Fmc Dialysis Mt Hood

“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: 37237 Based on interview and review of the facility’s Emergency Preparedness binder, it was determined the facility failed to comply with the Federal Emergency Preparedness (EP) requirement to establish and maintain a comprehensive EP program, 42 CFR §494.62 - Condition for Coverage: Establishment of the Emergency Preparedness Program - Dialysis. Findings: 1. Based on interview and review of documentation, it was determined the facility failed to update the EP plan since 2022. - Refer to findings cited in Tag 42 CFR §494.62(a) - Develop EP Plan, Review and Update Annually. 2. Based on observation, interview, review of personnel files and review of documentation, it was determined the facility failed to ensure: - All staff received emergency preparedness training. * Eight of 34 staff lacked annual emergency preparedness training. - Staff received training in the use of emergency procedures. * 7 of 34 staff lacked documentation of emergency procedures training. - The facility’s emergency evacuation kit contained updated staff contact information and patient contact and medication information. * The patient contact lists found in the emergency crash cart and the evacuation cart were outdated by six months. - Patients participated in quarterly fire drills and received training on the procedures of how to disconnect themselves from the dialysis machine if an emergency occurs. * The facility failed to provide documentation that patients who require a translator and patients who would require assistance during an emergency were properly trained for what to do during an emergency. * The facility failed to conduct fire drills during the last 4 quarters according to facility policy. - Refer to findings cited in Tag 42 CFR §494.62(d)(1) - ESRD EP Training Program. This Condition-level deficiency substantially limits the capacity of the clinic to furnish services of an adequate level of quality.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 37237 Based on interview, review of documentation and review of the facility’s emergency preparedness plan, it was determined the facility failed to update the EP plan annually. Findings: Review of Governing Body meeting minutes dated 02/25/2025 revealed 3 items listed under the section titled, “2025 Annual Book of Business ... Agreements, OSHA and Disaster Preparedness.” There was no documentation of the listed items to demonstrate they were discussed or voted on. It could not be determined from the GB meeting minutes that the emergency preparedness program was discussed, reviewed, adopted or approved for 2025. Review of Governing Body meeting minutes dated 07/10/2025 revealed in the section “Internal KIMA Audit Findings” that “Emergency Preparedness Binder ... not updated since 2022.” Review of the facility policy, “Guidelines for Emergency Preparedness,” dated 07/03/2023 stipulated in the section titled, “Corporate Disaster Committee:” * “The Corporate Disaster Committee will review and update disaster policies/procedures annually.” * “The Governing Body at each facility will review the disaster policies annually.” During interview with the interim FA on 07/16/2025 at 1600, they confirmed the items listed on the 02/25/2025 GB minutes looked like agenda items and could not confirm the EP plan had been updated since 2022.”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37237 Based on observation, interview, review of personnel files and review of documentation, it was determined the facility failed to ensure: * All staff received emergency preparedness training; * All staff received training in the use of emergency procedures; * The facility’s emergency evacuation kit contained updated patient contact and medication information; and * Patients participated in quarterly fire drills and received training on the procedures of how to disconnect themselves from the dialysis machine if an emergency occurs. Findings: 1. Review of a personnel audit worksheet revealed 8 of 34 staff (Staff #s 3, 4, 5, 7, 10, 14, 17 and 26) lacked current Emergency Preparedness Training. Other than the Medical Director, there was no documentation provided that medical staff (MDs, NPs and PAs) working on-site at the facility had received any Emergency Preparedness training. Review of the facility policy, “Guidelines for Emergency Preparedness,” dated 07/03/2023 stipulated: * Staff will be trained on emergency disaster preparedness such as fire drills, emergency disconnection and emergency evacuation. * Training on emergency preparedness is required annually for medical directors, physicians and extenders such as APRNs, APA-Cs for each location where they have privileges.” 