Davita Renal Center of Beaumont

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 48749 Based on observation, record review, and staff interview, the facility’s direct care staff failed to: A. to ensure that 3 (#8, #11, and #22) of 3 patients had washed their vascular access site before dialysis treatment. The facility staff failed to follow the facility’s “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Care” policy (Cross Refer to Tag V 0114) B. to ensure that medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. Also, the facility failed to store vaccines according to the CDC (Centers for Disease Control) guidelines. The facility staff failed to follow the facility’s “Medication Requiring Refrigeration” and “Medication Policy” policies. (Cross Refer to Tag V 0117) C. failed to identify 1 of 1 wet (wet with patient blood or other fluid) external transducer (pressure monitor) located at Station #17. The facility staff failed to follow the “Changing Transducer Protectors” policy. (Cross Refer to Tag V 0120) D. ensure that proper cleaning and disinfection of the dialysis station and equipment were performed before the next patient’s treatment. Also, the facility staff failed to follow the facility’s “Infection Control for Dialysis Facilities” policy. (Cross Refer to Tag V 0122)”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 48749 Based on observation,record review, and staff interview, the facility’s direct care staff failed to ensure that 3 (#8, #11, and #22) of 3 patients had washed their vascular access site before dialysis treatment. The facility staff failed to follow the facility’s “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Care” policy. This deficient practice had the potential to increase infections at the patient’s vascular access site. Findings include: On 09/23/2025 between 9:30 AM and 2:00 PM, the Surveyor observed Patient #8, Patient #11, and Patient #22 entering the treatment area. The patients weighed themselves and then went straight to their treatment chair without washing their vascular access site. Also, the Facility Staff did not ensure that Patient #8, Patient #11, and Patient #22 had washed their vascular access site before treatment. A review of the facility’s “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Care” policy dated April 2025 revealed the following; “PURPOSE: To reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss, and to maximize the lifetime of each access. 4. Patients are encouraged to wash access extremity with soap and water upon arrival for dialysis, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry.” An interview with Staff #28 was conducted on 09/23/2025 at 2:00 PM. Staff #28 acknowledged the surveyor’s findings that the patients had not washed their vascular access site prior to starting dialysis treatment.”

“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: 48749 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure that medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons. Also, the facility failed to store vaccines according to the CDC (Centers for Disease Control) guidelines. The facility staff failed to follow the facility’s “Medication Requiring Refrigeration” and “Medication Policy” policies. These deficient practices had the likelihood to cause harm to all patients who receive care at the facility by using vaccines that were not stored according to CDC guidelines. Findings include: During a tour of the facility on 09/23/2025 at 9:30 AM, the surveyor observed the following: * Inside the medication cabinet, there was an open bottle of Heparin. There was no date of opening, time, or staff initials written on the label or box. * Inside the medication refrigerator, the Hepatitis B and Tuberculin vaccines were stored on the top shelf, next to the wall of the refrigerator. * There was an open multi-dose vial of Tuberculin in the box with a date of opening on 08/21/2025. Per the manufacturer’s guidelines, Tuberculin must be discarded 30 days after opening. The Tuberculin was 3 days past the 30-day expiration. * There were 4 prefilled syringes of Heparin stored in a medication lock box on the counter at the nurse’s station for Pod #1. The medication lock box was left unlocked by facility staff. * There were 2 prefilled syringes of Heparin stored in a medication lock box on the counter at the nurse’s station for Pod #4. The medication lock box was left unlocked by facility staff. A review of the facility’s policy “Medication Requiring Refrigeration” dated April 2025, revealed the following: “PURPOSE: To provide guidance for the storage and management of medications requiring refrigeration. POLICY: 1. Medications that require refrigeration are stored in the facility refrigerator designated for medications only... i. Avoid storing vaccines and diluents in any part of the unit that may not provide stable temperatures or sufficient air flow, such as directly under cooling vents, in deli, fruit, or vegetable drawers, or on refrigerator door shelves. Place water bottles on the top shelf, and floor, and in the door racks to assist with maintaining stable temperatures caused by frequently opening and closing unit doors or a power failure ... ..... b. Daily checks will include: * Medication placed near center of refrigerator. *No expired medication *General refrigerator cleanliness *DDL buffered probe placed near center of refrigerator *Water bottles are in place, if required *Lock on door or refrigerator door, or in a room that locks 5. Per Centers for Disease Control (CDC), place vaccines in center refrigerator space, contained in original packaging, inside designated storage trays positioned 2 - 3 inches from refrigerator walls.” According to CDC guidelines for the storage of immunizations: www.cdc.gov/vaccines “Store between 35 and 46 degrees. Place the vaccine in bins with open airflow or leave the top off. Make sure the door is shut. Remove crisper bins and place water bottles labeled ‘Do Not Drink in the bottom.’ Leave 2-3 inches between all vaccine containers and refrigerator walls. Post do not unplug on the refrigerator. Don’t use a dormitory-style refrigerator. Don’t store vaccines on top shelf Don’t put food and beverages in the refrigerator. Don’t put vaccines or diluents in the door or floor of the refrigerator. Don’t drink or remove water bottles.” A review of the facility’s “Medication Policy” policy dated October 2023 revealed the following: “PURPOSE: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications. 11. All refrigerated medications, for example, erythropoietin-stimulating agents (ESA) and vaccines, are to be locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. Non-refrigerated medications are to be stored in cabinet(s) and locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. 13. All open or unopened medication packages (i.e., vials, ampules, etc.) are stored according to the manufacturer’s directions. Do not use any medication that has been stored improperly or has expired. 17. Medication preparation should be performed only for the current shift of patients, i.e., do not prepare medications for more than one shift of patients. 18. All syringes prepared from single-use vials/ampules (without preservatives) or multidose vials should be prepared and administered within a four (4) hour period [within one (1) hour for States of New Jersey and South Carolina] period, unless there is specific testing and documents on file, which extends dating. 23. Medications and needle/syringe storage are done in accordance with state regulations.” An interview was conducted with Staff #27 on 09/23/2025 at 9:50 AM. Staff #27 confirmed that the Heparin was not timed or initialed, and that the vaccines were not stored per the CDC guidelines An interview was conducted with Staff #28 on the morning of 09/23/2025. Staff #28 acknowledged the Surveyor’s findings that medication was left unsecured, vaccines were stored against the wall of the refrigerator, and a multidose Heparin vial was not labeled as to when opened by the facility staff.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 48749 Based on observation, record review, and staff interview, the facility staff failed to identify 1 of 1 wet (wet with patient blood or other fluid) external transducer (pressure monitor) located at Station #17. The facility staff failed to follow the “Changing Transducer Protectors” policy. Findings include: During a tour of the facility’s in-center treatment area on 09/23/2025 at 12:20 PM, the surveyor observed a wet transducer on the hemodialysis machine at Station #17. The external transducer had pink and red fluid inside it, and the patient’s pressures were elevated. Staff #17 was responsible for providing care to the patient being treated on that machine. Staff #17 did not identify or correct the wet transducer until the surveyor pointed out the wet transducer at 12:40 PM, 20 minutes after the wet transducer was first observed by the surveyor. A review of the facility’s “Changing Transducer Protectors” policy dated 04/2021 revealed the following; “PURPOSE: To provide guidance for changing transducer protectors and preventing cross-contamination. POLICY: 1. This policy is intended for all dialysis delivery systems that utilize blood tubing sets with external pressure transducer protectors in the arterial and venous pressure monitoring system. 2. During intradialytic treatment monitoring, the arterial and venous drip chamber level should be observed and adjusted as needed. 3. External transducer protectors will be inspected for presence of blood or saline every 30 minutes during patient treatment and included as part of the monitoring process. 4. The external transducer protector will be replaced: * Prior to each patient use *Whenever blood or saline is observed in contact with the patient side of the transducer protector 5. If the external transducer protector becomes contaminated with blood or saline, the teammate will replace the external transducer protector and adjust the arterial and/or venous drip chamber as needed. After adjusting the arterial and/or venous drip chamber levels, the patient’s arterial and venous pressures should be compared to previous treatment readings. 6. If the pressure readings appear to be inaccurate, the treatment is to be discontinued, the dialysis delivery system must be removed from service, and labeled with date, time, description of the problem, and the name of the teammate reporting the problem. The patient’s treatment is to be continued using another delivery system. 7. The back of the wet external transducer protector and the delivery system pressure module luer locks will be visually inspected for blood or saline contamination prior to placing the new sterile external transducer protector on the delivery system. If blood or saline is noted on the back of the wet external transducer protector, strikethrough has occurred. The treatment can continue for this patient on this delivery system if accurate pressures are observed as described in (#5 above). Upon completion of treatment, the delivery system is to be removed from service and labeled with date, time, description of the problem, and the name of the teammate reporting the problem. 8. The internal transducer protector will be changed only by a trained Biomed teammate, and the delivery system will be disinfected prior to return to use.” An interview was conducted with Staff #2 on 09/23/2025 at 12:40 PM. Staff #2 confirmed the surveyor’s findings of a wet transducer protector at Station #17.”

