Davita Okmulgee Dialysis Center

“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 three of three facility areas (Laboratory area, In-center 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 ensure that staff clearly designated areas, citing two of two facility area (Laboratory area and Peritoneal Dialysis area) for the storage of clean unused supplies and used equipment, in that, equipment were stored and did not indicate if “clean, ready for use,” or dirty. This practice had the potential for harm to all patients and personnel in the facility with possible cross contamination of clean and contaminated supplies and/or equipment. Cross refer to V tag: V 117. 3. The facility failed to ensure that infection control practices for proper infection control techniques for care, maintenance, and disposal of contaminated bio hazard wastes were followed, citing two of two personnel (Personnel #2 and #3) in that used arteriovenous fistula needles and needles were held in their hands and walked in the front of dialysis stations with patients prior to discarding in a bio hazard container/sharps container. This practice placed all patients and staff at risk for cross contamination and/or infection. Cross refer to V tag: V 121. 4. The facility failed to follow standard infection control precautions, citing two of two facility areas (Laboratory area and isolation room) by facility staff not maintaining procedures in accordance with applicable State and local laws and accepted public health procedures in cleaning, and disinfection of contaminated surfaces, medical devices, and equipment. This practice had the potential for creating an environment for the transmission of dangerous pathogens, which placed all patients and personnel at risk of infection. Cross refer to V tag: V 122.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 34689 Based on observation, record review, and interview the facility failed to ensure maintenance of the physical environment which could impact the safety and health of the patients and staff, as evidenced by: Findings included: 1. The facility was not maintained to provide a safe and functional treatment environment, citing, a). two of two facility areas (In center hemodialysis treatment area and water treatment room), and b) two of two patients blocked the facility’s emergency exit doors during their dialysis treatments (Patients #5 and #14). Cross refer to V tag: V 401. 2. The facility failed to ensure that two of two patients (Patients #4 and #6) were provided a safe environment to be able to call for assistance or help when needed during their dialysis treatment in the isolation rooms. Cross refer to V tag: V 402. 3. The facility staff failed to monitor patients’ vascular accesses to ensure patient safety, citing two of two patients (Patients #4 and #14), during patients’ dialysis treatment were not visible to staff. Allowing patients to cover access sites and line connections with blankets provides an opportunity for accidental needle dislodgement or disconnection to go undetected. This practice placed patients of the facility at risk for potential needle dislodgement and/or disconnection which could result in exsanguination and harm. Cross refer to V tag: V 407.”

“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 all staff have an Emergency Preparedness training, citing five of five facility staff (Personnel #2, #3, #6, #12, and #18) 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. Cross refer to E tag: E 0036. 2. The facility failed to ensure patients participate in the quarterly fire drill exercises in 2024, 1) citing three of three fire drill dates (Dates 04/23/24, 7/30/24, and 12/20/24) and 2) the facility failed to ensure fire drill exercises for patients and staff were done in 2025. Cross refer to E tag: E 0039. 3. 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. 4. The facility failed to ensure maintenance of the physical environment which could impact the safety and health of the patients and staff. Cross refer to V tag: V 400.”

“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 and supplies 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 12 of 12 months in 2024 (January, February, March, April, May, June, July, August, September, October, November, and December 2024) and two of two months in 2025 (January and February 2025) in that, the emergency evacuation kit were supplies were not checked and/or reviewed. 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: A review of the Facility Emergency Management Plan Policy dated October 2024, included, “...Emergency Evacuation Kit...1. Each facility will maintain an evacuation kit(s) with specified patient care supplies for use in case of an emergency evacuation...2. The contents of the evacuation kit(s) will include, at a minimum, enough supplies to provide care for a full shift of patients, including home patients, likely to be present in the facility at any given time...7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly...” A review of the facility’s Emergency Evacuation Kit showed no documented evidence facility staff checked and reviewed the contents of the evacuation kit monthly for availability and expiration of supplies and medications in the kit, for 12 months in 2024 and 2 months in 2025. There were no Heparin 1:1000 units/mil vials in the evacuation kits, which are needed to pack patients’ central venous catheters. On 02/27/2025 at 8:30 AM, the manager of clinical services (MCS) confirmed the above findings.”

