Davita Shawnee Dialysis Center

“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: 34696 Based on observation and interview, the facility failed to maintain the building in which dialysis services were furnished in three of six areas (Machine Repair area, Storage area, and restroom in the hemodialysis treatment area). Findings: On 06/30/2025 at 8:50 AM, the surveyor observed in the Machine Repair area that the under-counter cabinet had broken and /or used items. The cabinet had an old suction machine, six-one gallon bottles of Ameri Clean A, and a hose. At 9:50 AM, the surveyor further observed that the small Storage area adjacent to the hemodialysis treatment area had not been maintained. There were two sinks in the room that were dirty and contained trash. The floor throughout the area was dirty with stains and had not been cleaned. At 9:55 AM, the surveyor observed that floor in the restroom available for patient use in the hemodialysis treatment area was stained, faded, and porous. The condition of the floor did not allow for effective cleaning. On 06/30/2025 at 10:00 AM, the FA said the staff was responsible cleaning and maintaining the Machine Repair and Storage areas. They said the floor in the patient restroom could not be effectively cleaned.”

“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: 34696 Based on record review and interview, the IDT failed to ensure three of five patient’s (Patient #1, #2, and #4) 1) pre and post treatment BPs were obtained and documented, and 2) and an RN assessed patients’ intradialytic BPs when there was a question. Findings: A review of the “Pre, Intra, Post Treatment Data Collection, Monitoring, Nursing Assessment” policy dated April 2024 showed, “Patient data will be obtained and documented by the PCT or a licensed nurse...” “Data collection includes...” “Measurement of BP...” “Sitting and Standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...” “Intradialytic BP in the sitting/reclined or supine position...” “Heart or pulse rate...” “The nursing assessment will be performed by a licensed nurse; specifically an RN...” “Review of documentation for accuracy, completion, and patient data.” “A physical assessment of the patient which includes...” “Patient statement of well-being, level of pain or discomfort...” “Complaint of...” “cramping...” “Intradialytic Data Collection/Assessment...” “obtain and document the following...” “BP...” “HR...” “Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately...” “the licensed nurse notifies the physician (or non-physician practitioner if applicable) as needed of changes in patient status...” “All findings, interventions and patient response will be documented in the patient’s medical record...” “Post Treatment Data Collection/Assessment.” “The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings.” “Blood pressure-Intradialytic.” “Systolic greater than 180 mm/Hg or less than 90 mm/Hg...” “Diastolic greater than or equal 100 mm/Hg or less than 50 mm/Hg...” “Pre/Intra/Post Patient Reports/Complaints and/or teammate observation of...” “Cramping...” ~ Patient #1: A review of the hemodialysis treatment records dated from 04/04/2025 to 06/06/2025 showed incomplete data. The records showed Patient #1’s “Mobility...” “Ambulates, no assistance needed.” The “Treatment Nurse Assessment” and/or “Post Treatment Vitals” sections did not show documented evidence of Patient #1’s post treatment standing BPs and HRs. The hemodialysis treatment record dated 04/11/2025 showed Patient #1’s intradialytic BP was “79/49.” There was no documented evidence an RN assessed Patient #1’s low BP. The hemodialysis treatment record dated 04/21/2025 showed Patient #1 had low intradialytic BPs. The low systolic BPs ranged from 72 to 78. The low diastolic BPs ranged from 40 to 48. The treatment record showed, “Patient reports lightheadedness.” There was no documented evidence an RN assessed Patient #1’s low intradialytic BPs. ~ Patient #2: A review of the hemodialysis treatment records dated from 06/18/2025 to 06/27/2025 showed incomplete data. The records showed Patient #2’s “Mobility...” “Ambulates, no assistance needed.” The “Treatment Nurse Assessment” and/or “Post Treatment Vitals” sections did not show documented evidence of Patient #2’s post treatment standing BPs and HRs. ~ Patient #4: The hemodialysis treatment record dated 06/12/2025 showed Patient # 4’s treatment was initiated at 10:51 AM. The BP was 162/163. There was no documented evidence the RN was notified for assessment. The RN did not assess until 12:52 PM-two hours later when Patient #4 verbalized “cramping.” There was no documented evidence the RN provided intervention(s) to decrease Patient #4’s cramping. Patient #4 had high intradialytic diastolic BPs that ranged from 114 to 163. There was no notification to the physician for guidance. On 07/01/2025 at 12:30 PM, the FA said there was no documented post standing BPs for Patients #1 ad #2. They said that there maybe a problem with the computers. The FA said whenever there is a problem reported, the RN should assess as soon as possible and document interventions.”

