Davita Union Memorial Dialysis

“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 12/10/2025 of the facility’s policy 4-07-01 “Facility Emergency Management Plan” page 17 number 2, “The contents of the evacuation kit(s) will include, at a minimum, enough supplies to provide care for a full shift of patients”; Page 17 number 3 states, “The evacuation kit(s) should be portable, made of sturdy material, and easy to transport labeled Evacuation kit.” On 12/10/2025 at 11:30 a.m., during inspection of the facility’s emergency evacuation kit, the surveyor noted that the kit contained two (2) 500 ml Normal Saline bags, seven (7) sets of fistula needles, and four (4) Intravenous lines (IV). The kit did not contain enough supplies for the facility’s 27 stations. The Facility Administrator was informed of the findings on 12/10/2025.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 44367 Based on observations, staff interview, and record review, the facility’s administration and the Medical Director failed to ensure that the patient’s health records remained confidential and protected from unauthorized access. This failure denied the patients their rights to privacy and confidentiality of their health information. Findings Included: According to the facility’s policy “Facility Emergency Management Plan” page 21 number 2 states, “2. Digital and hard copy patient medical records shall be secured at all times from unauthorized use”; Number 3 states, “Health Insurance Portability and Accountability Act (HIPAA) policies will be followed to maintain patient privacy, policy access, use, and disclosure of protected health information.” On 12/10/2025 at 11:30 a.m., during the inspection of the facility’s emergency equipment, the surveyor observed the facility’s emergency evacuation kit binder contained all its patients’ “Summary Reports”. The binder was placed on top of the emergency evacuation kit, making it accessible for unauthorized access. The Charge Nurse and the Facility Administrator were informed of the findings on 12/10/2025.”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 44367 Based on observation and review of the facility’s policies and procedures, the facility’s administration failed to ensure that the facility provided and maintained a safe treatment environment for its patients by ensuring the facility conducted fire drills quarterly per the facility’s policy. This failure placed the patients and visitors at potential risk of harm in the event of a fire. Findings include: Review on 12/11/2025 of the facility’s policy 4-07-01 entitled “Facility Emergency Management Plan” revealed “Fire safety drills: Required on a Quarterly basis.” During review of the emergency preparedness binder on 12/11/2025, the surveyor noted that the facility conducted fire drills on 01/30/2025, 08/04/2025 and 12/03/2025. Based on the facility’s policy a total of four fire drills a year should be conducted. The Facility Administrator was given the opportunity to provide additional documentation. The Facility Administrator corroborated that a fire drill was not conducted for “2nd quarter” (April, May, June).”

“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: 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 encounter 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 and #3 Findings included: Review on 12/09/2025 of the facility’s policy 1-05-01 entitled, “Infection Control For Dialysis Facilities” states that, “All teammates, Physicians, and Non-Physicians (NPP) will perform hand hygiene: b. prior to gloving and immediately upon removal, c. after contamination with blood or other infectious material, g. before touching clean areas such as supplies, supply cart and chairside.” 1. During observation of the clinical treatment area on 12/09/2025 at 10:40 a.m., the surveyor observed that after treatment initiation of the patient at Station #5, Staff #1 removed the soiled gloves and did not complete hand hygiene before gathering clean supplies. 2. During observation of the clinical treatment area on 12/09/2025 at 11:02 a.m., the surveyor observed that during treatment initiation of the patient at Station #16, Staff #3 removed the soiled gloves and did not complete hand hygiene before gathering clean supplies. The Facility Administrator was informed of the findings on 12/09/2025.”