“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 five of five facility staff (Personnels #2, #3, #6, #12, and #18) 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 Management Emergency Plan Policy dated October 2024, included, “...Training and Education...1. The FA, or designee, is responsible to provide training...a. Teammates...:i. Annually...1. Policy Facility Emergency Management Plan...4. Facility specific emergency response procedures...ii. Quarterly...1. Fire Safety Preparedness...iii. Upon Hire...” A review of the following personnel files on 02/27/2025 showed no documented evidence of emergency preparedness training or testing: 1. Personnel #2 Licensed Practical Nurse (LPN). 2. Personnel #3 Patient Care Technician (PCT). 3. Personnel #6 Registered Nurse (RN). 4. Personnel #12 LPN. 5. Personnel #18 PCT. On 02/27/2025 at 11:15 AM, the manager of clinical services (MCS) (Personnel #11) confirmed the above findings.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 34689 Based on record review and interview, the facility failed to ensure patients participate in the quarterly fire drill exercises in 2024, 1) citing three of three fire drill dates (Dates 04/23/24, 7/30/24, and 12/20/24) and 2) the facility failed to ensure fire drill exercises for patients and staff were done in 2025. Findings included: A review of Facility Emergency Management Plan Policy dated October 2024, included, “...3. Fire safety drills...b. Required on a quarterly basis. c. One drill to be conducted for each shift of patients. f. Document training for both teammates and patients...iii. Teammate attendance sheet...e. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency. f. Document training for both teammates and patients...” 1. A review of the facility’s fire drill reports dated 04/23/24, 7/30/24, and 12/20/24 showed no documented evidence patients were included in the fire drills. 2. There were no documented evidence fire drill exercises were done in 2025. On 02/26/2025 at 2:30 PM, the manager of clinical services (MCS) (Personnel #11) confirmed the above findings. On 02/26/2025 at 12:43 PM, the surveyor conducted an interview with Patient #2 during her dialysis treatment at dialysis station #6. When Patient #2 was asked if she had participated or known of a fire drill exercise in the facility during her treatments, she stated no. When asked how long she had her dialysis treatments here, she stated since end of May 2024. On 02/27/2025 at 7:25 AM, the surveyor conducted an interview with Patient #6 during her dialysis treatment at dialysis station #10. When Patient #6 was asked if she had participated or known of a fire drill exercise in the facility during her treatments, she stated no.”

“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 three of three facility areas (Laboratory area, In-center 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: A review of the facility’s Infection Control For Dialysis Facilities Policy dated April 2023, included, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment...Disinfection #12. Cleaning and/or disinfection of equipment and work surfaces will be performed...” On 02/26/2025 between 12:15 PM - 1:40 PM, the surveyor and facility administrator (Personnel #1) conducted a tour of the facility’s in center hemodialysis treatment area and observed the following: 1. Laboratory area: At 12:15 PM, the cabinet shelf under the sink at the laboratory area was dirty, covered with dark orange sticky substance and grayish - black substance. On 02/26/2025 at 12:20 PM, the facility administrator (Personnel #1) was asked what were the dark orange sticky substance and grayish black substances were, he stated he does not know. 2. In-center hemodialysis treatment area: At 12:30 PM, all of the plexi glass splash guard dividers on top of the nursing stations and sinks that separated the bleach containers and supplies were stained with buildup of whitish substances. At 1:10 PM: - There was greenish/bluish gel sticky substance buildup approximately 6 inches - 6.5 inches in length and 3 inches in width on the floor under the sink #3 (without a cabinet under) across dialysis stations #7 - #8. - The cabinet’s main shelf under sink #4 across dialysis stations #9 - #11, was covered with whitish gel buildup approximately 1 inch - 2 inches thick. - The cabinet’s 4 door hinges were covered with thick dark reddish/orange colored corrossions. On 02/26/2025 at 1:12 PM, the facility administrator (Personnel #1) confirmed the above findings. When asked what the greenish/bluish gel sticky substance on the floor and the whitish gel buildup on the cabinet’s main shelf under the sink were, he stated that he doesn’t know what they were. 3. Peritoneal Dialysis (PD) area: At 1:35 PM, PD room #2 had 3 black non moving insects on the floor behind the door. On 02/26/2025 at 1:37 PM, the manager of clinical specialists (Personnel #11) confirmed the above findings. When asked when PD room #2 was used with patients, she stated that it was on the last clinical visit day, which was this past Monday, 02/24/2025.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure that staff clearly designated areas, citing two of two facility area (Laboratory area and Peritoneal Dialysis area) for the storage of clean unused supplies and used equipment, in that, equipment were stored and did not indicate if “clean, ready for use,” or dirty. This practice had the potential for harm to all patients and personnel in the facility with possible cross contamination of clean and contaminated supplies and/or equipment. Findings included: A review of the facility’s Infection Control For Dialysis Facilities Policy dated April 2023, included, “Facility Hygiene...#16. Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.” 1. Laboratory area: At 12:15 PM: - There were 2 Intravenous (IV) Pump on IV poles did not include a label whether the IV pumps were clean, ready for use or dirty, that were stored in the laboratory area. - There was an Oxygen (O2) concentrator in the laboratory area did not include a label whether clean or dirty that was stored in the laboratory area. On 02/26/2025 at 12:20 PM, the facility administrator (Personnel #1) confirmed the above findings. When the patient care technician (Persopnnel #17) was asked if the IV pumps and O2 concentrator were clean and ready for use, he stated he is not sure. 2. Peritoneal Dialysis (PD) area: At 1:35 PM, PD room #1 included a gray garbage container on top of a clean dialysis recliner. On 02/26/2025 at 1:37 PM, the manager of clinical specialists (Personnel #11) confirmed the above findings. When Personnel #11 was asked if the PD room #1 was clean, she stated that the room was cleaned and that the garbage container should not be on top of the dialysis recliner.”

