Bma - Rockville

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(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:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[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. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 44367 Based on inspection of the emergency evacuation box and binder, the facility’s administrative staff failed to maintain a current list of all its patients for the purpose of tracking in the event of an emergency evacuation. The failure to provide an updated patient list could potentially result in a patient’s injury or harm in the event of an evacuation. Patients: All Patients Findings include: Review on 05/22/2025 of the facility’s policy entitled “Emergency Medication, Equipment and Supplies” page 2 stated, “An emergency box must: Contain all patient and staff emergency contact information.” On 05/22/2025 at 11:00 a.m., the inspection of the facility’s emergency evacuation kit revealed that kit did not contain a patient contact list or a contact list of its employees. The Clinical Manager and the Charge Nurse corroborated that the kit did not contain any contact list of patients or staff.”

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(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:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 44367 Based on observations, staff interview, and record review, the facility’s administration and the Medical Director failed to ensure that enough supplies were available to provide care during an emergency evacuation. This failure placed the safety and well-being of the patients at potential risk of harm in the event of an emergency. Findings included: Review on 05/22/2025 of the facility’s policy entitled Emergency Medication, Equipment and Supplies” page 1 stated “Emergency Evacuation Box: An emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters, and provide saline as needed for every licensed station once the patient is in a secure location. Refer to Emergency Evacuation Box Contents.” On 05/22/2025 at 11:30 a.m., during inspection of the facility’s evacuation kit, the surveyor noted that the kit did not contain enough supplies to provide care for every licensed station. The kit only had enough supplies to accommodate six (6) stations, but the facility has 18 stations. The Clinical Manager and the Charge Nurse corroborated that the emergency evacuation kit did not have enough supplies for every licensed station.”

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility 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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 44367 Based on observations and interviews with facility staff, the governing body, the facility’s administration failed to ensure that all required emergency supplies were readily available in the event of an emergency. This failure placed patients at potential risk of harm and danger during a life-threatening situation. Findings include: Review on 05/22/2025 of the facility’s policy FMC-CS-IC-II-130-007A entitled, “Emergency Medications, Equipment and Supplies” states, “Emergency supplies must be contained in a box or cart that is locked and is equipped with a dedicated oxygen tank.” On 05/22/2025, Inspection of the facility’s emergency evacuation kit revealed that the kit was not secure. The kit did not have a lock in place. The Charge Nurse and the Clinical Manager corroborated that the emergency evacuation kit did not have a lock in place.”

“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: 44367 Based on clinical observations, the facility’s administration failed to ensure that the standards of care related to hand hygiene and glove use requirements were followed by all staff who come in contact with the dialysis patients in the facility. This failure placed the patients and staff at potential risk for nosocomial infections (infections acquired while in a healthcare setting). Staff: #1 Findings included: According to the Centers for Disease Control and Prevention (CDC), infection can be spread in a dialysis center through the passing of microorganisms from one patient to another by the hands of the caregiver; or if the environmental surfaces are contaminated and touched by a caregiver or patient. Even with glove use, hand hygiene is necessary before gloves are put on and after gloves are removed because hands can become contaminated through small defects in gloves and from the outer surface of the gloves during glove removal. Review on 05/21/2025 of the facility’s policy entitled “Hand Hygiene” page 2 stated that “Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water: Entering and leaving the treatment area...After contact with inanimate objects near the patient...After contact with other objects within the patient station or treatment space.” During observations of the clinical treatment area on 05/21/2025 at 11:15 a.m., Staff #1 was working with the incoming patient at station #6 and after handling patient’s items, Staff #1 removed gloves. Staff #1 did not perform hand hygiene after removing gloves and replacing gloves to assist another patient at Station #6. The Clinical Manager was informed of the findings on 05/21/2025.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 44367 Based on observations and review of the facility’s policies, the governing body failed to ensure that the clinical staff inspected the dialysis machine’s external transducer and changed it when wet. This failure placed the patient at risk for infection and harm. Staff: #2 Findings include: Transducer protectors are used in Hemodialysis blood lines to keep the blood side of the circuit separated from the machine side and to prevent contamination of the machine by the blood flowing through the circuit. According to the “National Institute of Health (NIH)”, “Wet external transducer protectors must be changed immediately, and the machine side of the protector should be inspected for contamination or wetting.” Review on 05/23/2025 of the facility’s policy entitled “Patient Assessment and Monitoring” stated, “Observe and ensure that: That the transducer protectors are dry, unclamped and pressure lines are free of fluid.” Observation of the clinical treatment area on 05/23/2025 at 10:00 a.m. revealed that the venous external transducer and the pressure line on machine #5 at Station #2 were wet (filled with blood). Staff #6 was assigned to Station #2. The Clinical Manager was informed of the findings on 05/23/2025.”