“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 staff #1 and #2 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 #2 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 09/22/2025 of the facility’s policy 1-04-02B entitled “Central Venous Catheter (CVC) with clearguard HD antimicrobial end caps” states to “Clean exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum of 30 seconds , apply to the CVC exit site in a “back and forth” pattern, using gentle friction progressing from the insertion site to the periphery ...Then wait 60 seconds for air dry time.” According to the facility’s policy 1-04-02B entitled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” page 3 number 1 states, “Perform hand hygiene per procedure: Rationale: Hand hygiene protects patient and teammate from cross contamination; number 2 states, set up clean field ...number 4 states ‘Remove old dressing and discard ...Page 4 number 7 states, Re-perform hand hygiene per procedure and put on clean gloves; Page 4 number 7 states, “Remove gloves and discard. Perform hand hygiene per procedure and re-glove; number 9 states, Clean each CVC limb/cap with a large alcohol prep ...Page 5 number 10 states, Remove gloves and discard, perform hand hygiene per procedure and re-glove; number 12 states, Place a sterile 2x2 gauze over the catheter exit site ... number 14 states, Remove gloves and discard, perform hand hygiene per procedure and re-glove ...” 1. During observation of the clinical treatment area on 12/09/2025 at 10:40 a.m., the surveyor noted that during initiation of treatment of a CVC patient at station #5, Staff #1 did not change gloves as required during the dressing change process. Staff #1 removed the dirty gloves after the clean dressing was placed; However, Staff #1 did not perform hand hygiene before placing new gloves. 2. During observation of the clinical treatment area on 12/09/2025 at 11:05 a.m., during initiation of treatment of a CVC patient at station #9, Staff #2 clean the exit site for only 20 seconds and allowed the site to dry for only 40 seconds before placing a new dressing. The Facility Administrator was informed of the findings on 12/09/2025.”

“IC-MONITOR CATH-RELATED BSI RATES/SURV CFR(s): 494.30(a)(2) Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. I. Surveillance A. Conduct surveillance ...to determine CRBSI rates, monitor trends in those rates, and assist in identifying lapses in infection-control practices. C. Investigate events leading to unexpected life-threatening or fatal outcomes. This includes any process variation for which a recurrence would likely present an adverse outcome. This Standard is not met as evidenced by: 44367 Based on review of the facility’s National Healthcare Safety Network (NHSN) reports and patient medical records, the medical director and the governing body failed to provide monthly documentation for effective surveillance. The failure place patients at risk for ineffective care related to infections. Findings include: The Dialysis Module of the National Healthcare Safety Network (NHSN) is reported monthly and should contain detailed information on individual patients for effective surveillance and tracking of infections and infection control practices. Review on 12/11/2025 of the facility’s infection surveillance binder revealed that the facility did not report to NHSN for October 2025 and November 2025. The Facility Administrator corroborated that October and November 2025 were not completed.”

“BICARB MIX SYS-STOR/USE TIME/MIN COMBINE CFR(s): 494.40(a) 5.4.4.3 Bicarbonate concentrate mixing systems: storage/use time limits/min combine Once mixed, bicarbonate concentrate should be used within the time specified by the manufacturer of the concentrate. 7 Strategies for bacterial control 7.1 General Storage times for bicarbonate concentrate should be minimized, as well as the mixing of fresh bicarbonate concentrate with unused portions of concentrate from a previous batch. The manufacturer’s instructions should be followed if they are available. This Standard is not met as evidenced by: 44367 Based on interviews with the clinical staff, observations of the clinical treatment area and a review of the facility’s policies and procedure, the facility’s administration and the medical director failed to ensure that the bicarbonate solution was labeled correctly. This failure placed the patients at potential risk for harm. Findings include: Review on 12/09/2025 of the facility’s policy 2-07-01 entitled, “Bicarbonate Concentrate System Mixing” states, “Bicarbonate concentrate is to be used the same day that it is mixed... Any bicarbonate concentrate left over at the end of the treatment day is to be discarded.” During observation of the water treatment room on 12/09/2025 at 12:00 p.m., the surveyor noted that the bicarbonate tank was completely full of clear liquid. The label attached stated “Bicarbonate Concentrate In Tank” with a date and time of “12/8/25 ... 0615” and initials “AD.” The Facility Administrator observed and agreed with the findings on 12/09/2025.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 44367 Based on observations, the Facility’s Administration and the Medical Director failed to ensure that Staff #1, #2 and #5 checked the pH of each dialysis machine according to the facility’s policy and procedures. This failure placed the patient affected at potential risk of harm. Staff: #1, #2 and #5 Findings Included: It is necessary for the operator of the hemodialysis machine to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. Each machine must be tested for pH using a handheld meter or other appropriate testing device before every dialysis treatment and whenever a different composition of acid concentrate is used. Review on 12/09/2025 of the facility’s policy 2-08-01B “Operation of Portable Myron L Conductivity Meter”, “Manual pH testing must be performed prior to each patient treatment.” Step 36. If all tests are completed successfully, press “Reset” ...Step 41. Check Independent pH with approved test method for final dialysate. Acceptable range for final dialysate pH is 6.9-7.6.” 1. On 12/09/2025 at 10:40 a.m., Staff #1 did check the manual pH for the machine at Station #5 prior to initiating the patient’s treatment. 2. On 12/09/2025 at 11:05 a.m., Staff #2 did check the manual pH for the machine at Station #9 prior to initiating the patient’s treatment. 3. On 12/10/2025 at 10:39 a.m., Staff #5 did not check the manual pH for the machine at station 11, prior to initiating the patient’s treatment. The Facility Administrator was informed of the findings on 12/09/2025 and 12/10/2025.”