“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 observation, record review, and interview, the facility failed to ensure that infection control practices for proper infection control techniques for care, maintenance, and disposal of contaminated bio hazard wastes were followed, citing two of two personnel (Personnel #2 and #3) in that used arteriovenous fistula needles and needles were held in their hands and walked in the front of dialysis stations with patients prior to discarding in a bio hazard container/sharps container. This practice placed all patients and staff at risk for cross contamination and/or infection. Findings included: A review of the facility’s Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles Procedure dated April 2023, included, “...8. With safety device engaged, dispose of safety fistula needle in the sharps container...” 1. On 02/26/2025 at 12:26 PM, the surveyor and the facility administrator (Personnel #1) observed the patient care technician (Personnel #3) discontinued Patient #’2 dialysis treatment at dialysis station #1. Personnel #3 removed Patient #2’s arteriovenous fistula (AVF) needle and placed the used AVF needle on top of chairside table, where Patient #2 rested her left arm while holding her AVF site. Personnel #3 picked up the used AVF needle and walked in front of the patient, facility administrator (Personnel #1), and this surveyor, and discarded the AVF needle in the sharps container located between dialysis station #1 and #2. Personnel #3 repeated the same procedure for the removal of the second AVF needle. On 02/26/2025 at 12:29 PM, the facility administrator (Personnel #1) confirmed the above findings. 2. On 02/26/2025 at 1:15 PM, the surveyor observed the Licensed Practical Nurse (LPN) (Personnel #2) discontinued Patient #3’s dialysis treatment using the right central venous catheter (CVC). Personnel #2 flicked the 10 milliliters (ml) Normal Saline (NS) syringe on the side of the patient, used the 10 ml NS syringe to flush the CVC catheter port, flushed the CVC catheter ports with Heparin. Personnel #2 placed the needle from the Heparin syringe on the chairside table, and reconnected the used needle to the 10 ml syringe and placed on top of the chairside table. Personnel #2 repeated the same procedure for the other catheter port. Personnel #2 picked up the 2 10 ml syringes with needles and discarded the used needles in the sharps container located on the far left corner of the isolation room. On 02/26/2025 at 1:27 PM, personnel #2 confirmed the above findings.”

