Davita Ardmore Dialysis Ranch

“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 was readily available to manage medical and non-medical emergencies that are likely to threaten the health and safety of patients, citing one of two emergency evacuation cart (In-center hemodialysis Emergency Evacuation Cart) included 1) expired supplies and medications available for use during an emergency in the facility, and 2) evacuation kit cart list and supplies have not been reviewed and checked for the year 2025. Findings included: A review of the facility’s Facility Emergency Management Plan (INCHD, HOME) 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...7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly...” 1. On 05/05/2025 at 11:25 AM, the surveyor and Personnel #1 opened the in-center hemodialysis (INCHED) emergency evacuation cart and observed expired medications and supplies, as follows: - 4 vials of Heparin 30,000 units per 30 milliliters (ml) expiration date 04/2025. - 38 pieces of 10 ml syringes expiration date 12/31/2024. On 05/05/2025 at 11:35 AM, Personnel #1 stated that the expired medications and supplies will be removed and replaced with unexpired medications and supplies. 2. A review of the facility’s Emergency Evacuation Kit Checklist, included, “Quarter (Q) 4 2024...date completed 12/2/24...teammate signature...Personnel #2...” On 05/05/2025 at 1:40 PM, Personnel #2 stated that they did not find evacuation checklist log that was checked and done for the year 2025.”

“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 one of one facility areas (Dialysis station #28) 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 minize the spread of infections or bloodborne pathogens in the dialysis facility environment...Disinfection...13. At the end of each treatment, the dialysis station/training room will be cleaned and disinfected. a. surfaces to disinfect include but are not necessarily limeted to...control panel...countertops...b. Dialysis stations...clean or disinfect the station and set up for the next patient...” On 05/05/2025 at 10:30 AM, the surveyor and Personnel #1 observed dialysis station #28 designated as the isolation room, included the following: - Cluttered with 2 neddles on the floor. -The floor was dirty with thick caked in whitish crusted substance under the coutner. - There was a dark sticky brownish reddish substance by the dialysis machine. - There was a white plastic jug covered with grayish fuzzy hair sediments. - The wall inside the isolation room had paint peeled off on 9 areas of the wall. On 05/05/2025 at 10:40 AM, Personnel #1 stated facility staff should clean the dialysis station after each treatment. When asked when this dialysis station #28 was last used for a dialysis treatment, she stated that she did not know when it was used.”

“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 were sustained, two of two facility personnel (Personnel #3 and #15) 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 Personnel #3 and #15’s personnel files showed no documented evidence of a current dialysis quality water systems training. Personnel #3’s clinical education & training certificate dated on 03/22/2024. Personnel #15’s clinical education & training certificate dated on 03/14/2024. On 05/12/2025 at 2:45 PM, Personnel #2 stated that those were the only training certifications that she have.”

“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 record review, and interview, the facility failed to evaluate the care received based on the dialysis prescription, citing one of one dialysis patient (Patient #9) who did not have physician’s orders for the provision of care. Findings included: A review of the facility’s Ectoparasitic Infestations (Fleas, Lice, Common Bed Bugs) Management Policy dated April 2024, included, “...Policy...1. Transmission based precautions: a. Implement and discontinue additional precautions in consultation with Physician. b. Additional precautions include...gown...separate long sleeved garment that is removed and discarded after caring for the patient...supplies/equipment...separate patient supplies, including stethoscope...duration...temporary until the situation is resolved...