ...” The section titled, “Abnormal Findings,” revealed, “ ...Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time...” The policy also indicated, “ ...Blood Pressure-Intradialytic: - Systolic [the top number of the blood pressure reading] greater than 180 mm/Hg [millimeters of mercury] or less than 90 mm/Hg - Diastolic [the bottom number of the blood pressure reading] greater than or equal to 100 mm/Hg or less than 50 mm/Hg...” The policy also indicated, “ ...Heart or Pulse Rate Pre/Intra/Post: - Less than 60 beats per minute [BPM] or greater than 100 beats per minute and/or an irregular heart beat...” Patient 1 Patient 1’s “Treatment Details Report” dated 07/15/2025, revealed the patient’s blood pressure (BP) documented by PCT #6 at 8:01 AM was 172/118 mm/Hg, at 8:31 AM was 168/109 mm/Hg, and at 9:01 AM was 160/106 mm/Hg. The Treatment Details Report revealed PCT #8 documented Patient #1’s blood pressure at 9:31 AM was 152/100 mm/Hg, at 10:31 AM was 147/109 mm/Hg, and at 10:51 AM a post-treatment standing blood pressure was 143/100 mm/Hg. The report revealed there was no evidence of notification to a registered nurse (RN) of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 1, dated 07/22/2025, revealed the patient’s pre-treatment standing blood pressure documented by PCT #7 at 7:09 AM was 168/108 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. Patient 2 Patient 2’s “Treatment Details Report” dated 07/14/2025, revealed the patient’s blood pressure (BP) documented by PCT #6 at 1:16 PM was 80/51 mm/Hg and at 1:33 PM was 84/56 mm/Hg. The report revealed there was no evidence of notification to a registered nurse (RN) of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 2, dated 07/16/2025, revealed no evidence of patient monitoring from 3:01 PM until 4:25 PM (1 hour and 24 minutes). A “Treatment Details Report” for Patient 2, dated 07/18/2025, revealed the patient’s BP documented by PCT #11 at 2:05 PM was 74/48 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient 2, dated 07/23/2025, revealed the patient’s BP documented by PCT #7 at 2:17 PM was 84/46 mm/Hg and PCT #6 documented the patient’s blood pressure reading at 2:46 PM was 94/49 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 2, dated 07/25/2025, revealed the patient’s heart rate documented by PCT #7 at 1:02 PM was 109 BPM and at 1:31 PM was 101 BPM. The report revealed there was no evidence of notification to a RN of the out-of-range heart rate readings. Patient 3 Patient 3’s “Treatment Details Report” dated 07/14/2025, revealed the patient’s blood pressure (BP) documented by PCT #6 at 6:32 PM was 184/101 mm/Hg, at 6:42 PM was 185/103 mm/Hg, and a post-treatment blood pressure reading at 6:53 PM was 179/104. The report revealed there was no evidence of notification to a registered nurse (RN) of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 3, dated 07/18/2025, revealed no evidence of patient monitoring from 5:30 PM until 6:30 PM (1 hour). A “Treatment Details Report” for Patient 3, dated 07/21/2025, revealed the patient’s blood pressure documented by PCT #11 at 6:30 PM was 159/101. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient 3, dated 07/23/2025, revealed no evidence of patient monitoring from 4:33 PM until 5:31 PM (58 minutes). Patient 4 Patient 4’s “Treatment Details Report” dated 07/14/2025, revealed the patient’s heart rate documented by PCT #7 at 3:16 PM was 103 BPM and PCT #6 documented the patient’s heart rate at 4:31 PM was 102 BPM and at 5:01 PM was 101 BPM. The report revealed there was no evidence of notification to a registered nurse (RN) of the out-of-range heart rate readings. A “Treatment Details Report” for Patient 4, dated 07/18/2025, revealed the patient’s pre-treatment blood pressure documented by PCT #6 at 12:06 PM was 157/110 mm/Hg standing and intradialytic blood pressure reading documented at 12:31 PM was 168/125 mm/Hg, 1:31 PM was 174/103 mm/Hg, 3:03 PM was 166/103 mm/Hg, and at 3:31 PM was 167/109 mm/Hg. The Treatment Details Report revealed PCT #7 documented the patient’s blood pressure reading at 2:31 PM was 187/108 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 4, dated 07/21/2025, revealed the patient’s blood pressure documented by PCT #11 at 5:02 PM was 158/101 mm/Hg and at 6:47 PM was 154/109 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 4, dated 07/23/2025, revealed the patient’s blood pressure documented by PCT #6 at 1:03 PM was 175/100 mm/Hg and at 1:35 PM was 192/103 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure readings. A “Treatment Details Report” for Patient 4, dated 07/25/2025, revealed no evidence of patient monitoring from 11:44 AM until 1:32 PM (1 hour and 48 minutes). Patient 5 Patient 5’s “Treatment Details Report” dated 07/16/2025, revealed the patient’s blood pressure documented by PCT #7 at 4:01 PM was 190/86 mm/Hg. The report revealed there was no evidence of notification to a registered nurse (RN) of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient 5, dated 07/18/2025, revealed the patient’s blood pressure documented by PCT #7 at 4:02 PM was 181/89 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. A “Treatment Details Report” for Patient 5, dated 07/23/2025, revealed the patient’s blood