2. Review of a personnel audit worksheet revealed 7 of 34 staff (Staff #s 13, 14, 21, 25, 27, 33 and 34) lacked current Emergency Procedures Training. - Review of the “Adverse Events Report” for dates between 07/07/2024 and 07/07/2025 revealed a patient who suffered a “Cardiac-Cardiopulmonary Arrest” on 06/20/2025. The “Final Outcome” was listed as “Patient Hospitalization-or ER/ED evaluation.” * On 07/17/2025 at 0915, the interim FA confirmed staff started CPR and the patient was transported via EMS to the hospital where the patient was pronounced deceased. They also confirmed that no “Cardiopulmonary Arrest Record” had been completed for the event. *Further review of the Adverse Events report revealed a patient that suffered a “Cardiac-Cardiopulmonary Arrest” event on 09/25/2024. Review of the “Cardiopulmonary Arrest Record” for the patient was dated 09/25/2025. 3. During observation of the facility on 07/15/2025 at 1010 revealed patient contact lists were stored both in the crash cart and in the evacuation cart. The list in the crash cart was dated 10/09/2024 and the list in the evacuation cart was dated 01/13/2025. The facility failed to update both lists quarterly. Review of the facility policy, “Guidelines for Emergency Preparedness,” dated 07/03/2023 stipulated: * “The facility must develop a communication plan for all patients ... This plan includes the following ... Quarterly, the CM will review and update ... The Emergency and Disaster Staff Contact Information Sheet ... The Emergency and Disaster Patient Contact Information Sheet ... A Current copy of the emergency lists must ... Be kept locked in the emergency supply boxes, or cart.” 4. Review of fire drill documentation of facility patients revealed: * A completed “Incenter HD Patient Participation in Emergency and Disaster Preparation Form” was filed as part of fire drill documentation for each patient. A form was completed for each patient by the facility’s AA, for the dates 12/30/2024, 03/05/2025, 03/06/2025, 06/05/2025 and 06/06/2025. The form included, but was not limited to, statements to be checked off if: - “The patient was able to:” * “Correctly verbalize location of emergency exits and fire extinguishers” * “Correctly verbalize location of designated meeting area inside ... and outside ...” * “Correctly perform/verbalize emergency clamp and disconnect procedure” * “Correctly perform/verbalize emergency rinseback (hand-crank) procedure” * “Correctly verbalize location of emergency diet/food and water supply” * “Correctly verbalize location of FKC Patient Emergency Hotline number” * “Correctly verbalize what to do if the facility is closed” * “Correctly verbalize what to do if unable to perform/receive regular dialysis treatment during a disaster” For every patient for every month, these statements were checked. - 32 of 104 current patients require translation services. There was no documentation the facility provided translation services to the patients that don’t speak or read English to complete the emergency forms. - 18 of 104 current patients require full assistance during an emergency. There was no documentation on the emergency form that indicated the patients needed assistance. - 26 of 136 patients treated at the facility from 03/01/2025 were not ambulatory and required full assistance during an emergency. There was no documentation on the emergency form that indicated the patients needed assistance. - 11 of 136 patients treated at the facility from 03/01/2025 required the use of a walker or cane. There was no documentation on the emergency form that indicated the patients may require assistance. 5. Review of documentation presented as quarterly fire drills revealed a “Staff Participation in Fire Drill” staff sign in sheet and a “Fire Drill Attendance Record” that included names of staff and patients. The documentation was dated for 12/30/2024, 03/05/2025, 03/06/2025, 06/05/2025 and 06/06/2025. No other fire drill documentation was presented. Review of the facility policy, “Fire Drill,” dated 08/02/2017 stipulated: *”Quarterly, all FKC facilities shall perform a fire drill for each shift of patients and staff ...” * “In addition to the drill, activation of the fire alarm once per staff shift shall occur ...” * “Verification that the fire alarm signal was received by the contracted monitoring service must occur.” * “Patients should be able to verbalize how they would disconnect themselves from the machine and evacuate the facility, or if unable, how they will be evacuated.” Review of the facility policy, “Fire Drill Procedure,” dated 08/02/2017 revealed the facility failed to perform fire drills according to the 17 steps outlined in the procedure for the last 4 quarters.”