“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: 44367 Based on clinical observations, the governing body failed to ensure that the clinical staff followed the standard regulations in the cleaning and disinfection of contaminated equipment being used in the facility. This failure put patients at risk for possible cross-contamination. Staff: #2 and #5 Findings included: Review on 05/21/2025 of the facility’s policy entitled “Prime Bucket Disinfection” revealed that the “Clean all surfaces of the prime bucket or approved receptacle, with 1:100 bleach solution or an approved 1:100 bleach disinfect wipe.” 1. Observation of the clinical treatment area on 05/21/2025 revealed the following: · At 11:14 a.m., during the disinfection process of Station #11, Staff #2 dumped the contents of the prime bucket in the dirty sink, but did not clean the bucket with bleach wipes. · At 11:19 a.m., during the disinfection process of Station #14, Staff #5 dumped the contents of the prime bucket and cleaned the outside of the bucket with bleach wipes, but did not clean the inside of the bucket. 1. During observation of the clinical treatment area on 05/28/2025 at 11:14 a.m., the surveyor noted that Staff #5 dumped the contents of the prime bucket in the dirty sink, cleaned the outside of the prime bucket, but did not clean the inside of the bucket. Failures in environmental cleaning and disinfection have led to transmission of bloodborne pathogens and other infections from one patient to another in Hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces) must be performed between patient uses to prevent transmission of dangerous pathogens. 1. Inspection of the water treatment disinfection logs on 05/22/2025 revealed the system is was not disinfected on 04/22/2025. According to the Biomedical Technician (Biomed) and the CWP Weekly Disinfection log (Minncare log) the disinfection process is done weekly. The system was not disinfected on 04/22/2025. The surveyor asked Biomed why the system wasn’t disinfected on 04/22/2025. Biomed responded “we haven’t had QAI yet.” Biomed refused to answer any further questions from the surveyor by sitting and looking straight ahead. The surveyor ended the interview. The Clinical Manager was informed of the findings on 05/21/2025, 05/22/2025 and 05/28/2025.”

“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: 44367 Based on observations and review of the facility’s policies and procedures, the governing body and the medical director failed to ensure that the clinical staff complied with the appropriate catheter care techniques and procedures. This failure placed patients at potential risk of infection or harm in maintaining their central venous catheter. Staff: #1 and #3 Findings include: According to the National Institute of Health (NIH), “A central venous catheter (CVC) is an indwelling device inserted into a large, central vein (most commonly the internal jugular, subclavian, or femoral) and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava, or right atrium [parts of the heart].” Review on 05/21/2025 of the facility’s policy “Initiation of Treatment Using a Central venous Catheter and Optiflux Single Use Ebeam Dialyzer” page 4 states, “Threads and end of the luer lock (hub) must be scrubbed with 70% sterile alcohol pad (or other antiseptic such as chlorhexidine, povidone if required by the hospital) for 10-15 seconds and any time caps are removed, or bloodlines are disconnected (i.e. end of treatment or treatment interruption) to reduce risk of contamination.” 1. Observation of the clinical treatment area on 05/21/2025 at 11:23 a.m. revealed that during treatment termination of a CVC patient at station #17, Staff #1 cleaned the arterial hub for only 8 seconds. 2. Observation of the clinical treatment area on 05/23/2025 at 10:31 a.m. revealed that during treatment termination of a CVC patient at station #13, Staff #3 did not clean the arterial or venous hub after disconnecting from the bloodlines before attaching the prefilled normal saline syringes. The Clinical Manager was informed of the findings on 05/21/2025 and 05/23/2025.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 44367 Based on observation, the Facility’s Administration and the Medical Director failed to ensure that the water room remained secure and restricted from unauthorized access. This failure placed the water system at risk for possible contamination and placed the patients at potential risk of harm. Findings included: Unauthorized access to the system could lead to tampering, which could have serious consequences for the safety and quality of the water supply. To maintain the quality and safety of the water supply, it is essential to make sure that the water purification and storage systems are secure and only accessible by authorized personnel. 1. On 05/21/2025 at 10:00 a.m., during the flash tour, the surveyors observed that the water room did not have a door or gate in place, leaving the system accessible to unauthorized. 2. On 05/21/2025 at 10:00 a.m. during the flash tour, the surveyor observed that the supplies, the Bicarbonate tank and the acid dissolution, are all housed in the same room and did not have a door or gate in place allowing unauthorized access. The surveyor observed an unaccompanied person (non-employee) sitting behind multiple boxes next to the acid tank. According to the Clinical Manager, the person is with the phone company and is unauthorized to work with the water room. 3. On 05/22/2025 at 11:00 a.m., the surveyor walked into the supply room and observed that the large bay door was completely open allowing easy access. According to the Charge Nurse, the Biomedical Technician (Biomed) “always leave the door open while doing supplies.” The surveyor noted that Biomed was not in the supply room for 10 minutes. The surveyor walked outside beyond the bay doors and did not observe a delivery truck or any other vehicles. The surveyor asked Biomed why the door was open and left unattended and Biomed stated, “I was doing supplies.” The Clinical Manager corroborated that the water treatment system, bicarbonate tanks, and the acid tank were not secure.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 44367 Based on observations of the facility’s bicarbonate tank and a review of the facility’s policies and procedure, the facility’s administration and the medical director failed to ensure that the bicarbonate tank’s content was labeled correctly. This failure placed the patients at potential risk for harm. Findings include: Review on 05/21/2025 of the facility’s policy entitled “Concentrate Labeling requirements” page 2 revealed, “Mix tank labeling must include: Contents identification. For example , “Bicarb”, “Acid”, “RO Water” or Disinfectant”...Date time of mixing.” On 05/21/2024 at 10:40 a.m., during a flash tour of the facility’s water treatment/supply room, it revealed that the Bicarbonate Mix tank was full of clear liquid, but the tank did not have a date, time, or initials. The tank was not properly labeled. The Clinical Manager observed the tank with the surveyor and corroborated that the tank was not properly labeled.”