pressure documented by PCT #6 at 1:31 PM was 192/101 mm/Hg. The report revealed there was no evidence of notification to a RN of the out-of-range blood pressure reading. During an interview on 07/30/2025 at 12:03 PM, PCT #6 stated that technicians were to report high and low blood pressures, pulses, if the patient was unresponsive, and anything outside of the patient’s baseline to the RN. PCT #6 also confirmed that patients were to be monitored every 30 minutes. During an interview on 07/30/2025 at 4:14 PM, RN #1 stated that patient monitoring and documentation included vital signs taken pre and post dialysis treatment and every 30 minutes or every 15 minutes as needed. During an interview on 07/29/2025 at 1:58 PM, the Facility Administrator confirmed the facility expectation for staff to check the patients every 30 minutes and report any out-of-range findings to the RN and document the notification based on facility policy.”

“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: 50873 Based on interview, facility document review, and policy review, the facility’s Quality Assurance and Performance Improvement (QAPI) Committee failed to measure, analyze, and track quality indicators for mortality. This failure had the potential to affect all 60 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Continuous Quality Improvement Program,” revised 04/2021, indicated, “7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following:” including, “Mortality - review of deaths.” A facility document titled, “Facility Health Meeting” dated 06/2025, revealed a “Mortality,” graph that included measurement data for deaths for the timeframe from June 2024 through May 2025. The document revealed one death recorded in 08/2024, with the cause being cardiac, one death recorded in 02/2025 with no cause documented, and one recorded in 03/2025 with no cause documented. A concurrent interview was held on 07/30/2025 at 2:48 PM with the Facility Administrator (FA) and the Manager of Clinical Services (MCS). The FA confirmed there was no evidence of analysis of mortality data and potential contributing factors in the facility QAPI documents. The FA stated that the mortality review conducted during QAPI meetings consisted only of reviewing the number of deaths along with the primary cause of death. The MCS confirmed there was no evidence of mortality analysis or review of potentially contributing causes of death in the QAPI records. The MCS confirmed that the Facility Health Meeting report was the meeting minutes from the QAPI meeting.”

“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: 50873 Based on interview, record review, facility document review, and policy review, the facility failed to identify and report adverse events for 1 (Patient 1) out of 7 sampled patients. Specifically, the facility failed to identify the cause of Patient 1’s line clotting and whether the patient received the correct dosage of heparin. This failure had the potential to affect 60 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Risk Event Reporting Policy (Non-Teammate Related),” revised 10/2024, indicated, “1. Any unexpected event that is inconsistent with the routine operation of a dialysis facility, routine provision of acute dialysis or ancillary renal-related services may be a risk event. Such risk events include, but are not limited to, personal injury or potential personal injury to a patient or third party, property damage, theft, equipment failure, flood or ‘near miss’ events. Please refer to the REM [Risk Event Management] Event Category List found on the [online portal].” A facility document titled “REM Categories” provided as the REM Event Category List. The document listed potential REM events sorted by categories. Clotted dialyzer and clotted lines was listed under the category titled, “Blood loss,” and incorrect dose was listed under the category titled, “Medication/Treatment.” Patient 1’s “Treatment Details Report” dated 07/15/2025, revealed, Patient Care Technician (PCT) #8 documented “lines and dialyzer clotted due to no heparin infused; set up changed” at 9:42 AM. The report further indicated Registered Nurse (RN) #2 documented that treatment was restarted with a new system at 9:52 AM. The report indicated that the heparin pump was on from 7:31 AM until 10:44 AM. The Medications Administered section indicated that the heparin infusion started at 7:26 AM and ended at 10:46 AM. There were no other notes regarding the heparin infusion. A concurrent interview was held on 07/29/2025 at 2:22 PM with the Facility Administrator (FA) and the Manager of Clinical Services (MCS). The FA confirmed that Patient #1’s incident should have been input as a REM but that was not done. Per the FA, since the event was not entered as a REM, the facility was unable to investigate the incident to determine what happened. The MCS confirmed the incident should have been input into the REM system and that it was unclear whether the patient received the heparin as ordered since the event was not entered into REM. The MCS stated that since the event was not entered into the REM, the facility was unable to investigate and determine if the medication was administered as ordered and if so, what caused the system to clot.”