“POC-OUTCOME NOT ACHIEVED-ADJUST POC CFR(s): 494.90(b)(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient’s current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT failed to ensure one of one patient’s (Patient #1) treatment and medical record reflected the patient’s current condition. Findings: ~ Patient #1: On 06/30/2025 at 10:00 AM, during observation of care, it was observed that a hemodialysis treatment chair sat off to the side with various supplies (red hazardous bag, paper scrubs etc). The FA said the supplies were for Patient #1. The FA said Patient #1 had bed bugs. The FA said Patient #1 changes into the paper scrubs and dialyzes in the first chair at the back of the hemodialysis treatment area. On 06/30/2025 at 3:30 PM, the FA said the IDT had not reassessed whether the patient still had bed bugs, but still treated with precaution. On 07/01/2025 at 9:30 AM, the SW said there had been no documentation regarding the bed bugs since 07/2024. On 07/02/2025 at 10:00 AM, the FA said the direct patient care staff had not reported seeing bedbugs. They said reassessments had not been performed and updates to the plan of care had not been documented to reflect Patient #1’s current condition.”

“Establishment of the EP Program Dialysis CFR(s): §494.62 Condition for Coverage: The dialysis facility must comply with all applicable Federal, State, and local emergency preparedness requirements. These emergencies include, but are not limited to, fire, equipment or power failures, care related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. The dialysis facility must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure emergency preparedness program was monitored and updated to meet the health and safety of all patients and staff of the facility during an emergency eventof medical and non-medical emergencies. Cross refer to E tag: E0028. 2. The facility failed to ensure all staff have an Emergency Preparedness training, citing two of two facility staff (Personnel #11 and #16) in that personnel files showed no documented evidence of an Emergency Preparedness training. This practice placed all patients and staff’s safety at risk during an emergency in the facility., as evidenced by: Findings included: 1. The facility failed to ensure that emergency equipment, supplies, and information, were readily available for use and checked for expiration dates to manage medical and non-medical emergencies that are likely to threaten the health and safety of patients, citing two of two facility’s emergency systems (Evacuation box and Evacuation Kit). This practice placed all patients treating in this dialysis facility for potential harm for using an expired IV solutions in management Cross refer to E tag: E0036.”

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 34689 Based on observation, interview, and record review, the facility failed to ensure that infection control practices and techniques were followed and maintained to prevent risk to patient health and safety, as evidenced by: Findings included: 1. The facility failed to ensure that two of two facility areas (In-center hemodialysis treatment area and Peritoneal Dialysis area) provided and monitored a sanitary environment to minimize the transmission of infectious agents within and between the units or other public areas. Cross refer to V tag: V 111. 2. The facility failed to monitor and implement biohazard and infection control policies and activities within the dialysis unit, citing one of one personnel (Personnel #9) verbalized an incorrect and improper procedure of disposal of waste. This practice placed all patients and staff at risk for accidental exposure to chemical concentrate. Cross refer to V tag: V 121. 3. The facility failed to ensure that biohazard and infection control practices were monitored and implemented, 1) citing one of one personnel (Personnel #7) and 2) citing one of one dialysis station (Dialysis station #6) in that, facility staff did not follow infection control practices and/or activities within the unit. This practice placed all patients and staff in the facility at risk for potential harm for infection and/or cross contamination. Cross refer to V tag: V 142.”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 34689 Based on observation, record review and interview, the Interdisciplinary Team (IDT) failed to assess patients according to changes in condition and/or individual patient needs, as evidenced by: Findings included: 1. The facility failed to evaluate the appropriateness of the dialysis prescription, citing two of two dialysis patients (Patients ##9 and #11) who did not have physician’s orders for the provision of care. Cross refer to V tag: V 503. 2. The IDT (Interdisciplinary Team) failed to ensure that each patient’s fluid management and/or status was assessed and/or addressed, citing two of two patients (patient #4 and #5) in that patient Blood Pressures were not evaluated and/or adjusted, the management of which may require reassessment of medication needs, adjustment in target weight, and changes to the Plan of Care. Cross refer to V tag: V 504.”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 34689 Based on record review and interview, the medical director failed to ensure that all policies and procedures relative to patient care, infection control, and safety were adhered to by all individuals who treat patient in the facility, as evidenced by: Findings included: 1. The facility failed to ensure emergency preparedness program was monitored and updated to meet the health and safety of all patients and staff of the facility during an emergency event. Cross refer to E tag: E003. 2. The facility failed to ensure that infection control practices and techniques were followed and maintained to prevent risk to patient health and safety. Cross refer to V tag: V 110. 3. The Interdisciplinary Team (IDT) failed to assess patients according to changes in condition and/or individual patient needs. Cross refer to V tag: V 500.”