“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: 37237 Based on observation and review of documentation, it was determined that the facility failed to ensure a sanitary environment to minimize the transmission of infectious agents within the facility. Findings: Observations of the treatment area on 07/16/2025 between 0940 and 1040 revealed the following: - 2 PCTs failed to perform hand hygiene in between glove changes. - An RN failed to clean the stethoscope after use on a patient. - A PCT who cleaned treatment station #12 failed to clean the entire BP cuff. They only wiped the top half and failed to clean the bottom portion of the cuff. - The prime rinse bucket on one of the machines had brown stains inside the bucket. - An unmarked sink and the clean (handwashing) sink were side-by-side in the medication area. The paper towel dispenser was hung between the two sinks and a paper towel was always hanging down and available for use. A portion of the paper towel was in contact with the counter and the edges of both sinks, leaving it subject to contamination. - Review of the document, “Clinic Audit Checklist ... Infection Prevention,” revealed no documentation for “Cleaning and Disinfection of the Dialysis Station” and “Isolation Practices” for the months of August 2024, April 2025 and May 2025. In an email dated 07/23/2025 at 12:04 PM, the interim FA confirmed they were not able to find documentation for those months. Review of the facility policy, “Hand Hygiene,” dated 11/06/2023 stipulated: - “Hands will be ... Decontaminated using alcohol-based hand-rub or by washing hands with antimicrobial soap and water ... Immediately after removing gloves.” - The hand washing sinks may be used for both staff and patients. Soap and a supply of paper towels protected form contamination must be available at each sink.” Review of the facility policy, “Cleaning and Disinfecting the Dialysis Station,” dated 09/05/2023 stipulated: - “Use a cloth wetter with 1:100 bleach solution or EPA-approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, chaise wall behind the chair).””

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 37237 Based on observation and review of documentation it was determined the facility failed to ensure that hemodialysis accesses were prepped appropriately prior to the initiation of dialysis treatments. Findings: Observations of the treatment area on 07/16/2025 between 0940 and 1040 revealed the following: - A PCT was prepping an access with an antiseptic wipe. The duration of the skin cleaning with the wipes of both the first and second prep was between 2 and 3 seconds. - Another patient was being prepped for cannulation by a PCT with an antiseptic wipe. The duration of the skin cleaning with the wipes of both the first and second prep was less than 10 seconds. - A third patient was being prepped for cannulation by a PCT. The PCT had an antiseptic wipe in each hand and with both hands side-by-side, simultaneously wiped in an up and down motion. - One patient ambulated into the treatment area and proceeded to the dialysis chair after recording their weight. The patient failed to wash their dialysis access. Staff did not ask the patient if they had washed their access. - All 3 patients observed at the end of dialysis treatments failed to perform hand hygiene before they exited the treatment floor. Review of the facility policy, “Access Assessment and Cannulation,” dated 05/05/2025 stipulated: - In the section, “Assessment of Vascular Access,” Step 1 - “Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure.” - In the section, “Skin Disinfection,” Step 1 - “Disinfect cannulation site as follows using any of the disinfectants below ... 70% isopropyl alcohol pad: Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating ... Povidone Iodine pad: Work outward 2 inches in a concentric circle using gentle friction for a minimum 30 seconds and allow to dry ... 2% Chlorhexidine and 70% alcohol: Work outward 2 inches in a concentric circle using gentle back and forth friction to clean for a minimum 30 seconds and allow to dry before cannulating.””

“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: 31224 Based on interview and review of documentation for 2 of 104 patients reviewed (Patient #s 15 and 16), it was determined the facility failed to ensure patients were routinely tested as required.: Findings: Review of the facility’s “Hepatitis B Summary Report” printed on 07/15/2025 and patient lab reports dated 07/15/2025 revealed: Patient #15 was identified as a “Non-Responder” to the hepatitis B vaccine on 10/16/2021 and susceptible to hepatitis B infection. Monthly HBsAg lab tests were drawn, however there were no lab results for the month of 08/2024. Patient #16 was identified as a “Non-Responder” to the hepatitis B vaccine on 10/02/2023 and susceptible to hepatitis B infection. Monthly HBsAg lab tests were drawn, however there were no lab results for the month of 05/2025. Review of facility policy “Patient Hepatitis B Testing Requirements,” dated 02/03/2025, stipulated patients who were susceptible to hepatitis B infection required monthly HBsAg testing. During interview with the interim FA and CN on 07/16/2025 at 1500, the above findings were confirmed.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 37237 Based on observation and review of documentation it was determined that the facility failed to ensure that equipment and supplies used for isolation patients were labeled for isolation only. Findings included, but not were not limited to: Observation of the isolation room on 07/16/2025 at 0940 revealed the following items found in the isolation room were not labeled for isolation only. Items included, but were not limited to: - The TV remote - The centrifuge - A container of pH testing strips - A bleach jug - A face shield - Two stethoscopes - A bin full of clamps - A folding chair - A walker - A trashcan - Portable sharps container - A visitor’s folding chair - Miscellaneous supplies - A glucometer Review of the facility policy “Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+),” dated 06/04/2025 stipulated: * “If ... There are current HBsAg positive patients on census ... Then ... Equipment cannot be used for HBV negative patients on other shifts or days due to the risk of cross contamination. Equipment used for HBsAg positive patients should be reserved for the HBsAg positive patient unless repair or maintenance is needed.” * “All supplies used in the isolation room/area such as clamps, blood pressure cuffs, testing reagents, etc., should be labeled ‘isolation’ and not routinely removed.””

