Davita South Dean Dialysis
A dialysis facility in Englewood, New Jersey 07631
100 West Forest Avenue, Ste G, Englewood, New Jersey 07631. (201) 816-9740.
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The short answer
Record last released by CMS on Oct 14, 2026.
- 4of 5 CMS’s star rating
- Not rated patient survey rating
- 1 deficiency cited in the last three years
- 19 dialysis stations
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on May 31, 2024: a standard inspection.
1 deficiency cited in the last three years.
CMS, QCOR Dialysis Facility (ESRD) 2567 statements of deficiencies. Released Oct 14, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited May 2024. Most serious: Standard-level. The last 3 years, to Oct 19, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Dialysis Facility (ESRD) 2567 statements of deficiencies. Released Oct 14, 2026. Updated monthly.
May 31, 2024: standard inspection1 deficiency
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Ic - Clean, Disinfect Surfaces & Equipment/Written Protocols
The inspectors’ words, 478 words
“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: 35949 Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each dialysis treatment in 3 of 3 stations observed (Stations 13, 14, and 16). This failure could potentially serve as a vehicle for transmission of infectious disease and negatively impact the safety and wellbeing of the patients who received dialysis treatments at this facility. Findings included: During an observation of the hemodialysis treatment area on 05/31/2024 at 9:30 AM, with the Facility Administrator, Registered Nurse (RN) #4 disinfected Station 16. RN #4 failed to disinfect the intravenous (IV) pole prongs, the blood pressure (BP) cuff storage basket on the left side of the dialysis machine, and the stethoscope stored on the IV pole prongs. During an observation of the hemodialysis treatment area on 05/31/2024 at 9:40 AM, with the Facility Administrator, RN #5 disinfected Station 13. RN #5 failed to disinfect the IV pole prongs, the BP cuff storage basket on the left side of the dialysis machine, and the stethoscope stored on the IV pole prongs. During an observation of the hemodialysis treatment area on 05/31/2024 at 10:07 AM, with the Facility Administrator, Patient Care Technician (PCT) #7 disinfected Station 14. PCT #7 failed to disinfect the BP cuff storage basket on the left side of the dialysis machine. During an interview on 05/31/2024 at 9:45 AM, RN #4 acknowledged the IV pole prongs, the BP cuff storage basket, and the stored stethoscope were not disinfected in Station 16. During an interview on 05/31/2024 at 10:00 AM, RN #5 acknowledged the IV pole prongs, the B/P cuff storage basket, and the stored stethoscope were not disinfected in Station 13. During an interview on 05/31/2024 at 10:05 AM, the Facility Administrator confirmed all environmental surfaces in the dialysis treatment stations should be disinfected after each dialysis treatment. During an interview on 05/31/2024 at 10:15 AM, PCT #7 confirmed the BP cuff storage basket, was not disinfected in Station 14. A facility policy titled, “Infection Control for Dialysis Facilities,” revised in 04/2023, indicated, “13. At the end of each treatment, the dialysis station/training will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. [exempli gratia, for example], dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops).” N.J.A.C. 8:43A-24.4(a)”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| May 31, 2024 | Standard inspection | 1 deficiency cited |
Is it certified?
- Medicare-certified dialysis facility, certified or last recertified on Nov 13, 2019.
- Run for profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Chain: DaVita.
CMS, Dialysis Facility - Listing by Facility. Released Jul 15, 2026. Updated quarterly.
CMS, QCOR Dialysis Facility (ESRD) 2567 statements of deficiencies. Released Oct 14, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for dialysis facilities.
- None of the deficiencies cited in the last three years came from an inspection that included a complaint investigation.
CMS, QCOR Dialysis Facility (ESRD) 2567 statements of deficiencies. Released Oct 14, 2026. Updated monthly.
What does it offer?
- Offers in-center hemodialysis.
- Doesn’t offer peritoneal dialysis, home hemodialysis training and a shift starting at 5 p.m. or later.
- 19 dialysis stations.
- CMS doesn’t publish staffing levels for dialysis facilities.
CMS, Dialysis Facility - Listing by Facility and Patient survey (ICH CAHPS) - Facility. Released Jul 15, 2026. Updated quarterly.
Who owns it?
- Part of the DaVita chain, as CMS lists it.
- CMS publishes no owners file for dialysis facilities, so no other owner is named.
CMS, Dialysis Facility - Listing by Facility. Released Jul 15, 2026. Updated quarterly.
How do patients fare?
- CMS rates it 4 of 5 stars (Jan 1, 2021 to Dec 31, 2024).
- Compared by CMS with what it expects for the facility’s patients: patient survival, as expected; hospital admissions, as expected; readmissions to hospital, as expected; emergency department visits, as expected; emergency department visits within 30 days of a hospital stay, as expected; bloodstream infections, better than expected; patients dialysing through a fistula, as expected; patients put on a kidney transplant waitlist in their first year of dialysis, better than expected; patients on a kidney transplant waitlist, as expected.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “Too few completed survey responses to report.”
CMS, Dialysis Facility - Listing by Facility and Patient survey (ICH CAHPS) - Facility. Released Jul 15, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Star ratingCMS’s star rating for dialysis facilities, 1 to 5 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the facility’s in-center hemodialysis patients (ICH CAHPS), 1 to 5 | Not rated |
How does it compare nearby?
- Of the 16 dialysis facilities CMS lists in Bergen County, 15 have a star rating from CMS: 9 rated 5 of 5, 4 rated 4 of 5, 1 rated 2 of 5, 1 rated 1 of 5.
- CMS rates this one 4 of 5.
CMS, Dialysis Facility - Listing by Facility. Released Jul 15, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for dialysis facilities, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- QCOR says it has no dialysis inspection reports after February 19, 2026, while it moves to a new system: a later inspection is not shown yet.
- CMS doesn’t publish staffing levels for dialysis facilities.
- CMS publishes no owners file for dialysis facilities: the chain it lists is the only owner named.
Sources
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Centers for Medicare & Medicaid Services, Dialysis Facility - Listing by Facility (23ew-n7w9).
Released Jul 15, 2026 and checked Oct 19, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (ICH CAHPS) - Facility (59mq-zhts).
Released Jul 15, 2026 and checked Oct 19, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Dialysis Facility (ESRD) 2567 statements of deficiencies (ESRD_2567s_2018_to_2026YTD.xlsx).
Released Oct 14, 2026 and checked Oct 19, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 19, 2026.
From the facility
The public record above comes first. Anything the facility adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the facility will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the facility”, and paying will never change a finding, a rating or the order of results.