“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: 34689 Based on observation, record review, and interview, the facility failed to ensure that emergency equipment, supplies, and information, were readily available for use and checked for expiration dates to manage medical and non-medical emergencies that are likely to threaten the health and safety of patients, citing two of two facility’s emergency systems (Evacuation box and Evacuation Kit). This practice placed all patients treating in this dialysis facility for potential harm for using an expired IV solutions in management of medical and non-medical emergencies. Findings included: On 05/29/2024, the surveyor and the facility administrator (FA) (Personnel #1) 1. At 12:00 PM, a review of the facility’s emergency evacuation box contents showed expired medications and supplies which were available for use when needed for a medical or non medical emergency or a disaster: - 15 1 liter Normal Saline IV bags expiration date October 2023. - 2 2500 milliliters (ml) Dianeal Peritoneal Dialysis (PD) Solution expired 03-03-2024. - PD site cleaner Alcavis expired 07-2023. - Exsept skin cleanser expired 12-15-2023. On 05/29/2024 at 12:28 PM, the facility administrator (FA) (Personnel #1) confirmed the above findings. 2. At 1:30 PM, a review of the Evacuation Kit did not include updated information: - Active Patient census detail period 01/31/2024. - Patient disaster & emergency contact dated 01/31/2024 information. - Patient treatment details report dated 01/31/2024. On 05/29/2024 at 1:40 PM, the FA (Personnel #1) confirmed the above findings. A review of the Facility Emergency Management Plan (ICHD, Home) Policy dated 04/07/01, included, “Emergency Evacuation Kit ...1. Each facility will maintain an evacuation kit ...6. Each Evacuation kit should contain: a. Copy of each patient’s treatment orders and medication list. FA or designed will verify patient information is updated and replaced at least monthly. B. A copy of the facility EMP. Replace with updated plan as needed. C. A roster of all facility teammates emergency contact information. Update information ...7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly ...””

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 34689 Based on record review and interview, the facility failed to ensure all staff have an Emergency Preparedness training, citing two of two facility staff (Personnel #11 and #16) in that personnel files showed no documented evidence of an Emergency Preparedness training. This practice placed all patients and staff’s safety at risk during an emergency in the facility. Findings included: A review of the facility’s Biomed (Personnel #11) and Social Worker’s (Personnel #16) files showed no documented evidence of training for emergency preparedness. A review of the Facility Emergency Preparedness Training Forms dated 06/12/2023 and 12/01/2023 showed no documented evidence that Personnel #11 and #16 attended the training. On 05/31/2024 at 10:10 AM, Personnel #1 confirmed the above findings.”