“PQ-PCT-COMPLETE TRAINING PROGRAM CFR(s): 494.140(e)(3) Patient care dialysis technicians must- (3) Have completed a training program that is approved by the medical director and governing body, under the direction of a registered nurse, focused on the operation of kidney dialysis equipment and machines, providing direct patient care, and communication and interpersonal skills, including patient sensitivity training and care of difficult patients. This Standard is not met as evidenced by: 50873 Based on interview and facility document and policy review, the facility failed to ensure staff had appropriate training and education to perform their job duties for 3 (Patient Care Technician [PCT] #6, PCT #7, and Registered Nurse [RN] #2) out of 4 staff records reviewed. This failure had the potential to affect all 60 patients who received dialysis treatments at the facility. Findings include: A facility policy titled, “Teammate Qualifications, Licensure and Adequate Teammate Staffing,” revised 10/2017, indicated, “3. The dialysis facility’s teammates (or contractors) will meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s teammates (or contractors) will have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions.” A facility policy titled, “Training Programs for New Patient Care Provider Teammates,” revised 04/2025, indicated, “5. The new teammate is required to enroll in Davita’s Clinical Training for New Teammates Program specific to the modality they have been hired to work in. The total number of hours of the program is specified in the modality specific Training Program Manuals located on the VillageWeb. Successful completion of the following theory and clinical elements are required before a new teammate can receive an independent patient care assignment: -Successful completion of the theory component of the DaVita Clinical Training for New Teammates Program includes participation in scheduled modality specific DaVita theory classes and completion of the final examination with a score of > 80% (unless the state requires a higher score). -Successful completion of the clinical component of the modality specific DaVita Clinical Training for New Teammates Program includes documentation of proficiency as evidenced by the completion of the Procedural Skills Verification Checklist, and the review of applicable policies and procedures. This checklist is to be completed by the preceptor with the new teammate. A registered nurse will sign off satisfactory performance of new skills. 6. The Facility Administrator/designee will verify that all critical components of the modality specific training are completed prior to the new teammate receiving an independent patient care assignment. Completion of critical components are outlined in the modality specific Verification of Competency for New Teammate form. -The form is to be signed by the clinical new teammate RN trainer, the Medical Director, and the Facility Administrator [FA].” 1. A review of PCT #6’s personnel record revealed, “PCT Procedural Skills Verification Checklist,” with a training start date of 06/12/2024, revealed the even numbered pages were missing from the checklist. The checklist also revealed RN #1 documented “07/31” under the column titled, “Satisfactory performance of skill by new teammate. Date/and initials of RN trainer.” PCT #6’s “Verification of Competency for New Non-Experienced In-Center Teammate,” revealed the document was signed by the Facility Administrator (FA) on 08/01/2024 and the Medical Director on 08/23/2024. There was no RN trainer signature on the document. On 07/31/2025 at 10:00 AM, the FA confirmed that half of the skills checklist for PCT #6 was missing and said he suspected that when copies were made of the checklist that only single-sided copies were made rather than double-sided copies. Per the FA, RN #1 started with the facility on 08/04/2024 and PCT #6’s skills checklist was incomplete, so RN #1 began to verify the skills checklist on 07/31/2025. 2. A review of PCT #7’s personnel record revealed no evidence the Medical Director had reviewed and signed the staff member’s training. During an interview on 07/31/2025 at 12:22 PM, the FA confirmed that the Medical Director reviewed and signed off on all employee training, even when an employee transferred from another clinic within the company. The FA confirmed that PCT #7’s employee record contained no evidence that the Medical Director had signed off on the employee’s training. 3. A review of RN #2’s personnel record revealed no evidence of an initial skills verification checklist. A document titled, “Nurse In-Center Annual Procedural Skills Verification Checklist,” revealed pages 5-8 of the document were incomplete. There was no completion date, no nurse signature, no trainer signature, and no Administrator signature on the document. A document titled, “Certificate of Completion” for RN #2 indicated successful completion of “RISE0505: Rise Training Final Exam” dated 10/03/2024. On 07/31/2025 at 10:00 AM, the FA stated RN #2 had been working on their own, without a preceptor, since 10/03/2024. The FA confirmed RN #2’s initial skills checklist was not complete.”