“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: 34689 Based on observation, record review, and interview, the facility failed to follow standard infection control precautions, citing two of two facility areas (Laboratory area and isolation room) by facility staff not maintaining procedures in accordance with applicable State and local laws and accepted public health procedures in cleaning, and disinfection of contaminated surfaces, medical devices, and equipment. This practice had the potential for creating an environment for the transmission of dangerous pathogens, which placed all patients and personnel at risk of infection. Findings included: A review of the facility’s Infection Control For Dialysis Facilities Policy dated April 2023, included, “Purpose: To minimize th spred of infections or bloodborne pathogens in the dialysis facility environment...Disinfection...12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible follwing exposure to blood or other potentially infectious materials...a.iii. Cleaning of visible blood should be performed when first observed...” 1. Laboratory area: On 02/26/2025 at 12:15 PM, the surveyor and facility administrator (Personnel #1) observed dried dark red blood spots on the refrigerator handle and approximately 2 - 3 dark red dried blood spots on the glass shelf inside the refrigerator. - The inside of the refrigerator was dirty with grayish fuzzy sediments on the inside door shelves and on the bottom of the refrigerator. On 02/26/2025 at 12:16 PM, the facility administrator (Personnel #1) confirmed the above findings. When asked who was responsible for cleaning the laboratory refrigerator, he stated the staff were responsible for cleaning the refrigerator. 2. Isolation room: On 02/26/2025 at 1:15 PM, there were approximately 2 dime sized dried cranberry colored stains on top of the sharps container cover. On 02/26/2025 at 1:27 PM, personnel #2 confirmed the above findings.”

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure staff were appropriately trained and/or have an updated skills that are sustained, three of three facility personnel (Personnel #2, #3, and #18) in that, personnel files showed no documented evidence of water dialysate, machine skills training or a current training. These findings have the potential to cause harm to all patients at the facility by the failure to train and evaluate the staff on their knowledge and understanding of the facility water treatment system skills and/or machine equipment procedures and skills. Findings included: A review of the facility’s Teammates Qualifications, Licensure, and Adequate Teammate Staffing Policy dated October 2017 included, “...17. Water Treatment System Technicians Standards: Any teammate who performs monitoring and testing of the water treatment system will complete a training program that has been approved by the medical director and the governing body. On 02/27/2025 at 10:50 AM, the surveyor reviewed facility staff personnel files and the following files did not show documented evidence of the following: 1. Personnel #2 Licensed Practical Nurse (LPN) did not include a water dialysate, machine training. 2. Personnel #3 Patient Care Technician (PCT) showed water dialysate, machine training dated 01/18/24 and did not include a current water dialysate, machine training. 3. Personnel #18 Patient Care Technician (PCT) showed water dialysate, machine training dated 12/30/23 and did not include a current water dialysate, machine training. On 02/27/2025 at 11:15 AM, the manager of clinical specialist (MCS) confirmed the above findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 34689 Based on observation and interview, the facility was not maintained to provide a safe and functional treatment environment, citing, a). two of two facility areas (In center hemodialysis treatment area and water treatment room), and b) two of two patients blocked the facility’s emergency exit doors during their dialysis treatments (Patients #5 and #14). Findings included: A review of the facility’s Physical Environment Policy dated April 2018 included, “Policy...1. The dialysis facility will be...equipped and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable environment. 2. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates, and the public...10. The dialysis facility will store supplies in a manner that is consistent with fire safety and appropriate regulations...” A review of the facility’s Emergency Management Plan (ICHD, HOME) Policy dated October 2024, included, “...5. Evacuation routes shall be, as per local fire code...d. Egress areas (exit to the outside of the building) will have at least 48 inches of clearance, or...e. The egress area must remain clear at all times...” A. On 02/26/2025 at 12:15 PM, the surveyor and facility administrator (Personnel #1) observed the following: 1. In center hemodialysis treatment area: - The hallway floor to the lab and treatment area had dirty grayish stain, with some cracked areas. - There was an approximately softball sized hole on the wall with the insulation out beside dialysis station #12, across the laboratory area. The base boards were broken and peeled off the wall. - The floor on the treatment area from dialysis stations #11, #12, #13, and #14, and nursing counter were dirty with grimy grayish colored stain with some cracked areas. - The drain in the middle of the treatment area across dialysis stations #13 - #15 was stained with grayish colored stain. The cabinet door in the treatment area across dialysis station #6 across the handwashing sink #2 was broken, hinges did not hold the door, cabinet door hung when opened. On 02/26/2025 at 12:25 PM, the facility administrator (Personnel #1) confirmed the above findings. 2. Water Treatment room: On 02/27/2025 at 7:42 AM, the surveyor observed the plastic ceiling tile that covered the lights above the water treatment room included an approximately football sized dark brownish orange stain. On 02/27/2025 at 8:00 AM, the facility administrator (Personnel #1) confirmed the above findings. B. The surveyor and the facility administratorator (Personnel #1) conducted a tour of the facility’s in center hemodialysis treatment area on 02/26/2025 and 02/27/2025, and observed that there’s one facility emergency exit door beside dialysis station #4 was blocked by the dialysis Patient on his dialysis recliner during dialysis treatment. 1. On 02/26/2025 at 12:15 PM, Patient #5 dialyzed at dialysis station #4 and blocked the facility’s emergency exit door. Patient #5 was approximately less than 12 inches away from the emergency exit door. On 02/26/2025 at 12:45 PM, the facility administrator (Personnel #1) confirmed the above finding. 2. On 02/27/2025 at 8:15 AM, Patient #14 dialyzed at dialysis station #4 and blocked the facility’s emergency exit door. Patient #14 was approximately less than 12 inches away from the emergency exit door. On 02/26/2025 at 8:16 AM, the charge nurse (Personnel #6) confirmed the above finding.”