“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: 34689 Based on observation, record review, and interview, the facility failed to ensure that two of two facility areas (In-center hemodialysis treatment area and Peritoneal Dialysis area) provided and monitored a sanitary environment to minimize the transmission of infectious agents within and between the units or other public areas. Findings included: On 0529/2024 at 12:00 PM - 12:40 PM, the surveyor and the facility administrator (FA) (Personnel #1) conducted a tour of the facility and observed the following: 1. In-Center Hemodialysis treatment area: - At 12:30 PM, the storage room for supplies was clutterred with boxes of supplies and the ceiling were missing ceiling tiles and was covered with black plastic garbage bag. When personnel #1 was asked what happened to the ceiling, she stated that they had a water leak from the air conditioner last week. - The cabinet under the designated clean sink outside the storage room was dirty with the whole cabinet base covered with thick sticky greenish gelatinous stain and yellowish stain. - The refrigerator that stored blood specimens was dirty with black/grayish sediments and dust. - The wall by the fire extinguisher was stained with reddish/brownish drips. On 05/29/2024 at 12:35 PM, personnel #1 confirmed the above finding. 2. Peritoneal Dialysis (PD) area: - At 12:40 PM, the cabinet under the sink inside the Exam Room of the PD home program unit was dirty with crusted yellowish buildup stain. On 05/29/2024 at 12:42 PM, personnel #1 confirmed the above findings. 3. During a tour of the in-center hemodialysis treatment area on 05/30/2024 at 10:30 AM, the surveyor and the manager of clinical specialist (MCS) (Personnel #6) observed an approximately dime sized red stain on top of the cover of sharps container at dialysis station #6, during a patient’s dialysis treatment. At 10:38 AM, the bloodlines during the patient’s dialysis treatment was inside the red trash container at dialysis station #6. On 05/30/2024 at 10:38 AM, Personnel #6 confirmed the above findings. A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 02/07/2022, included, “All areas must be kept clean and organized...facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff.” A review of the facility’s Infection Control for Dialysis Facilities POlicy dated April 2023, included, “...Supplies. 8. Supplies will be stored in a manner that maintains their integrity...d. Anytime the integrity of a package...is in question, i.e., torn...wet or contaminated, the package and its contents must be disposed of and not used...””

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 34689 Based on interview and record review, the facility failed to monitor and implement biohazard and infection control policies and activities within the dialysis unit, citing one of one personnel (Personnel #9) verbalized an incorrect and improper procedure of disposal of waste. This practice placed all patients and staff at risk for accidental exposure to chemical concentrate. Findings included: On 05/30/2024 at 10:45 AM, the surveyor and the manager of clinical specialist (MCS) (Personnel #6) observed a jug of Minncare attached to the facility’s Continuos Water Processing (CWP) system unlabeled as to the date, time as to when the Minncare was opened and an initial of the staff who opened the jug of Minncare. When a certified clinical hemodialysis technician (CCHT) (Personnel #9) was asked what happens when the Minncare jug needed to be changed, where do they throw and what the process was to discard the jug of Minncare, she stated we throw the used jug on the gray garbage can. When asked what is done when there’s Minncare left over in the jug, she stated, we throw the jug in the gray garbage can. On 05/30/2024 at 10:50 AM, personnel #6 confirmed the above findings. A review of the facility’s Disposal of Peracetic Acid and CM130 Reagent Containers Policy dated April 2019, included, “...Notes: Prior to disposal of any empty original manufacturer containers, the containers must be rinsed. This applies to quart/gallon or smaller containers...Procedure...1. Put on Personal Protective Equipment (PPE) Rationale: Exposure to chemical concentrate may cause chemical burns to eyes or skin...2. Turn on dialysis quality or tap water to dilute the residual chemicals as it flow down sink drain...4. Rinse the container three (3) times with dialysis quality or tap water to remove all traces of chemical. Rationale: Rinsing emptied chemicals containers is needed to protect waste handlers from accidental exposure...6. Discard rinsed and emptied chemical concentrate container in waste receptacle...””

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure that biohazard and infection control practices were monitored and implemented, 1) Citing one of one personnel (Personnel #7) and 2) citing one of one dialysis station (Dialysis station #6) in that, facility staff did not follow infection control practices and/or activities within the unit. This practice placed all patients and staff in the facility at risk for potential harm for infection and/or cross contamination. Findings included: 1. On 05/29/2024 at 10:50 AM, the surveyor observed the Patient Care Technician (PCT) (Personnel #7) at dialysis station #1, removed the arteriovenous fistula (AVF) needle from Patient #2’s left upper arm AV fistula, pulled out the AVF needle, applied the safety device of the AVF needle halfway with half of the needle uncovered, discarded in the sharps container and splattered drops of blood on the top of the sharps container. At 11:20 AM, Personnel #7 repeated the procedure above. On 05/29/2024 at 11:25 AM, Personnel #7 confirmed the above findings. 2. On 05/30/2024 at 10:35 AM, the surveyor observed the blood drop approximately dime sized red blood on top of sharps container at dialysis station #6. On 05/30/2024 at 10:38 AM, personnel #6 confirmed the above findings. A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 02/07/2022, included, “Contaminated needless/sharps...during use, sharps containers shall be...easily accessible and located as close as is feasible to the immediate area where sharps are used...contaminated sharps shall be discarded immediately...other regulated waste...regulated waste shall be placed in a container that is accordance with...bloodborne standard...is closeable, leak proof...closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport...” A review of the facility’s Post Treatment Fistula Needle Removal Procedure dated 07/06/21, read in part, “...Background...Incorrect needle removal technique can result in difficulty achieving hemostasis, potential injury to the access and increase the risk of contaminated needlestick to patients and staff...procedure...6. carefully remove...engage safe needle device per manufacturer’s directions...discard the needle in sharps container...” A review of the facility’s Infection Control for Dialysis Facilities POlicy dated April 2023, included, “... Disinfection. 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible...””