“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: 48749 Based on observation, record review, and staff interview, the facility’s direct care staff failed to ensure that proper cleaning and disinfection of the dialysis station and equipment were performed before the next patient’s treatment. Also, the facility staff failed to follow the facility’s “Infection Control for Dialysis Facilities” policy. During a tour of the facility’s in-center treatment area on 09/23/2025 at 9:30 AM with Staff #28, the surveyor observed the following; Staff #5 was performing cleaning and disinfection of dialysis Station #6 following a patient’s hemodialysis treatment. The surveyor observed Staff #5 open the wings of the dialysis chair, clean, and promptly close the wings. The staff member did not allow for adequate drying time of the disinfectant before closing the wings on the chair. Staff #12 was performing cleaning and disinfection of dialysis Station #10 following a patient’s hemodialysis treatment. The surveyor observed Staff #12 open the wings of the dialysis chair, clean, and promptly close the wings. The staff member did not allow for adequate drying time of the disinfectant before closing the wings on the chair. Staff #17 was performing cleaning and disinfection of dialysis Station #19 following a patient’s hemodialysis treatment. The surveyor observed Staff #17, one wing of the dialysis chair, clean, and promptly close the wing. Also, Staff #17, was observed wiping in between the chair wing and the seat of the chair without opening the wing. This had the likelihood of not allowing the dialysis chair to be cleaned thoroughly and to allow for adequate drying time. An interview was conducted with Staff #2 on 09/23/2025 at 12:50 PM. Staff #2 reported that the dialysis chair at Station #19 had a broken chair wing that could not be opened. A review of the facility’s “Infection Control for Dialysis Facilities” policy revealed the following; “PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients. Additional precautions recommended by the CDC are to be observed for patients with infectious hepatitis B and are included in the policy: Infection Control and Isolation Measures for Known or Suspected Hepatitis B Antigen Positive Patients. DISINFECTION 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e., used or brought into the station) and prior to returning to a clean/designated area or removal from treatment area. a. Prior to routine disinfection, remove all visible blood. *For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized. * After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time. * Cleaning of visible blood should be performed when first observed. b. Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. * Disinfection should be completed by using a wiping motion with friction. * Sufficient disinfectant should be applied so that surfaces are visibly wet. * Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time.” During an interview with Staff #28 on the morning of 09/23/2025. Staff #28 acknowledged that the facility’s direct care staff did not allow for adequate drying time of the disinfectant before closing the wings on the chair.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 48749 Based on observation, record review, and interview, the facility failed to ensure that 6 (#6, #9, #10, #21, #24, and #25) of 6 patient dialysis treatment chairs were maintained in a clean and comfortable manner for patients. This deficient practice had the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility, by allowing equipment to be used that had been exposed to microbial contamination and unclean surfaces. Findings include: During observation in the patient treatment area on 09/23/2025 at 9:30 AM, the surveyor observed the following; * Dialysis treatment chairs at stations (#6, #9, #10, #21, #24, and #25) had torn vinyl seat cushions and torn vinyl on the leg rests. There was no way to clean the cracked vinyl. * At station #19, observed Staff #17 wiping between the chair wing and the seat cushion of the chair without opening the wing. The clasp on the wing of the chair was broken and staff was unable to open the dialysis chair for disinfecting. An interview was conducted with Staff #17 on the morning of 09/23/2025. Staff #17 reported that the vinyl had been torn for a while. An interview was conducted with Staff #2 on the afternoon of 09/23/2025. Staff #2 confirmed the surveyor’s findings of ripped and torn vinyl on (#6, #9, #10, #21, #24, and #25) patient treatment chairs, and that Station #19 treatment chair had a broken wing that could not be opened.”