“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 staff, the facility’s governing body failed to ensure the water treatment room was free from defects. This failure placed the patients, staff, and visitors at potential risk of harm including injury or infection. Findings Included: All buildings and building systems must be maintained free from defects and/or hazards to ensure safety and functionality. The integrity of all surfaces, (e.g., countertops, floors, walls) must be intact, clean, and free from damage. Intact surface integrity allows for effective cleaning and free from damage. Intact surface integrity allows for effective cleaning and limits the potential for microbial growth on a porous surface. 1. Inspection of the water treatment room on 12/09/2025 revealed the following: · Erosion like appearance around the base of the floor along the right side wall of the water room. · Large amount of white crystallization on the surface of the acid dissolution tank. · White greenish colored substance on the wall behind the acid dissolution tank. The Facility Administrator observed and agreed with the findings on 12/09/2025.”

“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 review, the facility administrator and medical director failed to ensure that all the facility’s patients had a completed Medical Orders for Life-Sustaining Treatment Form (MOLST) and was given information regarding creating an advance directive. This failure denied the patients their rights to formulate treatment decisions that served their emergency interventions that may be required. Patients: #1, #4, #6, #9, and #10 Findings included: According to Maryland.gov on 12/11/2025, “MOLST forms must be completed for newly admitted patients during the admission process in all assisted living programs, home health agencies, hospices, kidney dialysis centers, and nursing homes.” Review on 12/11/2025 of the facility’s policy 3-02-19 entitled “MOLST Form” revealed, “This is a document that must be prepared for each patient... The Patient’s Rights and Responsibilities document, presented to the patient at the initiation of treatment will advise the patient of his/her right to execute an Advanced Directive.” A review of the facility’s medical records on 12/11/2025 revealed that five (5) out of ten or 30% of the selected patients selected did not have a MOLST and/or an advanced directive acknowledgment form in their chart. 1. Patients #1 did not have a MOLST or an advanced directive acknowledgment form in their paper or electronic chart. 2. Patients #4 did not have a MOLST form in their paper or electronic chart. 3. Patients #6 did not have an advanced directive acknowledgment form in their paper or electronic chart. 4. Patients #9 did have a MOLST form in their chart, however the form was not filled out or signed by the physician. 5. Patients #10 did not have an advanced directive acknowledgment form in their paper or electronic chart. The Facility Administrator corroborated that the five (5) identified patients did not have a documented MOLST and/or an advanced directive acknowledgment form.”