“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: 44367 Based on observations and interviews with the facility’s administration, the governing body failed to ensure that the physical structure of the dialysis facility and the water treatment room was kept intact and obstacle free at all times. This failure placed the patients, staff, and visitors at potential risk of harm including exposure to hazardous or infectious material from a potentially contaminated water system. Findings included: Review on 01/15/2025 of the “American Journal of Kidney Diseases” revealed, “Physical environment requirements of the CfC address building safety, equipment maintenance, the patient care setting, emergency preparedness, and fire safety. This includes the ensurance of proper maintenance and repair of such items as the dialysis equipment, operating systems, water treatment systems, and physical building and grounds.” On 05/21/2025 at 10:40 a.m., during the flash tour of the water treatment/supply room, the surveyor noted the following: · Four large electrical panels with two large pallets directly in front of them. One pallet had 12 large bags of Activated Carbons, which were directly on the electrical wiring. The other pallet had Four (4) boxes which contained four (4) gallons of bleach. The panel has signage that stated, “Warning Electrical Panel Keep Clear up to 36 inches.” The Clinical Manager observed and corroborated that the electrical panels were blocked. · A gross amount of a white substance on the floor behind the two Bicarbonate tanks.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 44367 Based on observations, and a review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the facility was free of expired supplies. This failure placed the patients at potential risk of harm. Findings include: When medications and supplies are no longer needed, they should be disposed of promptly. Healthcare providers should remove expired medications and supplies as quickly as possible to help reduce the chances that others accidentally receive or intentionally misuse them. Review on 05/21/2025 of the facility’s policy entitled “Storage of Supplies” page 1 states “Appropriately dispose of items that have reached the expiration date.” 1. Observations of the supply room on 05/21/2025 revealed the following expired supplies: “ Three (3) 32 oz. bottles of Standard Buffer Solution 7.0 ph, lot number ML-P7-1815, expired 03/03/2025. “ Three 16 oz. bottles of Standard Buffer Solution 10.00 ph, lot number ML-P10-1841, expired 05/15/2025. “ Three 32oz. bottles of Conductivity Standard Solution 14.0 ms/cm, lot number ML-C14-1826, expired 03/29/2025. “ Three 16 oz. bottles of Standard Buffer Solution 4.00 ph, lot number ML-P4-1822, expired 03/22/2025. “ Two (2) boxes of Critline CLIC Blood Chamber, lot number 20LR01211, expired 09/30/2023. “ Three (3) boxes of Critline CLIC Blood Chamber, lot number 20LR01014, expired 03/31/2024. 2. Observation of the clinical treatment area on 05/22/2025 revealed the following expired supplies: “ 250 packs of Fistula Needle sets, lot number 220324F2, expired 03/31/2025. “ 100 - 21-gauge Safey Lancets, lot number 2004092, expired 04/08/2025. “ One (1) box of Glucose Control Solution, lot number C23C270, expired 03/27/2025. The Clinical Manager was informed of the findings on 05/21/2025 and 05/22/2025.”