“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: 34689 Based on observation, record review, and interview, the facility failed to ensure that two of two patients (Patients #4 and #6) were provided a safe environment to be able to call for assistance or help when needed during their dialysis treatment in the isolation rooms. Findings included: A review of the facility’s Physical Environment Policy dated April 2018, included, “...Policy...9. Systems to assure patient safety will be in place, such as a method for patients to call for help...” 1. On 02/26/25 at 12:50 PM, the surveyor observed Patient #4 dialyzed alone in the facility’s isolation room. The isolation room did not include a call light or call system that Patient #4 can use when she needed assistance or help. When Patient #4 was asked how she would call for help during her dialysis treatment in this room, she that she would call out. On 02/26/2025 at 1:45 PM, the manager of clinical specialist (Personnel #11) confirmed the above findings. 2. On 02/27/2025 at 7:25 AM, the surveyor observed Patient #6 dialyzed alone in the facility’s isolation room. The isolation room did not include a call light or call system that Patient #6 can use when she needed assistance or help. On 02/27/2025 at 7:26 AM, the charge nurse (Personnel #6) confirmed the above findings.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 34689 Based on observation and interview, the facility staff failed to monitor patients’ vascular accesses to ensure patient safety, citing two of two patients (Patients #4 and #14), during patients’ dialysis treatment were not visible to staff. Allowing patients to cover access sites and line connections with blankets provides an opportunity for accidental needle dislodgement or disconnection to go undetected. This practice placed patients of the facility at risk for potential needle dislodgement and/or disconnection which could result in exsanguination and harm. Findings included: A review of the facility’s Physical Environment Policy dated April 2018, included, “...8. Teammates will be able to visualize patients at all times during hemodialysis treatments for patient safety...” A review of the facility’s Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy dated April 2024, included, “...Intradialytic data collection/assessment...c. The vascular access site, blood line connections, and the patient’s face should be visible throughout the dialysis treatment...” 1. On 02/27/2025 at 8:15 AM, the surveyor observed Patient #14 at dialysis station #4 with whole body covered with a blanket and vascular access covered during his dialysis treatment. 2. On 02/27/2025 at 8:17 AM, the surveyor observed Patient #4 at dialysis station #1 with his whole face covered with a blue fabric during his dialysis treatment. On 02/27/2025 at 8:15 AM and at 8:17 AM, the charge nurse (Personnel #6) confirmed the above findings.”