“CARBON ADSORPTION-10 MINUTES EBCT CFR(s): 494.40(a) 5.2.5 Carbon adsorption: 10 min EBCT Refer to RD62:2001, 4.3.9 Carbon adsorption media: When granulated activated carbon is used as the adsorption medium ... each adsorption bed shall have an [empty bed contact time] EBCT of at least 5 minutes at the maximum product water flow rate (a total EBCT of at least 10 minutes). This Standard is not met as evidenced by: 34689 Based on observation and interview, the facility failed to ensure that staff testing for the chlorine/chloramines were knowledgeable of what the carbon tanks do, 1) citing one of one staff member (Personnel #9) in that staff did not know what the empty bed contact time of the carbon tanks were, what empty bed contact time (EBCT) meant, and/or where to find the information; and 2) the facility’s carbon tank was labeled for a different facility. Findings included: On 05/30/2024 at 10:45 AM, the surveyor and the manager of clinical specialist (MCS) (Personnel #6) observed the certified clinical hemodialysis technician (CCHT) (Personnel #9) checked the facility’s water treatment supply for total Chlorine. When asked what the facility’s empty bed contact time (EBCT) was and what EBCT meant, she stated that she did not know. The posted label on the facility’s carbon tank read, “EBCT- DaVita Paul’s Valley.” On 05/30/2024 at 10:46 AM, personnel #9 confirmed the above findings. A review of the facility’s Water Treatment Systems Minimum Component Requirement Policy dated October 2021, included, “...Purpose: To identify the appropriate water treatment system components utilized to prepare dialysis quality water...Policy...16. Carbon filters are required...All carbon tanks will be labeled with the type of carbon, amount of cubic feet installed...EBCT...””

“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: 34689 Based on observation, record review and interview, the facility failed to evaluate the appropriateness of the dialysis prescription, citing two of two dialysis patients (Patients ##9 and #11) who did not have physician’s orders for the provision of care. Findings included: 1. Patient #9: On 05/30/2024 at 7:30 AM, when the facility administrator (Personnel #1) was asked who the patient was that the facility observed for bed bug, she stated, Patient #9. When Personnel #1 was asked when did staff bed bug on patient, she stated that staff found it on 01/23/2024. A review of Patient #9’s clinical records showed no documented evidence physician #13 was notified of Patient #9 having bed bugs. No documented evidence orders to place on bed bug protocol. A review of patient note dated 01/24/2024, included, “..team reported bed bug on patient during treatment (tx) on Tuesday 01/23/2024. Attempted to reach out to patient today...to discuss bed bug protocol, education...Personnel #1...” Treatment sheets dated 01/23/2024 - 01/27/2024 showed no documented evidence of assessment or reassessment of presence or absence of bed bug. No documented evidence of facility staff observed and/or maintained bed bug protocol to prevent the spread of bed bug and to protect other patients and staff from the spread of bed bug. There was no documented evidence of reassessment if bed bug was still present or absent. On 05/30/2024 at 5:45 PM, Personnel #1 confirmed the above findings. On 05/31/2024 at 8:50 AM, the surveyor conducted an interview via telephone with the Nurse Practitioner (Personnel #17) and when asked if she knew of the patient’s bed bug issue, she stated, no and that she hadn’t noticed Patient #9 wearing paper gowns during dialysis treatment. 2. Patient #11: A review of Patient #11’s clinical record showed Patient #11 was hospitalized from 05/02/2024 - 05/16/2024 and returned to the facility for dialysis treatment on 5/17/2024. Treatment sheet dated 05/17/2024 included, “...Pre treatment vitals...sitting Blood Pressure (BP) 131/71 Heart Rate 71 beats per minute (BPM)...1:43 PM...treatment started without complications...Heparin infusion started...Registered Nurse (RN) (Personnel #2)...4:40 PM...treatment ended...Patient Care Technician (PCT) (Personnel #9)...” There was no documented evidence facility staff called Patient #11’s physician for orders or clarification of hemodialysis orders post hospitalization. On 05/30/2024 at 5:33 PM, Facility Administrator (FA) (Personnel #1) confirmed the above findings. A review of the facility’s Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy dated April 2024, included, “...Pre treatment data collection/assessment...4. Any abnormal findings or findings outside of any patient specific physician ordered parameters...the nurse will assess the patient prior to to the initiation...Abnormal findings...Hospitalization...report of medical procedures, trips to the ER, urgent care or admission to hospital...” A review of the facility’s Ectoparasitic Infestations (Fleas, Lice, Common Bed Bugs) Management Policy dated April 2024, included, “Purpose: To provide guidance for the care of the patient who exhibits possible signs and symptoms of flea or bed bug infestation ...Policy: 1. Transmission Based Precautions: a. Implement and discontinue additional precautions in consultation with Physician. B. Additional precautions include ...Patient placement/distancing ...personal items (e.g., overcoat) brought to the facility by the patient should be bagged and returned to the patient at the end of the treatment ...supplies/equipment ...separate patient supplies, including stethoscope ...label for this patient only ...3. Reporting: a. Patients reporting or exhibiting signs or symptoms of an ectoparasitic infestation must immediately be reported to the Medical Director and attending Nephrologist. B. Report to state, county or local health authorities in accordance with local regulations ...Common Bed Bugs ...Patients who exhibit possible signs ...of bed bug infestation may require in information about the need for home pest control services ...Social Worker intervention (e.g., resource referral) may be indicated. The frequency of the dialysis facility pest control services/inspections may need to be temporarily increased until the situation is resolved or the patient is no longer dialyzing in the facility ...””