“PR-CAN HAVE ADVANCE DIR,TOLD FAC AD P&P CFR(s): 494.70(a)(6) The patient has the right to- (6) Be informed about his or her right to execute advance directives, and the facility ’ s policy regarding advance directives; This Standard is not met as evidenced by: 44367 Based on medical record reviews, the facility administrator and medical director failed to ensure that all the facility’s patients were given information about creating an advance directive on admission. This failure denied the patients their rights to formulate treatment decisions that served their end-of-life needs. Patients: #2, #3 and #4 Findings included: Review on 05/22/2025 of the facility’s policy entitled “Advance Directive” page 1 states, “All new patients will be asked if they have a current Advance Directive (otherwise known as a “Living Will”) designating a health care agent and/or specifying the medical care they wish to receive or not receive...If the patient does not currently have an Advance Directive, they will be asked if they would like information regarding end-of-life options and Advance Directives.” A review of the medical records on 05/22/2025 revealed that three (3) out of four (4) or 75% of the selected patients were not provided with information or given the option to create an advanced directive. One patient’s chart did not have a form and two of the patients’ charts had forms that were not signed by the patient or a patient representative. The findings were as follows: “ Patient #2 was admitted to the facility on 11/04/2020. No advanced directive acknowledgement form was found in Patient #2’s paper or electronic chart. “ Patient #3 was admitted to the facility on 03/24/2024. An advanced directive acknowledgement form was found in Patient #3’s paper or electronic chart; However, the form was not signed by the patient or a patient representative. “ Patient #4 was admitted to the facility on 01/31/2025. An advanced directive acknowledgement form was found in Patient #4’s paper or electronic chart; However, the form was not signed by the patient or a patient representative. The Clinical Manager was informed of the findings on 05/22/2025.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 44367 Based on observations, the facility’s administration failed to ensure that a copy of the address and contact numbers of the End Stage Renal Disease (ESRD) Network and State survey agency, were prominently displayed where it can be easily seen and read by the patients, and/or patient advocates. This failure denied the patients their rights. Findings included: The facility must post all the patients’ rights in a common area of the facility which is routinely available to in-center dialysis patients. This posting is meant to augment, not substitute for communicating these rights to each individual patient in a way the patient can understand. Information that must be posted includes the list of patient rights and the mailing addresses and contact information for the applicable ESRD Network and State Survey Agency (SSA), as well as the complaint telephone numbers for each. During observation of the facility’s waiting room on 05/28/2025, the surveyor noted that the contact information of ESRD Network 5 was not posted. The Clinical Manager corroborated that Network 5 information was not posted.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 44367 Based on review of medical records, and interviews with the facility’s administrative staff, the governing body failed to ensure that a registered nurse (RN) completed an initial nursing assessment prior to the patients’ initial dialysis treatment when being admitted to the facility. This failure placed the affected patients at risk for harm. Patients: #1 and #2 Findings included: Review on 05/22/2025 of the facility’s policy entitled “Comprehensive Interdisciplinary Assessment and Plan of Care” revealed that “A registered nurse must perform an initial assessment on patient new to dialysis before initiation of their first treatment to determine immediate needs.” During a review of ten selected patients’ medical records on 05/22/2025, the surveyor noted that two (2) or 50% out of the four of the selected patients did not have an initial nursing assessment documented in their paper or electronic charts. The assessment should have been completed prior to the patient being placed on the dialysis machine on the day of admission. The Clinical Manager was given the opportunity to provide the missing initial nursing assessments; However, the Clinical Manager corroborated that the initial nursing assessments were not completed.”