“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: 48653 Based on record review and staff interview, the facility staff failed to ensure patient vital signs that fell outside of the facility’s set parameters were reported to the Charge Nurse (CN) and/or physician for further assessment and intervention on 2 (Patient # 1 and # 7) of 2 patient medical records reviewed. The facility staff failed to follow the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. Findings include: Patient # 1 A review of Patient # 1’s treatment sheet dated 05/21/2025 revealed the following, “05:45 AM: Treatment started: Blood Pressure: (BP) 233/100 05:46 AM: BP: 228/121 06:01 AM: BP: 211/82 06:32 AM: BP: 224/38 07:01 AM: BP: 220/97 07:38 AM: Treatment Terminated: BP: 220/97” The patient was discharged home with an elevated blood pressure of 220/97 mmHg (millimeters of mercury). There was no documentation to support that the physician was made aware or that the facility’s hypertension protocol was implemented for the patient. The patient died 3 days later after diagnosis of a subdural hematoma with a midline shift. Patient # 7 A review of Patient # 7’s treatment sheet dated 07/24/2025 revealed the following, “08:10 AM: Treatment started: BP: 81/40 Pulse: 114 08:34 AM: BP: 83/54 Pulse: 134 9:02 AM: BP: 86/66 Pulse: 122 9:04 AM: BP: 89/62 Pulse: 123 9:07 AM: Pulse: 125 9:25 AM: BP: 89/59 Pulse: 115 9:32 AM: BP: 90/74 Pulse: 105 9:34 AM: BP: 90/66 Pulse: 115 9:48 AM: BP: 85/50 Pulse: 105 9:51 AM: 83/57 Pulse: 121 9:56 AM: Treatment ended: BP: 90/60 Pulse: 112 10:05 AM: BP: 90/74 Pulse 122” The patient was discharged home and signed an “AMA” (against medical advice) with “feels unwell/cramping” as the indication. There was no documentation regarding the patient’s tachycardia (elevated heart rate) throughout hemodialysis treatment. The MD was not contacted. A review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy, with a date of April 2024, revealed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. A. Data collection includes, but is not necessarily limited to: Measurement of patient temperature, measurement of blood pressure (BP) ...Heart or pulse rate, noting also if the beat is regular or irregular, patient’s weight, patient’s report of well-being, level of pain or discomfort, complaints, hospitalizations, vascular access status. 2. The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) ....a. The assessment includes the following components: i. Review of patient reports, data collection, complaints, and response to treatment. ii.Verification that machine safety checks have been completed and documented. Iii. Verification of prescription, including machine parameters iv. Verification that the patient’s access is visible, and the face is not covered. V. Review of documentation for accuracy, completion, and patient data ....Pre-treatment Data Collection/Assessment: 4. Any abnormal findings or findings outside of any patient-specific physician-ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician will be notified of any concerns that may preclude the initiation of dialysis ....Post Treatment Data Collection/Assessment: 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. 16. If an abnormal finding or concern is identified post-treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. A licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of the physician is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility’s Governing Body and documented in the Governing Body meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient-specific order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report any changes in patient conditions or concerns about patient well-being immediately to the licensed nurse at any time ....Blood Pressure: Pre-Dialysis: Systolic greater than 180 mmHg or less than 90 mmHg. Diastolic greater than or equal to 100 mmHg or less than 50 mmHg. Blood pressure- Intradialytic: Systolic greater than 180 mmHg or less than 90 mmHg. Diastolic greater than or equal to 100 mmHg or less than 50 mmHg ...Blood Pressure Post Treatment: If the patient can stand, Standing Systolic Blood pressure greater than 140 mmHg or less than 90 mmHg. Standing diastolic BP greater than 90 mmHg or less than 50 mmHg. If the patient is not able to stand, document the reason and the sitting BP. Sitting BP for patients who cannot stand: Sitting systolic BP greater than 140 mmHg or less than 90 mmHg. Sitting Diastolic BP greater than 90 mmHg or less than 50 mmHg ...Heart Rate or Pulse Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat ...” An interview was conducted with Staff # 2 on 09/23/2025 at 11:30 AM in the administrative conference room. Staff # 2 confirmed the facility staff failed to document notification to the MD regarding the out-of-parameter vital signs.