“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: 34689 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure that each patient’s fluid management and/or status was assessed and/or addressed, citing two of two patients (patient #4 and #5) in that patient Blood Pressures were not evaluated and/or adjusted, the management of which may require reassessment of medication needs, adjustment in target weight, and changes to the Plan of Care. Findings included: 1. Patient #4: A review of Patient #4’s clinical records showed the following: Treatment Parameters Orders, “Heart Rate (HR) Pre-treatment (Tx) may start with HR above 100 Beats per minute (BPM)...May start with HR below 100 BPM...Post Tx may leave with HR above 100 BPM...post tx may leave with HR below 100 BPM...” Medication Order: Clonidine 0.1 milligram (mg) start date 02/29/2024. Treatment sheets showed elevated BP, included, “...dated 05/04/24 pre tx BP 162/109, post tx BP 180/124, HR 105...dated 05/07/24 pre tx 192/132, during tx 198/145, 206/138...dated 05/28/24 BP 167/118...” There were no documented evidence facility staff administered Clonidine or offered Clonidine for high blood pressure. There were no documented evidence facility staff called and notified the physician #13 of patient #4’s Blood Pressures. On 05/30/2024 at 3:10 PM, Personnel #1 confirmed the above findings. 2. Patient #5: A review of Patient #5’s clinical records showed the following: Treatment Parameters Orders, “Blood Pressure (BP) Systolic...Pre-Treatment (Tx) May dialyze above Systolic BP 190...post treatment Post May leave above SBP 190...BP Diastolic: pre-treatment Diastolic above Diastolic BP 110...post tx may leave with above DBP 110...” Medication Order: Clonidine 0.1 Milligram (mg) start date 02/12/2024...provider instructions: If no blood pressure response notify provider...” TX sheets dated 04/09 BP 131/104, BP 133/115, 04/10 BP 131/104, 1, 134/108, 125/106, 04/11 BP 136/112, BP 146/119, Heart Rate (HR) 107, BP 139/117, 161/100, 164/109. A review of the treatment sheets dated 05/14/24 - 05/18/24 Patient #5 experienced elevated blood pressure pre, during, and/or post dialysis treatments. There were no documented evidence facility staff administered Clonidine or offered Clonidine for high blood pressure. There were no documented evidence facility staff called and notified the physician #12 of patient #5’s Blood Pressures. On 05/30/2024 at 4:10 PM, Personnel #1 confirmed the above findings.”