“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 record review of medical records, the Facility’s Administration and the Medical Director failed to ensure that initial nursing assessments were performed by the assigned registered nurse prior to the patients’ first dialysis treatment when being admitted to the facility. This failure placed the affected patient(s) at risk of receiving insufficient and ineffective care and denied the patients their rights. Patient: #4, #6 and #7 Findings included: A nursing assessment consists of weight (pre and post), including a physical examination, the measurement of vital signs, observation of the vascular access, and assessment of a patient’s general condition. It also includes a neurological assessment of the level of alertness and the mental status of the patient, subjective complaints, pain status, activity levels, assessment of the respirations, including auscultation of breath sounds; assessment of cardiac status to include auscultation of the heart sounds, fluid gains, skin color and temperature, and bowel sounds. The RN on duty must make and document an initial assessment of the newly admitted patient prior to his or her first treatment. Review on 12/11/2025 of the facility’s policy 1-03-07 “New Patient Pre-Treatment Evaluation” page 1 states, “An RN, as required by federal regulation, will perform an initial pre-treatment evaluation of all new patients prior to the initiation of their first treatment at the facility.” During inspection of the patients’ charts on 12/11/2025, the surveyor noted three (3) out of the ten (10) or 30% selected patients did not have an initial nursing assessment in their paper or electronic chart. The facility Administrator and the Charge Nurse were given the opportunity to provide additional documentation. Additional documentation was provided except for three patients. The Facility Administrator was informed of the findings on 12/11/2025.”

“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 followed as prescribed by the Nephrologist. This failure placed the patients at potential risk of harm and denied the patients their rights. Patients: #1, #2 and #4 Findings included: The hemodialysis prescription includes the number of treatments per week, the length of treatment time, the dialyzer, the primary access being used for the patient; specific parameters of the dialysis delivery system, such as the blood flow rate (BFR), dialysate flow rate (DFR), and electrolyte composition of the dialysate; anticoagulation, and the patient’s target weight. Review on 12/10/2025 of the facility’s policy 1-03-08 entitled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” page 4 number 10, “If the dialysis prescription is not being met (including the inability to obtain prescribed blood flow rate or BFR) the reason will be documented, and the licensed nurse informed.” A review of the ten (10) selected patients’ treatment flowsheets on 12/10/2025 revealed that three (3) or 30% of the patients did not receive the correct dialysis prescription as ordered by the Nephrologist. 1. On treatment date 12/04/2025, Patient #1’s DFR was prescribed for 600 ml/min. However, the DFR was set at 800 ml/min for the entire treatment. There was no documentation from the clinical staff explaining why Patient #1’s DFR was not set on the dialysis machine as prescribed. 2. On treatment date 12/06/2025, Patient #2’s BFR was prescribed for 400 ml/min. However, the BFR was set at 300 ml/min from 11:31 a.m. - 12:01 p.m., 330 ml/min from 12:01 p.m. to 12:31 p.m., and then 350 ml/min from 01:01 p.m. to 01:24 p.m. There was no documentation from the clinical staff explaining why Patient #2’s BFR was not set on the dialysis machine as prescribed. 3. On treatment date 11/24/2025, Patient #4’s DFR was prescribed for 500 ml/min. However, the DFR was set at 800 ml/min for the entire treatment. There was no documentation from the clinical staff explaining why Patient #4’s DFR was not set on the dialysis machine as prescribed. The Facility Administrator was informed of the findings on 12/10/2025.”