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 37237 Based on interview and review of personnel records, it was determined the facility failed to ensure 4 of 34 staff (Staff #s 13, 26, 27 and 28) received annual infection control training. Findings: Review of the personnel worksheet completed by the interim FA on 07/17/2025 revealed: * Staff #13 - Identified as a PCT with a DOH of 01/24/2022 last completed “Infection Control Training” on 02/02/2023. * Staff #26 - Identified as a Float RN with a DOH of 12/23/2023 last completed “Infection Control Training on 05/08/2024. * Staff #27 - Identified as an RN with no DOH listed had no date listed for “Infection Control Training. * Staff #28 - Identified as a Float RN with no DOH listed last completed “Infection Control Training on 05/27/2024. Review of the facility policy titled, “Bloodborne Pathogen and Infection Control Training,” dated 11/02/2020 stipulated “All staff who have occupational exposure to bloodborne pathogens must participate in an OSHA training program ... At least annually ... Within one year of the previous years’ training.” During interview with interim FA, DO and Strategic Clinical Quality Manager on 07/17/2025 at approximately 1600, they confirmed the above findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 31224 Based on observation, interview, and review of documentation it was determined that the facility failed to ensure that medications were prepared and stored correctly. Findings: Observation of the treatment floor and medication preparation areas on 07/15/2025 starting at 0950 revealed: - Three prefilled syringes labeled with a preprinted patient label indicating “Heparin” and one prefilled syringe labeled with a preprinted patient label indicating “Lidocaine” on the counter of two separate medication preparation areas. Each label on the syringes lacked the time and the preparer’s initials. - An opened MDV of Lidocaine lacked the date and time the vial was opened and the initials of who opened the vial. Review of the facility policy titled, “Medication Preparation and Administration,” dated 07/07/2025, stipulated: * “All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication.” * “When preparing medications if the vial is not used immediately in its entirety, the nurse or PCT must place the date and time the vial was opened on the medication label along with their initials.” During an interview on 07/15/2025 at 1525, the interim FA 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: 37237 Based on interview and review of personnel records, it was determined that the facility failed to ensure that all 6 of 30 staff (Staff #s 13, 14, 27, 29, 30 and 31) responsible for operating, testing and monitoring the water and dialysate systems completed the required training and annual skills checks. Findings: Review of the personnel audit worksheet completed by the interim FA on 07/17/2025 revealed: * Staff #13 - Identified as a PCT with a DOH of 01/24/2022 had no date listed for water dialysate training. * Staff #14 - Identified as an RN with a DOH of 01/24/2022 last completed water training on 07/12/2024. * Staff #27 - Identified as an RN with no DOH listed had no date listed for water training. * Staff #29 - Identified as a Biomed tech with a DOH of 04/04/2022 last completed water training on 05/05/2024. * Staff #30 - Identified as a PCT with a DOH of 06/26/2023 last completed water training on 05/23/2024. * Staff #31 - Identified as a PCT with a DOH of 08/19/2024 last completed water training on 04/28/2024. During interview with interim FA, DO and Strategic Clinical Quality Manager on 07/17/2025 at approximately 1600, they 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: 37237 Based on observation and interview, it was determined that the facility failed to maintain a safe, functional, and comfortable environment for the patients, staff and public. Findings: Observations of the facility on 07/15/2025 beginning at 1010 revealed the following: - The lab fridge lacked a biohazard label. - Areas throughout the facility had tape remnants/sticky residue on the surface, including but not limited to: * Cabinet doors in the medication prep area * The lab fridge * The privacy screens * Countertops - The eyewash station located with the drench shower had one of caps resting inside the basin and the nozzle was left exposed. - Areas throughout the facility had chipped and peeling paint that exposed the wall board underneath. These areas could not be cleaned effectively for infection control purposes. - There were holes in the ceiling in an area of the lobby where the acoustic ceiling tiles were not securely in place. During interview with the interim FA, DO and Strategic Clinical Quality Manager on 07/17/2025 at 1600, the above findings were confirmed.”