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...” Patient #9: A review of Personnel #4’s documented notes on 07/24/2024 and 01/31/2025, showed Patient #9 had issues with bed bugs, as follows: - Patient Note dated 07/24/2024, included, “Master of Social Work (MSW) went over bed bug resources with patient (pt). Pt stated they are spraying...” - MSW Quarterly Progress Note dated 01/31/2025, included, “Pt still dealing with bed bugs at home. Pt brings minimal items with him to treatment (tx) but teammates still find them on pt...” A review of Patient #9’s clinical records showed no documented evidence of facility staff’s assessment, reassessment of Patient #9’s condition status regarding presence or absence of bed bugs. There was no documented evidence facility staff notified Patient #9’s physician (Personnel #10) of condition status regarding assessment or reassessment of presence of bed bugs. There were no documented evidence of orders to observe bed bug protocol and/or remove Patient #9 off bed bug protocol. A review of Patient #9’s Hemodialysis Treatment Orders dated 05/12/2024 - 05/12/2025 and Ancillary Orders dated 01/01/2025 - 05/12/2025 did not include orders to observe bed bug protocol and/or to maintain bed bug protocol precautions. A review of Patient #9’s Treatment Detail Report dated 05/05/2025 - 05/09/2025 showed no documented evidence facility staff observed and maintained bed bug protocol precautions during dialysis treatments. On 05/12/2025 at 1:30 PM, the surveyor conducted an interview with Personnel #10. When asked if he was aware Patient #9 had bed bugs, he stated he was not aware Patient #9 had bed bugs. On 05/12/2025 at 1:40 PM, Personnel #2 stated that she did not find orders for bed bug protocol and did not find facility staff documented if Patient #9 was reassessed for presence or absence of bed bug, and if facility staff maintained bed bug protocol.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 34689 Based on record review and interview, the Interdisciplinary Team (IDT) failed to provide the necessary care and services to manage the volume status, citing one of one patient (Patient #8). Findings included: A review of the facility’s Physician’s Order for Patient Care Policy dated October 2024, included, “...4. Orders must be received prior to the delivery of the treatment or service ordered...Protocol...18...are not simply practice guidelines, they are patient specific and when ordered by a physician...the protocol becomes part of the order...19. If the physician orders deviate from the protocols the order source should not be protocol but one of the other order source options defined by this policy..” Patient #8: A review of Personnel #4’s Notes dated 03/17/2025, included, “Patient (Pt) stated he went to the emergency room (ER) today for chest pain and was told it was fluid related. Pt has 10 kg of fluid on after doing extra last week...” A review of Patient #8 Treatment Details Report dated 05/05/2025, 05/07/2025, and 05/09/2025, showed pre dialysis weight gains of 11.3 kilogram (kg) - 18.7 kg over ordered target weight (TW) of 141.0 kg. and post dialysis weights of 7.7 kg - 14.0 kg over TW. - Treatment Details Report dated 05/05/2025, included, “...Pre treatment fluid calculations...ordered target weight 141.0 kg...target weight last updated 01/13/2025...pre weight 159.7 kg...difference from target weight 18.7 kg... treatment nurse assessment...observations...pre shortness of breath...post treatment weight...scale port weight 155.0 kg...difference from target 14.0 kg...treatment nurse assessment...observations...pre shortness of breath...post...no complaints...discharge status...discharge to home...” - Treatment Details Report dated 05/07/2025, included, “...Pre treatment fluid calculations...ordered target weight 141.0 kg...target weight last updated 01/13/2025...pre weight 155.9 kg...difference from target weight 14.9 kg... treatment nurse assessment...observations...pre diminished (lower left) diminished (lower right)...post treatment weight...scale port weight 152.0 kg...difference from target 11.0 kg...treatment nurse assessment...observations...pre diminished (lower left) diminished (lower right)...shortness of breath...” - Treatment Details Report dated 05/09/2025, included, “...Pre treatment fluid calculations...ordered target weight 141.0 kg...target weight last updated 01/13/2025...pre weight 155.9 kg...pre treatment nurse assessment...shortness of breath upon exertion, wheezes...post treatment nurse assessment...diminished lower left, diminished lower right...upper right...post treatment weight...scale port weight 152.0 kg...difference from target 11.0 kg...” The Treatment Detail Reports dated 05/05/2025, 05/07/2025, and 05/09/2025 showed Patient #4 was symptomatic with diminished breath sounds and showed no documented evidence facility staff notified Personnel #10 of Patient #4’s condition status of weight gains 11.3 kg -18.7 kg pre dialysis and 7.7 kg - 14.0 kg post dialysis. There was no documented evidence facility staff notified Personnel #10 of 14.0 kg over target weight post treatment on 05/05/2025 (Friday) to obtain orders for extra treatment and/or condition status report. On 05/13/2025 at 11:20 AM, Personnel #9 stated that there were no documentation that facility staff that they notified the physician regarding Patient #4’s weight gains.”