“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 patients’ record review, the facility’s administration failed to ensure that the clinical staff followed standard clinical practices when setting the ultrafiltration rate as prescribed by the Nephrologist. This failure placed the affected patients at potential risk of injury. Patient: #1, #2, and #3 Findings include: According to the National Institute of Health National Library of Medicine “Several studies have examined the increased risk of death as average UFR increases, and an upper limit of 13 ml/kg per hour has been suggested as a quality metric (8-17). Most studies place the inflection point for increased risk of death above 13 ml/kg per hour, and this finding is consistent across all groups of sex, race, dialysis session duration, and body size. Presumed mechanisms of higher mortality associated with high UFR are putative and include myocardial disease, increased risk of arrhythmias, sudden death, and intradialytic hypotension with associated consequences, among others.” Review on 12/10/2025 of the facility’s policy entitled “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” number 3(d) stated, “The prescription components are confirmed by the licensed nurse within one (1) hour of treatment initiation ...Prescription components include but not necessarily limited to: UFR and Max UFR.” Review on 12/10/2025 of the facility’s treatment flowsheets revealed that three (3) of the ten or 30% of the selected patient’s dialysis prescriptions on the dialysis machine was not verified by the licensed nurse to ensure that the patients hourly UFR did not exceed 13 ml/hr. The patients’ flowsheets revealed the following: 1. Based on the documented weight, Patient #1’s maximum UFR was supposed to be 1178 ml/hr. Review of Patient #1’s treatment flowsheets revealed that the UFR was set at 1560 milliliters/hour (ml/hr) from 11:31 a.m. to 12:01 p.m. and 1200 ml/hr on 12/04/2025. According to Patient #1’s flowsheet the “Ordered maximum Ultra Filtration (UF) Rate” was documented as “13.0 ml/kg/hr.” 2. Based on the documented weight, Patient #2’s maximum UFR was supposed to be 1240 ml/hr. Review of Patient #2’s treatment flowsheets revealed that the UFR was set at 1380 milliliters/hour (ml/hr) from 12:02 p.m. to 12:32 p.m. and 1260 ml/hr on 12/03/2025. According to Patient #2’s flowsheet the “Ordered maximum Ultra Filtration (UF) Rate” was documented as “13.0 ml/kg/hr.” 3. Based on the documented weight, Patient #3’s maximum UFR was supposed to be 954 ml/hr. Review of Patient #3’s treatment flowsheets revealed that the UFR was set at 1090 milliliters/hour (ml/hr) from 05:50 a.m. to 07:30 p.m. At 07:48 a.m., the UF was turned off (the machine stopped pulling fluid) and given 100 ml of normal saline, due to Patient #3’s blood pressure dropping from 156/68 to 83/43. According to Patient #1’s flowsheet the “Ordered maximum Ultra Filtration (UF) Rate” was documented as “13.0 ml/kg/hr.” The Facility Administrator was informed of the findings on 12/10/2025.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 44367 Based on the patients’ medical record reviews and interviews with the facility’s administration, the governing body and interdisciplinary team (IDT) failed to ensure that an initial comprehensive assessment and Plan of Care (POC) was completed for all in-center patients within the latter of 30 calendar days or 13 Hemodialysis sessions beginning with the first outpatient dialysis session. This failure placed the affected patients at potential risk of harm and denied patients their rights. Patients: #1, #4, #6, #7, and #8 Findings included: Review on 12/11/2025 of the facility’s policy 1-14-01 entitled “Patient Assessment and Plan of Care,” revealed that “A comprehensive assessment will be conducted on all patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” On 12/11/2025, during a review of the selected in-center hemodialysis (ICHD) patients’ plans of care (PoC), the surveyor noted that five (5) out of the ten (10) or 50% of the patients did not have a 30-day PoC completed. There was no documentation on the 30-day PoCs in Patients #1, #4, #6, #7, and #8’s paper or electronic charts. The Facility Administrator corroborated that the five (5) identified patients did not have a 30-day PoC.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 44367 Based on the patients’ medical record reviews and interviews with the facility’s administration, the governing body and interdisciplinary team (IDT) failed to ensure that a 3 month (90-day) comprehensive assessment and Plan of Care (PoC) was completed 3 months after the completion of the initial (30-day) comprehensive assessment and PoC. This failure placed the affected patients at potential risk of harm and denied patients their rights to effective care. Patients: #2, #6, #7 and #8 Findings included: Review on 12/11/2025 of the facility’s policy 1-14-01 entitled “Patient Assessment and Plan of Care” states, “A follow-up 90-day reassessment will be completed to evaluate the patient’s status and provide information to adjust the patient’s plan of care.” Review on 12/11/2025 of the facility’s medical records revealed that four (4) out of the 10 or 40% of the selected patients did not have a 90-day assessment completed. Patient #2, #6, #7, and #8 did not have a 90-day assessment in their paper or electronic charts. The Facility Administrator corroborated that the four (4) identified patients did not have a 90-day PoC.”