“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: 31224 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis monitoring or that the dialysis prescription was followed for 8 of 10 patients (Patient #s 1-5 and 8-10). Findings: 1. Review of patient medical records revealed BFR and DFR rates were not as prescribed and lacked documentation to explain why the dialysis orders were not followed for 8 of 10 patients (Patient #s 1-5 and 8 - 10). Examples included: * Patient #5’s treatment sheets dated 06/18/2025 through 07/14/2025 (11 treatments) revealed the BFR and/or DFR were not as prescribed during 7 of 13 treatments. The prescribed BFR was 350 mL/min and DFR was 600 mL/min. - On 06/25/2025, the PCT reduced the BFR to 300 mL/min without documentation to show the RN was notified or the rationale for why the prescription was not followed. - On 07/07/2024, the machine was set by the PCT with a BFR at 400 mL/min and DFR at 800 mL/min, where it remained for the duration of the treatment. The machine set up was verified by a second PCT and there was no documentation to show the RN was notified or the rationale for why the prescription was not followed. - Similar findings were noted on 06/20/2025, 06/23/2025, 06/30/2025, 07/09/2025, and 07/11/2025. * Similar findings were noted for Patient #s 1, 2, 3, 4, 8, 9 and 10. 2. Review of patient medical records revealed machine settings and patient checks were not conducted at least every 30 minutes for 6 of 10 patients (Patient #s 1, 2, 4, 5, 8 and 10). Examples included: * Patient #4’s treatment sheets dated 06/16/2025 through 07/14/2025 (13 treatments) revealed patient check or machine settings were not conducted at least every 30 minutes during 10 of 13 treatments. - On 06/16/2025, the PCT documented machine settings at 1122. The next machine settings were documented at 1232, 70 minutes later. The PCT also documented machine settings at 1302, however the next machine settings were not documented until 1408, 68 minutes later. - On 07/04/2025, the PCT documented machine settings and a patient check at 1235. The next machine settings and patient check were documented at 1408, 93 minutes later. - Similar findings were noted on 06/23/2025, 06/27/2025, 06/30/2025, 07/02/2025, 07/07/2025, 07/09/2025, 07/11/2025, and 07/14/2025. * Similar findings were noted for Patient #s 1, 2, 5, 8 and 10. 3. Review of patient medical records revealed blood pressures were out of parameters and not reported to the RN and/or the RN did not administer PRN medications as ordered to address the elevated blood pressures for 2 of 10 patients (Patient #s 5 and 8). Examples included: * Patient #5’s treatment sheets dated 06/16/2025 through 07/14/2025 (11 treatments) revealed Patient #5 had documented elevated blood pressures during 3 of 11 treatments that were not reported to the RN and/or the RN did not administer PRN medications as prescribed. - Patient #5’s Orders Summary Report printed on 07/15/2025 revealed a physician order for Clonidine HCl PRN for SBP >190 with a start date of 06/30/2025. - On 06/18/2025 at 1802, the PCT documented Patient #5’s BP was 185/105, was asymptomatic, and the RN was notified. At 1830, the PCT documented a BP of 191/108 with no RN notification. At 2053, the PCT documented a BP of 201/112 with no RN notification. - On 07/09/2025 at 1732, the PCT documented Patient #5’s BP was 194/106 with no RN notification. At 1804, the PCT documented a BP of 192/103 and the RN was notified. At 1830, the PCT documented a BP of 193/99 with no RN notification. At 1901, the PCT documented a BP of 195/98 with no RN notification. At 2034, the RN documented “No Unusual findings noted” and “Discharged in stable condition.” There was no documentation to show the PRN clonidine was given as ordered. - Similar findings were noted on 07/11/2025. * Patient #8’s treatment sheets dated 06/19/2025 through 07/15/2025 (11 treatments) revealed Patient #8 had documented elevated blood pressures during 2 of 11 treatments that were not reported to the RN.- On 06/26/2025, the PCT documented a DBP >100 at 0631, 0731, and 0832 with no RN notification. The RN documented a DBP of 100 at 0801. At 0936, the RN documented “BP WNL.” - On 07/12/2025, the PCT documented a DBP >100 at 0530, 0600, and 0923 with no RN notification. 