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to perform routine testing for the HBV (Hepatitis B virus) and promptly review results for seven of 105 patients (Patients #7, #8, #9, #10, #11, #12, and #13). Findings included: A review of the “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” policy dated April 2024 included, “Purpose...To prevent the spread of Hepatitis B in the dialysis setting...All patients will be routinely tested as required by the schedule for routine surveillance testing for Hepatitis B virus...Admission Screening utilizing facility baseline/admit results...Antigen...Negative...Total Core...Negative...Antibody...less than ten...Status...Susceptible Next steps...Offer vaccination series...Routine Surveillance Testing...Antigen...Negative...Core...Negative...Antibody...less than 10...Status...Susceptible...Surveillance Testing...Monthly antigen...Antigen...Negative...Core...Negative...Antibody...greater than or equal to 10...Status...immune due to vaccination...Annual antibody....Hepatitis B Vaccination...An order will be obtained for Hepatitis B vaccination...The patient will consent to the vaccination or decline...Patients who start hemodialysis may have a history of vaccination against Hepatitis B. These persons should have responded to the vaccine when their immune status was normal, but if their Hepatitis B surface antibody levels are less than 10 mIU/mL (mill-international units per milliliter) when they begin dialysis, they should be revaccinated with a complete primary series...On annual retesting of immune patients due to vaccination, HbsAb less than ten mIU/mL, with nephrologist order, administer a booster dose of vaccine...If the HbsAb is less than ten mIU/mL following the booster dose, no subsequent/future doses of vaccine will be provided. Patient will be considered a non-responder and managed as a susceptible patient.” ~ Patient #7: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated, “Hepatitis B Serological Status...HBV Susceptible/HbsAb (Hepatitis B Surface Antibody) less than 10 on 01/05/2024.” There was no docuented evidence the monthly HbsAg (Hepatitis B Surface Antigen) was tested in February 2024. On 04/30/2024 at 9:40 AM, the FA (Facility Administrator, Personnel #3) said the lab was cancelled. ~ Patient #8: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated Patient #8’s HbsAb was less than three from August 2021 to February 2024. The HbsAg was negative from November 2023 to April 2024. There was no documented evidence Patient #8 was offered the Hepatitis B vaccination series. ~ Patient #9: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated, “Hepatitis B Serological Status...HBV Susceptible/HbsAb (Hepatitis B Surface Antibody) less than 10 on 12/14/2023.” There was no docuented evidence the monthly HbsAg (Hepatitis B Surface Antigen) was tested in January 2024, February 2024, and March 2024. On 04/30/2024 at 10:00 AM, the FA said the labs were missed. ~ Patient #10: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated, Patient #10’s HbsAb was less than three from November 2022 to February 2024. The HbsAg was negative from November 2023 to April 2024. There was no documented evidence Patient #10 was offered the Hepatitis B vaccination series. ~ Patient #11: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated, Patient #11’s HbsAb was less than 10 from June 2022 to February 2024. The HbsAg was negative from November 2023 to April 2024. There was no documented evidence Patient #11 was offered the Hepatitis B vaccination series. ~ Patient #12: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated, Patient #12’s HbsAb was less than three in February 2024. The HbsAg was negative from February 2024 to April 2024. The report further indicated the “Hepatitis B Serological Status...HBV Susceptible/HbsAb (Hepatitis B Surface Antibody) less than 10 on 03/24/2024.” There was no documented evidence Patient #12 was offered a booster of the Hepatitis B vaccine. ~ Patient #13: The “Vaccinations and Surveillance Report” dated 04/29/2024 indicated, Patient #13’s HbsAb was less than three in February 2024. The HbsAg was negative from February 2024 to April 2024. The report further indicated the “Hepatitis B Serological Status...HBV Susceptible/HbsAb (Hepatitis B Surface Antibody) less than 10 on 12/11/2024.” There was no documented evidence Patient #13 was offered a booster of the Hepatitis B vaccine. On 04/30/2024 at 10:30 AM, the FA said Patients #8, #10, and #11 did not have documented evidence the Hepatitis B vaccine series was offered to them. The FA said there was no documented evidence Patients #12 and #13 were offered the Hepatitis B vaccine booster.”