“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 #7 and #8) who did not have physician’s orders for the provision of care. Findings included: A review of the facility’s Physician Orders for Patient Care Policy dated October 2024, included, “...General...1. Physicians must be credentialed by the facility prior to issuing orders and/or providing services in the facility...4. Orders must be received prior to the delivery of the treatment or service ordered...” A review of the facility’s Routine Support Services Policy dated April 2024, included, “...10. Telephone and...care connect support...include...reviewing of care plan...Addressing patient problems...flowshee/treatment record evaluation...PD access management...11. All support services are documented in the patient’s electronic health record...” 1. Patient #7: On 02/27/2025 at 7:50 AM, the surveyor observed Patient #7’s treatment. Patient #7’s has a right central venous catheter (CVC) and a left arm arteriovenous fistula (AVF) vascular site. One bloodline was connected to the CVC and one bloodline on the left arm AVF vascular site. When the Licensed Practical Nurse (LPN) (Personnel #12) was asked why the CVC and the left arm AVF were both used, she stated this was the first time the left arm AVF vascular site was cannulated. A review of Patient #7’s clinical record showed a letter from a physician (Personnel #13) dated 02/26/2025, included, “...it is ok to access the fistula at this time...” - There was no documented evidence of an order from Patient #7’s physician (Personnel #14) to use and/or cannulate Patient #7’s left arm AVF on 02/27/2025. On 02/27/2025 at 1:30 PM, the manager of clinical services (MCS) (Personnel #11) confirmed the above findings. When asked who Personnel #13 was, she stated Personnel #13 was the surgeon. When asked if Personnel #13 was credentialed in this facility, she stated no. 2. Patient #8: A review of Patient #8’s peritoneal dialysis (PD) clinical records included PD catheter placement date on 10/11/2024 and was first flushed in the facility on 10/16/2024. - There was no documented evidence order from Patient #8’s physician for first flush Patient #8’s PD catheter on 10/16/2024. On 02/27/2025 at 12:50 PM, the manager of clinical services (MCS) (Personnel #11) confirmed the above findings.”

“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 #7 and #10) 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: A review of the facility’s Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy dated April 2024, included, “Note...The scope of practice and other statutes, rules and regulations that impact the practice of the RN, LPN?LVN and PCT may vary among states...Pre treatment...4. Any abnormal findings...outside of any patient specific physician orders...Abnormal findings...unless other abnormal parameters are established...Blood Pressure Pre-dialysis: systolic greater than 180 mm/Hg...Diastolic greater than or equal to 100 mm/Hg...Blood Pressure-intradialytic: systolic greater than 180 mm/Hg or less than 90 mm/Hg...diastolic greater than or equal to 100 mm/Hg...” 1. Patient #7: A review of Patient #7’s treatment sheets included elevated blood pressure readings, as follows: Treatment sheet dated 02/20/2025, included, “...pre treatment vitals...current Blood Pressure (BP) 186/100...5:49 AM BP 188/93...6:19 AM BP 176/100...6:49 AM BP 185/101...7:19 AM BP 178/101...7:49 AM BP 199/106...9:21 AM BP 152/110...” Treatment sheet dated 02/27/2025, included, “...6:41 AM BP 179/100...7:41 AM BP 187/103...8:41 AM BP 159/118...9:11 AM BP 185/105...9:41 AM BP 173/122...Licensed Practical Nurse (LPN) (Personnel #12...” - There was no documented evidence Personnel #12 notified the charge nurse, Registered Nurse (RN) regarding Patient #7’s blood pressure status. - There was no documented evidence facility staff notified Patient #7’s physician (Personnel #14) of elevated blood pressures and/or blood pressure status for orders. A review of IDT Patient Profile Worksheet for Patient #7 included, “...Medications...In-center medication...Clonidine...0.10 milligram, oral, every 4 hours as needed...Personnel #14...11/06/2024...” - There was an order for BP medication and no documented evidence facility staff offered and/or administered medication for elevated BP. On 02/27/2025 at 1:30 PM, the manager of clinical services (MCS) confirmed the above findings. 2. Patient #10: A review of Patient #10’s clinical records included hospitalization from October 2024 - November 2024 and returned to the facility for his dialysis treatment on 12/04/2024. A review of the treatment sheets included elevated blood pressure readings, as follows: Treatment sheet dated 12/04/2024, included, “...3:05 PM BP 148/101...4:33 PM BP 159/117...6:03 PM BP 163/109...6:33 PM BP 174/120...” Treatment sheet dated 02/17/2025, included, “...pre treatment vitals...current standing BP 174/116...current sitting BP 182/125...1:58 PM BP 180/119...2:28 PM BP 151/107...2:58 PM BP 101/82...cuff readjusted...2:58 PM BP 77/52...LPN (Personnel #12)...” There was no documented evidence Personnel #12 notified the charge nurse, Registered Nurse (RN) regarding Patient #10’s blood pressure status. - There was no documented evidence facility staff notified Patient #10’s physician (Personnel #14) of elevated blood pressures and/or blood pressure status for orders. On 02/27/2025 at 2:45 PM, the manager of clinical services (MCS) confirmed the above findings.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 34689 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure the self-monitoring records of one of two home Peritoneal Dialysis patients (Patient #8) was reviewed for completeness and accuracy. Findings included: A review of the facility’s Routine Support Services Policy dated April 2024, included, “...10. Telephone and...care connect support...include...reviewing of care plan...Addressing patient problems...flowsheet/treatment record evaluation...PD access management...11. All support services are documented in the patient’s electronic health record...” Patient #8: A review of Patient #8’s Dialysis Prescription dated 12/16/2024, 01/07/2025, and 02/03/2025, included, “...Peritoneal treatment order Continuous Cycling Peritoneal Dialysis (CCPD)...Frequency...One time a day...” A review of Patient #8’s Homechoice Claria Prescribed Versus Actual Report home Peritoneal Dialysis (PD) treatment sheet 02/01/2025 - 02/26/2025. - There were no documented evidence of PD treatments from 02/13/2025 - 02/23/2025. - There was no documented evidence facilty PD staff reviewed and called to check with Patient #8 if Patient #8 was having a problem or reason for no PD treatments for 10 days. There was no documented evidence of re assessment of patient condition status. On 02/27/2025 at 1:50 PM, Personnel #20 confirmed the above findings.”