4. Review of patient medical records revealed treatment times were shortened with no AMA documentation for 2 of 10 patients. * Patient #1’s treatment sheets dated 05/02/2025 through 07/11/2025 (9 treatments) revealed the patient’s treatment time failed to follow the physician’s prescription for 3 of 9 treatments. - Physician orders for hemodialysis treatment included a prescription for “Scheduled Hours: 04:00.” On 06/20/2025, treatment was initiated at 1304 and completed 3 hours and 03 minutes later at 1607. The treatment was shortened by 57 minutes. At 1310, the RN documented “Late arrival. Assessment @ 1308” There was no AMA documentation provided for the shortened treatment time. - Similar findings were identified for treatment sheets dated 06/09/2025 and 06/23/2025. * Similar findings were identified for Patient #9 Review of facility policy titled, “Patient Assessment and Monitoring,” dated 05/01/2023, stipulated: * “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” * “Document machine parameters and safety checks every 30 [min] or more often as needed but not to exceed 45 minutes or per state regulations.” * “Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.” * “Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” * “If heparin pump is used, ensure heparin is infusing at prescribed rate.” * “Recheck blood pressures after a drop that requires interventions such as administering normal saline.” * “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg ... Diastolic blood pressure greater than 100 mm/Hg” During interview with the interim FA on 07/17/2025 at 1600, the above findings were confirmed.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 31224 Based on review of documentation, it was determined that the facility failed to reassess patient consent to receive vaccinations or offer pneumococcal or hepatitis B vaccines to patients on an annual basis (Patient #s 11-14). Findings: Review of the “Pneumonia Vaccination Report,” printed on 07/14/2025, revealed: * Patient #s 11-14 had a history of declining the vaccine, but there was no documentation to show this was reevaluated annually. Review of the facility policy titled, “Pneumococcal Vaccine for Adults,” dated 07/02/2025, stipulated: * “Pneumococcal vaccination is recommended for adults with chronic renal failure.” * “Patients should be offered pneumococcal vaccination on an annual basis, at minimum” for any patient who previously declined the vaccine.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 31224 Based on patient clinical record review, it was determined the facility failed to provide the necessary care and services to achieve or sustain the clinically appropriate hemoglobin/hematocrit level for 2 of 10 patients (Patient #s 2 and 5) reviewed. Findings: 1. Review of Patient #2’s Order Summary Report printed on 07/15/2025 revealed a medication order for “Mircera 100 mcg IVP During Dialysis Every 2 weeks” with a start date of “07/11/2025.” A clinical note dated 7/11/2025 documented the RN received an order to decrease the dose from 120 mcg to 100 mcg. Review of Patient #2’s treatment sheets dated 06/16/2025 through 07/14/2025 (13 treatments) revealed a dose of 120 mcg of Mircera (a red blood cell stimulating medication) was given on 06/20/2025. The next dose was due on 07/04/2025, however the next dose was not administered until 07/11/2025, one week late. 2. Review of Patient #5’s Order Summary Report printed on 07/15/2025 revealed a medication order for “Mircera 75 mcg IVP During Dialysis Every 2 weeks” with a start date of 05/19/2025. Review of Patient #5’s Treatment Sheets dated 06/18/2025 through 07/14/2025 (13 treatments) revealed a dose of Mircera was administered on 06/30/2025. The next dose was due on 07/04/2025, however no doses were documented as administered after 06/30/2025.