“PQ-H20 TREATMENT SYSTEM TECHS TRAINING CFR(s): 494.140(f) Technicians who perform monitoring and testing of the water treatment system must complete a training program that has been approved by the medical director and the governing body. This Standard is not met as evidenced by: 50873 Based on interview and facility document and policy review, the facility failed to ensure patient care technicians (PCTs) who operated the water treatment system had appropriate training and education to perform their job duties for 2 (PCT #6, and PCT #7) out of 4 staff records reviewed. This failure had the potential to affect all 60 patients who received dialysis treatments at the facility. Findings included: A facility document titled, “Initial and Annual Training Requirements for Water and Dialysate Concentrate,” revised 01/2025, indicated “Initial training on water/dialysate systems operations will be completed during Rise ICHD [incenter hemodialysis] New Teammate Training and must be completed annually thereafter.” 1. A review of PCT #6’s personnel record revealed a document titled, “Clinical Education & [and] Training,” for “CEC4012: Basic Components and Monitoring of Dialysis Quality Water Systems” dated 07/16/2024 and indicated successful completion of the training. On 07/31/2025 at 10:00 AM, the Facility Administrator (FA) confirmed the 07/16/2024 education was the most recent and that PCT #6’s water/dialysate education was out of date. The FA stated PCT #6 conducted water checks and was required to have the training annually. 2. A review of PCT #7’s personnel record revealed a document titled, “Star Learning,” for “CEC4012: Basic Components and Monitoring of Dialysis Quality Water Systems” dated 07/05/2024 and indicated successful completion of the training. On 07/31/2025 at 10:00 AM, the FA confirmed the 07/16/2024 education was the most recent and that PCT #7’s water/dialysate education was out of date. The FA stated PCT #7 conducted water checks and was required to have the training annually.”

“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: 50873 Based on interview, record review, and facility policy review, the Medical Director failed to ensure the facility adhered to policy and procedure related to patient care for 1 (Patient 1) of 7 sampled patients. Specifically, the facility failed to conduct an initial nursing assessment of Patient 1 and failed to notify Patient 1’s physician of a missed medication. This failure had the potential to affect 60 patients who received dialysis treatments at the facility. Findings included: 1. A facility policy titled, “Initial Patient Nursing Assessment For New Patients,” revised 04/2024, indicated, “1. A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility.” On 07/29/2025 at 2:22 PM, during a medical record review for Patient 1, the Manager of Clinical Services (MCS) confirmed that there was no evidence of an initial nursing assessment having been performed prior to the patient’s first treatment at the facility. 2. A facility policy titled, “Medication Policy,” revised 10/2023, indicated, “36. All medication errors are reported to the Facility Administrator/designee. She/he will then notify the patient’s physician of the event and of any adverse changes in the patient’s condition. Physician will be notified of any medication errors prior to patient leaving the facility. Examples of medication errors include: -Administration of a medication not prescribed for the patient -Administration of an incorrect dosage of an ordered medication -A prescribed medication not administered to the patient.” Patient 1’s “Treatment Details Report” dated 07/17/2025, revealed a comment in the “Treatment Nurse Assessment” section that indicated “meds [medications] missed d/t [due to] emergency with other pt [patient].” The report further indicated Patient 1’s calcitriol one microgram was not given and the reason documented was “missed administration.” On 07/29/2025 at 2:22 PM, a concurrent interview was held with the Manager of Clinical Services (MCS) and the Facility Administrator (FA). The MCS confirmed that there was no evidence of provider notification of the missed dose of medication and that it was facility policy to notify the provider of any missed dose of medication. The FA confirmed the incident was not reported to him. The FA stated the designee at the clinic was RN #1. On 07/29/2025 at 4:16 PM, the MCS stated that the Medical Director was unavailable during the survey for an interview.”