“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: 44367 Based on review of the dialysis patients’ treatment flowsheets, the facility’s administration and clinical staff failed to ensure that the dialysis prescriptions were the same as what the patients received. Failure to ensure that the dialysis prescription was implemented according to the doctor’s orders placed the patients at potential risk of harm, injury, and denied the patients their rights. Patients: #3 and #4 Findings included: The treatment flowsheet is the form used to record the patient’s care during dialysis. Recorded information includes the patient’s blood flow rates (BFR) and the dialysate flow rate (DFR), the patient’s blood pressure, administration of medications, visual observations of the patient and any patient complaints. This information may be handwritten or computer generated. According to the facility’s policy entitled “Patient Assessed and Monitoring” page 6 revealed, “check prescribed blood flow is being achieved, or reason is documented in medical record if unable to meet prescribed flow. Check dialysate flow rate setting in correct, and the prescribed flows are being delivered.” A review of four (4) selected patients’ treatment flowsheets on 05/23/2025, revealed that two (2) or 50% of the selected patients did not receive the correct dialysis prescription as ordered by the Nephrologist. 1. On treatment date 03/14/2025, Patient #3’s BFR was prescribed for 400 ml/min. However, the BFR was set at 300 ml/min from 06:33 p.m. to 07:19 p.m. Patient #3 DFR was prescribed for 600 ml/min. However, the DFR was set at 500 ml/min from 05:00 p.m. to 07:19 p.m. There was no documentation found explaining why Patient #3’s BFR and DFR were not set on the dialysis machine as prescribed. 2. On treatment date 06/03/2024, Patient #4’s BFR was prescribed for 350 ml/min. However, the BFR was set at 310 ml/min from 02:27 p.m. to 03:37 p.m. and then 250 ml/min from 04:16 p.m. to 04:40 p.m. There was no documentation found explaining why Patient #4’s BFR was not set on the dialysis machine as prescribed. 3. On treatment date 06/03/2024, Patient #4’s BFR was prescribed for 350 ml/min. However, the BFR was set at 310 ml/min from 02:27 p.m. to 03:37 p.m. and then 250 ml/min from 04:16 p.m. to 04:40 p.m. There was no documentation found explaining why Patient #4’s BFR was not set on the dialysis machine as prescribed. The Clinical Manager was informed of the findings on 05/23/2025.”

“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: 44367 Based on patient record review, the facility’s administration failed to ensure that the clinical staff followed standard clinical practices in addressing blood pressures beyond the normal limits. This failure placed the affected patients at potential risk of injury or harm. Patient: #3 Because of the adverse effects of End Stage Renal Disease, many patients experience the instability of blood pressure and fluid management, the management of which may require reassessment of medication needs, adjustments in target weight, and changes to the plans of care. The patient’s heart rate must be monitored for abnormally high and low in addition to the blood pressure. Patients’ blood pressures must be monitored before, during and after dialysis treatment, and abnormally high and low values must be addressed immediately to ensure patient safety. Review on 05/23/2025 of the facility’s policy entitled “Patient Assessment and Monitoring” page 4 stated, “Follow the steps below for monitoring patient and machine parameters during treatment: recheck blood pressures after a drop that requires interventions such as administering normal saline...Report to the nurse: Systolic blood pressures greater than 180 mm/hg. Diastolic blood pressures greater than 100 mm/hg. Blood Pressures less than or equal to 100 mg/hg systolic.” Review of the selected four (4) selected patients’ treatment flowsheets revealed that one (1) out of the four or 25% of the patients’ blood pressures were not reported and/or addressed by the registered nurse. 1. According to the treatment flowsheet dated 05/31/2024, Patient #3’s diastolic blood pressures results ranged from 102 mm/hg - 120 mm/hg from 06:545 a.m. to 10:32 a.m. There was no documentation found stating that the Nurse was informed or any documentation from the Nurse addressing Patient #3’s blood pressures. The Clinical Manager was informed of the findings on 05/23/2025.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 44367 Based on observations and review of the facility’s policies and procedures, the facility’s administration failed to ensure that the clinical staff complied with the appropriate procedures when assessing the patients’ vascular access after the fistula needles have been removed from the access. This failure placed the safety and well-being of the patients at potential risk of harm in maintaining their vascular access and/or infection. Patient: #8 Staff: #1 Findings included: Review on 05/23/2025 of the facility’s policy entitled “Venipuncture Site Clamps” page 1 stated ‘It is recommended to use only one clamp at a time to prevent excessive pressure which can cause thrombosis. While the clamp remains on the access, check the thrill every 10 minutes. It is recommended not to exceed clamps in place longer than 20 minutes.” 1. Observation of the clinical treatment area on 05/23/2025 at 10:58 a.m. revealed that the patient at station #7 had clamps placed on both needle sites. The surveyor and the Clinical Manager (standing next to the surveyor) noted that the clamps were in place for 25 minutes before being removed and the access assessed. The Clinical Manager asked Staff #1 (Charge Nurse) on three occasions to assess the patient’s access because the assigned Patient Care Technician was working with another patient, but Staff #1 did not assess the patient. The Clinical Manager Corroborated that the clamps were in place for more than 20 minutes.”