“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 Staff #3 complied with the appropriate procedures when assessing the patients’ vascular access prior to cannulation and practiced the correct infection control protocol. This failure placed the safety and well-being of the patients at potential risk of harm in maintaining their vascular access. Staff: #6 and #7 Findings included: Review on 12/10/2025 of the facility’s policy entitled “Cannulation of Fistula or Graft”, Procedure 01-04-01E page 3 #13 states: “Do not palpate insertion site once area has been prepped. Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” 1. During observation of the clinical treatment area on 12/10/2025 at 10:10 a.m. at station 24, the surveyor noted that during treatment initiation, Staff #6 palpated patient’s access after cleaning, prior to cannulation. Staff #6 did not re-clean the patient’s access. 2. During observation of the clinical treatment area on 12/10/2025 at 10:38 a.m. at station, the surveyor noted that during treatment initiation, Staff #7 palpated patient’s access after cleaning, prior to cannulation. Staff #7 did not re-clean the patient’s access. The Facility Administrator was informed of the findings on 12/10/2025.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 44367 Based on in-center and home dialysis patient records review and interviews with the facility’s staff, the interdisciplinary team (IDT) members (physician, nurse, dietician and social work); facility administration, medical director, and governing body failed to ensure that a Registered Dietician participated in all patient plan of care (PoC) meetings. This failure denied patients’ rights and placed the patients at risk for receiving insufficient and ineffective care. Patients: #3, #8, #9, and #10 Findings included: Review on 12/11/2025 of the facility’s policy 1-14-01 entitled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” states, “The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician, or Non-physician Practitioner (NPP) ... a social worker, and a dietician ... The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and be signed by team members...” Review on 12/11/2025 of the facility’s medical records revealed that the dietician and/or the social worker did not participate in the IDT meeting four (4) out of the ten or 40% of the selected patient meetings. The documentation revealed the following: 1. Patient #3’s annual PoC dated 03/27/2025 was not signed by a registered dietician to verify attendance. 2. Patient #8’s annual PoC dated 11/12/2025 was not signed by a dietician to verify attendance. 3. Patient #9’s 30-day PoC dated 09/03/2025 was not signed by a social worker to verify attendance. 4. Patient #10’s 30-day PoC dated 12/03/2025 was not signed by a social worker to verify attendance. The Facility Administrator was given the opportunity to provide additional information. The Facility Administrator corroborated that the social worker and/or the dietician did not attend the identified meetings.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 44367 Based on medical record review, the facility administrator and medical director failed to ensure that all the facility’s patient’s medical records were completed and accurate. This failure denied the patients their rights to formulate their own treatment decisions. Patients: #7 and #9 Findings included: Review on 12/11/2025 review of the facility’s policy 3-02-02 entitled “Medical records Documentation Guidance” revealed “All handwritten entries must be legible in the medical record... Do not chart in advance (before the service, observation or order)... Document accurately and concisely but completely.” 1. Review on 12/11/2025 of selected Patient #9’s chart revealed that the MOLST form was incomplete. The form did not have a “Practitioner’s Signature”, did not have a “Printed Practitioner’s Name”, a Maryland License number, or a Practitioner’s phone number. The form only had Patient #9’s name. 2. Review on 12/11/2025 of Patient #7’s chart revealed that the “Authorization for and Verification of Consent to Hemodialysis Procedure” was signed but did not have a date to verify when the form was signed. The Facility Administrator was informed of the findings on 12/11/2025.”