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 48749 Based on observation, record review, and staff interview, the facility’s direct care staff failed to assess the vascular access to determine the access patency for 2 (#9 and #12) of 2 patients observed. Also, the facility staff failed to follow the facility’s “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Access Care” policy. This deficient practice of not assessing the patient’s access had the likelihood of not detecting potential problems, such as infection, clotting, stenosis, and access failure. Findings include: During a tour of the in-center treatment area on 09/23/2025 at 9:30 AM, the surveyor observed the following; * Staff #12 accessed Patient #9’s arteriovenous (AV) graft without completing a full assessment of the access. Staff #12 failed to auscultate the AV graft to determine patency and check for a bruit (the sound of blood flowing through the graft, which should sound like a continuous hum or whooshing). * Staff #10 accessed Patient #12’s AV graft without completing a full assessment of the access. Staff #10 failed to auscultate the AV graft to determine patency and check for a bruit. A review of the facility’s “Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Access Care” policy revealed the following; “PURPOSE: To reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss and to maximize the lifetime of each access. POLICY: 1. Inspection of the AVF or AVG access includes the following: *Presence/absence of thrill and/or bruit *Physical location of the access, including depth and direction of flow * Condition of incision(s), especially in newly placed access or revised access *Presence of swelling or edema *Signs and symptoms of infection, including temperature, redness, pain, swelling, drainage *Bruising and/or bleeding * Aneurysms and/or pseudoaneurysms * Condition of previous cannulation sites *Erosion of skin over access site *Signs and symptoms of stenosis *Checking of skin for trauma or skin tears 3. Inspection of the access and access extremity should be performed each dialysis pre-, during and post-treatment.” An interview was conducted with Staff #2 on the afternoon of 09/23/2025. Staff #2 acknowledged the Surveyor’s findings of direct care staff not auscultating graft sites before cannulation.”

“PQ-STAFF NURSE-MEET STATE REQUIREMENTS CFR(s): 494.140(b)(4) Each nurse who provides care and treatment to patients must be either a registered nurse or a practical nurse who meets the practice requirements in the State in which he or she is employed. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, per Texas Occupations Code §301.351(c)(1)-(5), the facility staff failed to ensure that 2 (Staff # 5 and # 27) of 2 licensed nurses were wearing an identification badge while providing patient care. Findings include: During a tour of the facility’s in-center treatment area with Staff #1 on 09/23/2025 at 12:20 PM, the surveyor observed 2 licensed nurses (Staff # 5 and # 27) providing care to hemodialysis patients. The staff were not wearing a name badge with identification and title while providing patient care. A review of the Texas Occupations Code [TOC] §301.351(c)(1)-(5) revealed, “ ...While interacting with the public in a nursing role, each nurse shall wear a clearly legible insignia identifying the nurse as a registered or vocational nurse. The insignia may not contain information other than: (1) the registered or vocational nurse designation; (2) the nurse’s name, certifications, academic degrees, or practice position; (3) the name of the employing facility or agency, or other employer; (4) a picture of the nurse; or (5) any other information authorized by the board ...” A review of “Section 5: Work Environment of Employee Handbook” (no date provided) revealed, “...When wearing a gown in the patient treatment area, any item such as name badge, lanyard, pin, and/or button must remain under the teammate’s gown ...” An interview was conducted with Staff # 1 on 09/23/2025 at 5:00 PM. Staff # 1 confirmed that the Employee Handbook conflicted with the Texas Occupations Code.”

“GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS CFR(s): 494.180 The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ’ personal and property rights, and to the general operation of the facility. This Standard is not met as evidenced by: 48653 Based on record review and staff interview, the facility’s Governing Body failed to ensure the facility’s “Reportable Parameters” were reviewed and approved by the Governing Body before implementation. Also, the facility staff failed to follow the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. Findings include: During a review of the facility’s document, “Reportable Parameters”, the surveyor observed that the reportable vital signs parameters were different than the parameters in the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy. The surveyor observed that the facility staff were given two different sets of parameters for which to report patient vital signs. The “Reportable Parameters” did not require notification of tachycardia (elevated heart rate) to the charge nurse (CN) until the pulse was higher than 120 bpm (beats per minute). Tachycardia is defined as a heart rate greater than 100 bpm. The facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy required a notification to the charge nurse when the patient’s heart rate is greater than 100 bpm. The “Reportable Parameters” did not require notification of a change in blood pressure until the change was by more than 40 mmHg (millimeters of mercury) from the previously recorded blood pressure reading. The facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy required a notification after a change of 20 mmHg from the previously recorded reading. A review of the facility’s Governing Body Meeting Minutes revealed there was no documentation to support that the “Reportable Parameters” had been approved by the Governing Body as required by policy, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment”. A review of the facility’s “Reportable Parameters” document revealed, “Reportable to the CN-Pre-Treatment: Any change in prescription must be reported to the charge nurse ...Blood Pressure: Systolic greater than 180 or less than 90. Diastolic greater than 90 or less than 50 ...Pulse: Greater than 120 or less than 50 ....Reportable to CN-Intradialytic: Systolic greater than 180 or less than 90. Diastolic greater than 90 or less than 50. Any 40 mmHg change ...Reportable to the CN-Post Treatment: ...Blood Pressure: Systolic greater than 180 or less than 90. Diastolic greater than 90 or less than 50. Pulse: Greater than 120 or less than 50, or irregular, rapid or weak pulse ...ANY Complaint voiced by the patient needs to be reported by direct patient care team to the charge nurse ... ACTION: Blood Pressure: Report to CN for evaluation and CN to notify MD if BP is non-responsive to intervention and/or patient becomes symptomatic. Report to CN and complete any or all the following depending on the severity:recline the patient, give normal saline bolus per PRN order, turn off UF, recheck BP, then every 15 minutes until within limits. CN to evaluate for change in fluid removal goal, refer to PRN medication orders, and notify the MD if symptoms persist or BP remains higher or lower than acceptable limits. CN to evaluate and report to the MD if the patient is symptomatic. Heart Rate: Report to CN to evaluate and report to MD as patient symptoms indicate ....” An interview was conducted with Staff # 27 (Charge Nurse) on 09/23/2025 at 3:15 PM in the facility’s administrative conference room. Staff # 27 was asked which reportable parameters the facility staff follow when caring for patients. Staff # 27 stated, “I did not realize the reportable parameters were different than the facility policy; you would assume they would be the same”. Staff # 27 stated, “We updated all the patients’ orders to match the reportable parameters in January 2025”. A review of the facility’s “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy with a date of April 2024 revealed, “Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment, and for reviewing the patient’s response to the treatment and status prior to discharge. Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. A. Data collection includes, but is not necessarily limited to: Measurement of patient temperature, measurement of blood pressure (BP) ...Heart or pulse rate, noting also if the beat is regular or irregular, patient’s weight, patient’s report of well-being, level of pain or discomfort, complaints, hospitalizations, vascular access status. 2. The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) ....a. The assessment includes the following components: i. Review of patient reports, data collection, complaints, and response to treatment. ii.Verification that machine safety checks have been completed and documented. Iii. Verification of prescription, including machine parameters iv. Verification that the patient’s access is visible, and the face is not covered. V. Review of documentation for accuracy, completion, and patient data ....Pre-treatment Data Collection/Assessment: 4. Any abnormal findings or findings outside of any patient-specific physician-ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician will be notified of any concerns that may preclude the initiation of dialysis ....Post Treatment Data Collection/Assessment: 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings. 16. If an abnormal finding or concern is identified post-treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. A licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of the physician is necessary prior to discharge of the patient from the facility. Abnormal Findings: Unless other abnormal parameters are established by the facility’s Governing Body and documented in the Governing Body meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient-specific order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report any changes in patient conditions or concerns about patient well-being immediately to the licensed nurse at any time ....Blood Pressure: Pre-Dialysis: Systolic greater than 180 mmHg or less than 90 mmHg. Diastolic greater than or equal to 100 mmHg or less than 50 mmHg. Blood pressure- Intradialytic: Systolic greater than 180 mmHg or less than 90 mmHg. Diastolic greater than or equal to 100 mmHg or less than 50 mmHg ...Blood Pressure Post Treatment: If the patient can stand, Standing Systolic Blood pressure greater than 140 mmHg or less than 90 mmHg. Standing diastolic BP greater than 90 mmHg or less than 50 mmHg. If the patient is not able to stand, document the reason and the sitting BP. Sitting BP for patients who cannot stand: Sitting systolic BP greater than 140 mmHg or less than 90 mmHg. Sitting Diastolic BP greater than 90 mmHg or less than 50 mmHg ...Heart Rate or Pulse Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heartbeat ...” A review of the facility’s Governing Body Meeting Minutes dated 03/27/2024 revealed that the “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment” policy was reviewed and approved by the Governing Body on 03/27/2024. An interview was conducted with Staff # 1 on 09/23/2025 at 4:00 PM, which confirmed that the “Reportable Parameters” were not approved by the facility’s Governing Body.”