“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 to ensure the safety of the patients, staff, and the public in three of five areas (Home Therapies area, Lab area, and In-center treatment area) that were not maintained free from defects and/or hazards. Findings included: On 03/29/2024, the following was observed: ~ At 9:15 AM, it was observed in the Lab area of the Home Therapies program that the counter top surrounding the sink was faded, porous, and did not allow for effective cleaning and disinfection. It was observed in Home Therapies room #1 that the counter top surrounding the sink was faded, porous, and did not allow for effective cleaning and disinfection. It was observed in HHD (home hemodialysis) room #2 that the under-counter cabinet was not clean. The inside bottom of the cabinet was stained with a brownish rust like substance. On 04/29/2024 at the time of the findings, the Home Therapies RN (Registered Nurse, Personnel #2 said the counters were faded and porous. ~ At 9:30 AM, it was observed that the “Dirty” sink in the Lab area near the storage area was splattered with white stains. It was further observed that the counter top surrounding the sink was faded, porous, and did not allow for effective cleaning and disinfection. ~ At 9:55 AM, it was observed in the ICHD (In-center hemodialysis) treatment area that the counter tops surrounding the sinks near stations #10 and #12 were faded and porous. It was further observed that the wood on the outside of the under counter cabinets did not have the protective coating, and was faded and porous. The surfaces of the sinks and cabinets did not allow for effective cleaning and disinfection. On 04/29/2024 at 10:00 AM, the Facility Administrator (Personnel #3) said the counters and cabinets were faded and porous.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to conduct reassessments on all patients deemed unstable, citing one of one patients (Patient #6). Findings included: A review of the “IDT (Interdisciplinary Team) Patient Assessment and POC (Plan of Care)” dated 07/2023 included, “A comprehensive reassessment of each patient and a revision in the plan of care will be conducted...at least monthly for unstable patients...Plan of Care following re-assessments must be completed within 15 days of completing the re-assessment. This process would occur monthly for unstable patients...Monthly (unstable patients)...Assessment...Monthly until patient is determined by interdisciplinary team to be stable...Plan of Care...Complete patient plan of care meeting within 15 days of the completion of the re-assessment and POC.” ~ Patient #6: The facility’s “ESRD (End Stage Renal Disease) Core Survey Data Worksheet” dated 04/29/2024 indicated Patient #6 was designated as “unstable” 02/2024 and 03/2024. On 04/29/24 at 3:15 PM, the Home Therapies Nurse (Personnel #7) said there was no documented evidence of a monthly unstable comprehensive interdisciplinary assessment and POC for 04/2024.”

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure complete information about one of one patient’s (Patient #2) treatment was entered into the dialysis flow sheet. Findings included: A review of the “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” policy dated 04/2024 indicated, “Patient data will be obtained and documented by the PCT (patient care technician) or a licensed nurse...Sitting and standing blood pressure measurement required pre and post treatment (if patient unable to stand, documentation in the patient electronic record or flow sheet)... Blood pressure post treatment...If patient is not able to stand, document reason and sitting blood pressure.” ~ Patient #2: A review of Patient #2’s hemodialysis treatment records dated form 04/01/2024 to 04/26/2024 indicated in the “Pre-Treatment Vitals” section,”Mobility...Ambulates...No assistance needed...Ambulatory...No assistance needed.” Patient #2’s hemodialysis treatment records did not include pre and/or post treatment standing blood pressures. ~ 04/30/24 at 11:10 AM, the Clinical Services Manager (Personnel #8) said the direct patient care should document if a patient refuses standing vital signs.”