“QAPI-ONGOING;USES INDICATORS=IMPROVEMENT CFR(s): 494.110(a)(1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. This Standard is not met as evidenced by: 34689 Based on record review and interview, the facility failed to continuously monitor its performance improvements for hospitalizations, in one of one month of Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (October 2024) and did not analyze and/or track performance to ensure that improvements were sustained over time. Findings included: A review of the facility’s hospitalization logs included 10 patients’ hospitalization reported with diagnoses included, “gastrointestinal bleed, infection access, cardiovascular - fluid overload congestive heart failure, and other unknown.” A review of the facility’s quality assessment and performance improvement (QAPI) meeting minutes for October 2024, dated 11/18/2024 showed no documented evidence of discussion of diagnosis and action plans to help prevent hospitalizations, improve and promote patients’ health outcomes. The interdisciplinary team did not include an ongoing program to track, trend, and develop action plans to achieve measurable improvements in health outcomes and reduction of patient hospitalization with the use of indicators and performance measures associated with improved health outcomes. On 02/27/2025 at 5:10 PM, the facility administrator (Personnel #1) confirmed the above findings.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 34689 Based on record review and interview, the facility failed to continuously monitor its performance improvements for adverse events, in one of one month of Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (October 2024) and did not analyze and/or track performance to ensure that improvements were sustained over time. Findings included: A review of the facility’s adverse events log included, “...10/10/2024 blood loss...10/25/2024 clotted/dysfunction of arteriovenous graft (AVG)...10/31/2024 blood loss less than 500 milliliters (ml)...” A review of the facility’s quality assessment performance and improvement (QAPI) meeting minutes on 11/18/2024 for October 2024 information showed no documented evidence the interdisciplinary team (IDT) trended, tracked, analyzed and developed action plans for the adverse events to ensure improve and promote patients quality of care. On 02/27/2025 at 5:15 PM, the facility administrator (FA) (Personnel #1) confirmed the above findings.”

“PQ-PCT-TRAINING PROGRAM CONTENT CFR(s): 494.140(e)(3) The training program must include the following subjects: (i) Principles of dialysis. (ii) Care of patients with kidney failure, including interpersonal skills. (iii) Dialysis procedures and documentation, including initiation, proper cannulation techniques, monitoring, and termination of dialysis. (iv) Possible complications of dialysis. (v) Water treatment and dialysate preparation. (vi) Infection control. (vii) Safety. (viii) Dialyzer reprocessing, if applicable. This Standard is not met as evidenced by: 34689 Based on observations, record review and interview, the facility staffs personnel files did not have current competencies, citing two of two facility staff (Personnel #2 and #18). Findings included: A review of Personnel #2 a Licensed Practical Nurse (LPN) and Personnel #18 a Patient Care Technician (PCT) showed no documented evidence of current competencies. Personnel #2’s personnel file showed compentencies dated 12/8/23 and Personnel #18’s personnel file showed competencies dated 01/18/24. On 02/27/2025 at 11:15 AM, the manager of clinical specialist (MCS) (Personnel #11) confirmed the above findings”