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 37237 Based on interview, review of 7 of 10 patients’ plan of care (Patient #s 2, 3, 4, 5, 6, 7, and 9). and review of documentation, it was determined that the facility failed to ensure that plans of care were signed by the patient and/or the patient’s designee or that a reason for refusal was documented. Findings: Patient #7 Review of Patient #7’s medical record revealed a Plan of Care dated “POC MTNG Date 07/30/2024.” The POC was approved by the MD, RN, MSW and RD on 07/30/2024. The section, “Patient Approval Signature,” lacked a dated signature by the patient and/or Designee and the “Patient Chooses not to sign plan of care” box was not marked. Patient #9 Review of Patient #9’s medical record revealed a Plan of Care dated “POC MTNG Date 09/19/2024.” The POC was approved by the MD, RN, MSW and RD on 09/19/2024. The section, “Patient Approval Signature,” lacked a dated signature by the patient and/or Designee and the “Patient Chooses not to sign plan of care” box was not marked. Similar findings were identified for Patient #s 2, 3, 4, 5 and 6. Review of the facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated 07/03/2023 stipulated, “The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” During interview with the interim FA, DO and Strategic Clinical Quality Manager on 07/17/2025 at 1600, the above finding were confirmed.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 37237 Based on interview, and review of documentation, it was determined that the facility failed to ensure 18 of 34 staff (Staff #s 3, 4, 5, 7, 10, 13, 14, 17, 21, 25-31, 33 and 34) had the qualifications and demonstrated competencies required to meet the comprehensive care needs of the patients. Findings: The review of documentation included a “Personnel Audit Tool” worksheet completed by the interim FA on 07/17/2025 revealed: 1. 4 of 34 staff (Staff #s 13, 26, 27 and 28) lacked current annual infection control training. * Refer to findings identified in Tag V132, IC - Training & Education -494.30(a)(1)(i). 2. 6 of 30 staff (Staff #s 13, 14, 27, 29, 30 and 31) responsible for operating, testing and monitoring the water and dialysate systems lacked current annual water and dialysate training and skills checks. * Refer to findings identified in Tag V260, Personnel - Training Program/periodic Audits - 494.40(a). 3. 7 of 34 staff (Staff #s 13, 14, 21, 25, 27, 33 and 34) lacked current Emergency Procedures Training. * Refer to findings identified in Tag E0038, ESRD EP Training Program 494.62(d)(1) 4. 8 of 34 staff (Staff #s 3, 4, 5, 7, 10, 14, 17 and 26) lacked current Emergency Preparedness Training. Other than the Medical Director, there was no documentation provided that medical staff (MDs, NPs and PAs) working on-site had received any Emergency Preparedness training. * Refer to findings identified in Tag E0038, ESRD EP Training Program 494.62(d)(1) During interview with the interim FA, DO and Strategic Clinical Quality Manager on 07/17/2025 at 1600, the above findings were confirmed.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 37237 Based on the review of documentation, it was determined that the facility failed to implement an effective internal grievance process. Findings: Review of the facility’s “Patient Grievance Report” from 07/07/2024 through 07/07/2025 revealed the facility failed to follow their written complaint/grievance policies and procedures in 5 of 8 grievances filed with the facility. A grievance was submitted on 09/16/2024 and resolved over two months later, on 11/25/2024. The grievance was not escalated to the AM/DO. Reviewing the “Resolution/Corrective Actions” revealed there were no dates noted to create a timeline of when specific steps were taken and by what staff. A grievance was submitted 11/25/2024 and resolved approximately 4 months later, on 03/21/2025. The grievance was not escalated to the AM/DO. Review of the “Grievance Details” and Resolution/Corrective Actions” section revealed there was only one date noted, 03/21/2025, with no documentation to explain the lapse of 4 months. There was no other dates noted to create a timeline of when specific steps were taken any by what staff. Similar findings were identified for grievances filed on 10/11/2024, 12/31/2024 and 06/04/2025. Review of the facility policy, “Patient Grievance” dated as 05/05/2025 stipulated in the section “Responding to Grievances:” * “Step 2. If unable to resolve the complaint to the patient/representative’s satisfaction within the current patient encounter, the Nurse in Charge (or designee) must report as a grievance to the Clinic Manager (CM) or Facility (FA) Administrator soon as possible, preferably within 24 hours.” * “Step 3. The CM/FA will investigate the grievance and contact the patient within 3 business days, either verbally or in writing, to provide an update or resolution ...” * “Step 4. If the grievance us unable to be resolved by the CM/FA, it must be escalated to the Director of Operations within 24 hours.””